2022 clinical management of COVID 19 2022 clinical management of COVID 19 2022 clinical management of COVID 19 2022 clinical management of COVID 19 2022 clinical management of COVID 19 Guideline Clinical management of COVID 19 patients living guideline Clinical management of COVID 19 LIVING GUIDELINE 15 SEPTEMBER 2022 {lfl�� World Health ��J Organization � WHO2019 nCoVClinical20.
Background
As of August 18, 2022, over 590 million people globally have contracted COVID-19, resulting in more than 6.4 million deaths, according to the WHO The Omicron variant, which emerged in late November 2021, has become the dominant strain and is driving surges in various countries While vaccination efforts are significantly reducing case numbers and hospitalizations in high-income nations, many populations remain at risk due to limited vaccine access Additionally, uncertainties persist regarding the duration of vaccine protection and their effectiveness against Omicron and other variants This underscores the urgent need for more effective COVID-19 treatments The pandemic has also emphasized the importance of reliable, updated living guidelines to contextualize new research findings and offer clear clinical recommendations.
Understanding the proportion of asymptomatic infections with SARS-CoV-2 is crucial, as estimates vary widely A meta-analysis indicated that approximately 31% of infected individuals remained asymptomatic, while a systematic review of 79 studies reported a range of 20% (17–25%) Another systematic review with low bias found that 17% of cases were asymptomatic (14–20%) Additional findings revealed significant variability, with asymptomatic rates in general populations ranging from 20% to 75%, and 8.2% to 50% among contacts Notably, 54% of nursing home residents were asymptomatic at testing, with 28% remaining so during follow-up A recent meta-analysis of 28 studies indicated that asymptomatic infections can range from 1.4% to 78.3%, with a weighted average of 25% Cohort studies, such as the Diamond Princess cruise ship, showed an asymptomatic rate of 17.9%, while 40.3% of dialysis patients exhibited undetected asymptomatic disease through serological testing.
In patients who exhibit symptoms of COVID-19, approximately 80% experience mild to moderate disease, with 40% classified as mild and another 40% as moderate About 15% progress to severe disease requiring oxygen support, while 5% face critical conditions involving complications such as respiratory failure, ARDS, sepsis, and multi-organ failure, including acute kidney and cardiac injuries These proportions may vary based on surveillance strategies, therapeutic interventions, demographic differences, vaccination rates, and the emergence of new variants For a comprehensive overview of risk factors associated with severe disease or death, refer to Table 6.2.
COVID-19 is linked to a range of mental and neurological symptoms, including anxiety, depression, sleep disturbances, headaches, dizziness, and altered senses of smell or taste Individuals with pre-existing mental health issues, like dementia or psychosis, experience higher mortality rates and more severe outcomes when infected with SARS-CoV-2 Even after the acute phase, many patients with post-COVID-19 condition report cognitive dysfunction and reduced cognitive abilities compared to healthy individuals, lasting up to seven months post-infection Anxiety and depression are particularly prevalent among those hospitalized for COVID-19.
A study of hospitalized COVID-19 patients from Wuhan, China, found that over 34% experienced anxiety symptoms and 28% showed signs of depression Additionally, preliminary data from retrospective cohort studies involving over 60,000 COVID-19 cases in the United States revealed an 18.1% incidence of psychiatric diagnoses, including anxiety disorders and insomnia, within the first 2 weeks to 3 months post-diagnosis, with 5.8% representing new diagnoses.
Neurological symptoms have been frequently observed in COVID-19 patients, often occurring without respiratory issues In a U.S cohort, over 80% of hospitalized COVID-19 patients exhibited neurological manifestations, which were linked to a four-fold increase in the risk of severe illness A French observational case series found that 65% of ICU patients with COVID-19 displayed confusion or delirium, while 69% experienced agitation, with delirium correlating with higher mortality rates Additionally, COVID-19 has been associated with acute cerebrovascular diseases, including both ischemic and hemorrhagic strokes, as documented in multiple studies from various countries Reports of Guillain-Barré syndrome and meningo-encephalitis in COVID-19 patients have also emerged, highlighting the diverse neurological complications linked to the virus.
Clinical characterization of COVID-19 in children reveals that while the symptoms are similar to those in adults, they are generally milder, with most cases being asymptomatic or resulting in mild to moderate illness that resolves within 1 to 2 weeks Severe cases, including fatalities, have been documented, but they are rare Common symptoms reported include fever, chills, and cough, which overlap with various other clinical syndromes such as pneumonia, bronchiolitis, and gastroenteritis Notably, there have been relatively few confirmed cases in infants, where additional symptoms may include feeding difficulties and unexplained fever.
Children with underlying medical conditions, such as chronic pulmonary disease (including asthma), obesity, neurologic and developmental disorders, cardiovascular disease, and immunosuppression, face a heightened risk of severe illness Key indicators of severe disease include elevated inflammatory markers like CRP and interleukin 6, as well as symptoms such as dyspnoea, tachypnoea, hypoxia, and gastrointestinal issues upon admission Additionally, a rare but serious condition known as multisystem inflammatory syndrome in children (MIS-C) can lead to multi-organ failure and shock, presenting symptoms similar to Kawasaki disease and toxic shock syndrome Common clinical features of MIS-C include persistent fever, hypotension, gastrointestinal symptoms, rash, myocarditis, and significant inflammation, although respiratory symptoms may be absent.
A living systematic review conducted as of April 27, 2021, indicates that pregnant and recently pregnant women diagnosed with COVID-19 are less likely to exhibit symptoms compared to non-pregnant individuals, with an odds ratio of 0.66 (95% CI 0.52–0.86) based on data from 15 studies.
Pregnant and recently pregnant women exhibit common COVID-19 symptoms such as fever, dyspnoea, cough, and myalgia, particularly when compared to non-pregnant women of reproductive age Research indicates that these findings are primarily based on studies involving hospitalized pregnant women, with limited data on those in early pregnancy or postpartum Severe COVID-19 significantly increases the likelihood of requiring ICU admission (OR=2.61) and invasive ventilation (OR=2.41) for pregnant women Factors such as older maternal age, high body mass index (BMI), non-white ethnicity, pre-existing comorbidities like chronic hypertension and diabetes, as well as pregnancy-specific complications, contribute to serious outcomes, including severe COVID-19 and maternal death Notably, complications related to COVID-19 do not appear to be higher in women during the third trimester compared to earlier stages of pregnancy, nor in multiparous versus primiparous women, although the sample sizes for these comparisons remain limited.
The World Health Organization (WHO) has defined "post COVID-19 condition," commonly referred to as "Long COVID-19," through a Delphi consensus, establishing a clinical case
Emerging evidence indicates that post COVID-19 conditions may be linked to several factors, including female gender, poor pre-pandemic mental health, general health issues, asthma, and being overweight or obese, while non-white ethnic minorities may experience some protective effects A cohort study highlights that neurological and psychological diagnoses are more prevalent among individuals who experienced severe COVID-19, characterized by hospitalization, intensive care treatment, and encephalopathy Additionally, meta-analyses reveal common post COVID-19 symptoms such as fatigue, dyspnoea, cough, sleep disturbances, anxiety, depression, cognitive impairment, and difficulty concentrating, with fatigue and concentration issues persisting beyond 12 weeks.
Variants of concern and severity of disease: At present, there are five variants of concern (VoC) recognized by WHO: Alpha, Beta,
The Omicron variant of COVID-19 has shown to be more transmissible than previous variants, such as Gamma and Delta, currently dominating the spread of the virus While initial analyses from the WHO and various countries indicate that Omicron may cause less severe disease and lower mortality rates, caution is necessary due to potential confounding factors like vaccination status and previous infections Despite these findings, nearly one-third of hospitalized Omicron patients experienced severe disease, and 15% succumbed to the illness, highlighting significant risks The variant's high transmissibility continues to strain healthcare systems worldwide, underscoring the urgent need for ongoing international efforts to combat the pandemic, particularly among vulnerable populations, including the elderly, those with multiple health issues, and the unvaccinated, who remain at risk for serious outcomes.
What triggered this version of the guideline?
The WHO's latest living guideline focuses on the rehabilitation of adults experiencing post COVID-19 condition This update is informed by a rapid living systematic review, along with a summary of indirect evidence related to other chronic health issues and a scoping review The recommendations were developed to provide essential guidance for planning rehabilitation programs, addressing the most common symptoms and impairments associated with post COVID-19 condition.
The WHO has appointed a new Guideline Development Group (GDG) consisting of 23 members, including 22 experts in clinical, methodological, and scientific fields, along with seven individuals who have experienced Post COVID-19 Condition The discussions were led by a methods chair with methodological expertise and a clinical chair with content expertise For more information, you can view the short bios of the GDG members through the provided link.
Methods
The initial versions of this document were created in collaboration with key organizations such as the International Forum for Acute Care Trialists (InFACT), the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), and the Surviving Sepsis Campaign 2019 These versions were also adapted from the previously published interim guidance on the clinical management of severe acute respiratory infections suspected to be caused by Middle East respiratory syndrome coronavirus (MERS-CoV).
The WHO Steering Committee expanded the scope of the third version (v3) of the COVID-19 clinical guideline to encompass the entire spectrum of the disease, including mild, moderate, and severe cases, as well as the complete patient care pathway from screening to rehabilitation A diverse Guideline Development Group (GDG) was assembled, featuring experts from various specialties and regions Due to the expedited timeline and broad scope, a formal GRADE process was not feasible for each recommendation Instead, the GDG drafted PICOs and synthesized published evidence through rapid systematic reviews coordinated by the Science Division The Steering Committee then formulated intervention recommendations based on these reviews, which were shared with the GDG prior to multiple meetings where consensus was reached Recommendations were communicated using symbols to indicate the direction and strength, rather than employing formal GRADE terminology.
The fourth to seventh versions (v4-v7) of the guidelines feature new recommendations based on established standards for trustworthy guidelines An innovative process has been implemented to enhance the efficiency of dynamically updating these recommendations, in accordance with the WHO Handbook for guideline development.
This living WHO guideline for the clinical management of COVID-19 is related to the Therapeutics and COVID-19: living guideline (71), also published in the BMJ (72) and available in MAGICapp
This guideline is designed to be reliable and adaptable, with updates made globally whenever new evidence necessitates changes in COVID-19 recommendations The goal is to provide a minimum of two updates annually, ensuring the guidelines maintain high standards of trustworthiness.
We outline a systematic approach to enhance the efficiency and timeliness of our reliable guidelines, focusing on the development and dissemination of recommendations This involves the simultaneous execution of various processes to ensure optimal results.
Step 1: Evidence monitoring and mapping and triggering of evidence synthesis
The WHO rapid review team, along with its network of collaborators, consistently monitors evidence on critical topics In February 2021, the WHO Steering Committee initiated the process to update guidelines, including the development of PICO The need to create or revise specific recommendations is driven by this ongoing evaluation of evidence.
For this seventh (V7), version, the guideline development has been based on 1 overarching PICO:
• Population: adult post COVID-19 condition population (WHO clinical case definition, ≥19 years old), disaggregated by age and gender
• Outcome: selected impairments, functioning outcomes (incl return to work), and system-level outcomes (cost-effectiveness, access, etc.)
The WHO selected members for the Guideline Development Group (GDG) to ensure diverse geographical representation, gender balance, and relevant technical and clinical expertise, including patient representatives The technical unit managed declarations of interests (DOIs) and confirmed that no GDG member had any conflicts of interest During the meeting, the WHO Secretariat explained the DOI process, allowing members to disclose any unreported interests; however, no verbal conflicts were declared Additionally, web searches revealed no further interests that could compromise the objectivity and independence of the GDG in developing recommendations.
The pre-selected expert GDG (see Acknowledgements) convened on October 20 2021 to address rehabilitation of adults with Post COVID-19 Condition guideline scope, priority outcomes and PICO
The WHO Rehabilitation Programme, in collaboration with the Quality Assurance of Norms and Standards (QNS) unit, initiated an independent systematic review, which included a summary of indirect evidence from Cochrane systematic reviews and a scoping review The Cochrane Rehabilitation systematic review team, comprising librarians, methodologists, and clinicians skilled in GRADE methodology, ensured the rigorous evaluation and rating of evidence certainty Additionally, the technical unit managed declarations of interests (DOIs) and confirmed that no team members had any conflicts of interest.
Cochrane Rehabilitation activities produced three key outputs, focusing on impairment-specific recommendations These included a comprehensive summary of evidence regarding rehabilitation interventions for selected impairments in post-COVID-19 conditions, assessed with GRADE certainty of evidence for all evaluated comparisons (see Annex 6) Additionally, a summary of evidence for rehabilitation interventions in other chronic health conditions was compiled, drawing from an overview of Cochrane resources.
The systematic review findings summarize evidence on post COVID-19 rehabilitation care, based on a systematic search of expert papers without GRADE certainty assessments Adhering to PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines, a data extraction and charting framework was created to map evidence across five topics, utilizing 12 signaling questions to synthesize rehabilitation care models A narrative synthesis of this evidence was presented to the Guideline Development Group (GDG) to aid in formulating recommendations.
The GDG panel members are responsible for the following critical activities:
• To advise on the priority questions and scope of guideline;
• To advise on the choice of important outcomes for decision-making;
• To comment on the evidence used to inform the guideline;
• To advise on the interpretation of the evidence, with explicit consideration of overall balance or risks and benefits;
• To formulate recommendations, taking into account diverse values and preferences according to GRADE
The GRADE approach serves as a framework for determining the certainty of evidence and formulating recommendations In cases where substantial indirect evidence supports a recommended action, good practice statements may be issued instead of formal recommendations, especially when gathering further evidence is impractical This process must maintain transparency and clarity, providing a solid rationale for the decisions made Although a priori voting procedures were prepared to address potential disagreements, they were ultimately unnecessary as the panel achieved consensus on the recommendations.
The following key factors were used to formulate transparent and trustworthy recommendations:
• absolute benefits and harms for all patient-important outcomes through structured evidence summaries (e.g GRADE summary of findings tables);
• quality/certainty of the evidence (73)(75);
• values and preferences of patients (76);
• resources and other considerations (including considerations of feasibility, applicability, equity) (76);
Each outcome will include an effect estimate and confidence interval, reflecting the certainty of the evidence, as shown in the summary of findings tables In cases where this data is unavailable, narrative summaries will be provided.
Recommendations will be classified as either conditional or strong based on GRADE criteria In cases where panel members have differing opinions on the evidence assessment or the strength of the recommendations, the World Health Organization (WHO) will implement a voting process following established methods.
Four consecutive GDG meetings were held to discuss key topics, including the presentation of evidence summaries, consensus discussions, and the alignment of intervention terminology with the WHO Package of Interventions for Rehabilitation, which is currently in development.
Recommendations for managing specific impairments in clinical rehabilitation were developed, recognizing that rehabilitation is usually multimodal and involves various interventions Consequently, the interventions included in these recommendations may not necessarily have been part of the evidence synthesis process.
Step 5: External and internal review
Who the recommendations apply to
The Clinical Management living guidelines offer valuable recommendations for all individuals involved in the care of COVID-19 patients, including clinicians, allied health professionals, and hospital administrators.
This guideline is applicable to all COVID-19 patients, with recommendations varying according to the severity of the disease as defined by the WHO These severity definitions are designed to ensure that patient subgroups are identified without depending on healthcare access.
WHO definitions of disease severity for COVID-19
Critical COVID-19 is characterized by conditions such as acute respiratory distress syndrome (ARDS), sepsis, or septic shock, which typically necessitate life-sustaining treatments These treatments may include mechanical ventilation, whether invasive or non-invasive, and vasopressor therapy to support vital functions.
• Severe COVID-19 – Defined by any of:
◦ oxygen saturation < 90% on room air;
Severe respiratory distress in adults is characterized by the use of accessory muscles, an inability to complete full sentences, and a respiratory rate exceeding 30 breaths per minute In children, signs include significant chest wall in-drawing, grunting, central cyanosis, and other critical indicators such as the inability to breastfeed or drink, lethargy, convulsions, or a reduced level of consciousness Recognizing these symptoms is crucial for timely medical intervention.
• Non-severe COVID-19 – Defined as the absence of any criteria for severe or critical COVID-19
The GDG cautioned that the oxygen saturation threshold of 90% for defining severe COVID-19 is arbitrary and should be interpreted carefully Clinicians need to apply their judgment when assessing low oxygen saturation levels, particularly in patients with chronic lung conditions, where such levels may not indicate severity Conversely, a saturation of 90–94% in patients with healthy lungs could signal an early stage of severe disease, especially if their clinical condition is deteriorating In uncertain situations, the GDG recommends leaning towards classifying the disease as severe.
The infographic illustrates these three disease severity groups and key characteristics to apply in practice
Infographic co-produced by the BMJ and MAGIC; designer Will Stahl-Timmins (see BMJ Rapid Recommendations)
Post COVID-19 condition affects individuals who have had a probable or confirmed SARS-CoV-2 infection, typically emerging three months after the onset of COVID-19 This condition is characterized by symptoms lasting at least two months that cannot be attributed to another diagnosis Symptoms can either appear anew after recovery from the acute phase of COVID-19 or persist from the initial illness According to the WHO clinical case definition, these symptoms may manifest as clusters or isolated issues, significantly hindering daily activities and social engagement Furthermore, symptoms can persist for extended periods and may experience relapses over time.
COVID-19 care pathway (see Annex 1)
We recommend that COVID-19 care pathways be established at local, regional and national levels COVID-19 care pathways are for persons with suspected or confirmed COVID-19
1 A person enters the COVID-19 care pathway after s/he is screened, based on a standardized case definition, including assessment of symptoms, and meets criteria for a suspect case
• Suspect cases may be referred to as “persons or patients under investigation” (PUIs) in some contexts
• Probable cases are suspect cases for whom testing for SARS-CoV-2 is inconclusive or not available
• Confirmed cases are persons with laboratory confirmation of infection with SARS-CoV-2 (molecular (NAAT/PCR) or antigen-detection test (i.e.Ag-RDT)
See Recommendations for national SARS-CoV-2 testing strategies and diagnostic capacities, Interim guidance June 2021 (77)
Individuals suspected, probable, or confirmed to be infected with SARS-CoV-2 must be promptly isolated to prevent the spread of the virus For detailed guidelines on infection prevention and control (IPC) measures, please refer to the chapter addressing the cohorting of these cases.
See Infection prevention and control during health care when coronavirus disease (COVID-19) is suspected or confirmed, Interim guidance
When developing the COVID-19 care pathway, it is essential to consider co-infections such as influenza, malaria, and tuberculosis, as well as chronic diseases Proper management of these conditions should align with established national or local protocols to ensure comprehensive patient care.
All suspected COVID-19 cases must undergo testing to confirm their status Until a negative result is obtained, these individuals should continue to follow the COVID-19 care pathway In instances where testing is unavailable, individuals may be classified as probable cases based on clinical assessment and should also receive care within the COVID-19 pathway.
The COVID-19 Clinical Care pathway should include the CARE principles: Confirm, Assess, Respond and Evaluate (79)
• Confirm SARS-CoV-2 infection: ensure prompt diagnosis using molecular (NAAT(PCR) or antigen-detection test (i.e.Ag-RDT)
Early clinical assessment is crucial for evaluating symptoms, risk factors, and severity in patients This process helps identify emergency signs that may require immediate treatment, clinical referral, or hospital admission.
• Respond with appropriate care and treatment: treatment selection is determined by severity of disease and risk factors
Effective evaluation of clinical response and recovery is essential for all patients undergoing COVID-19 treatment Continuous clinical monitoring and follow-up by healthcare professionals are crucial throughout the illness and recovery phases, particularly for those who experience post-COVID-19 conditions.
This section is under review and will be updated in the next iteration of the guidelines
Discontinue transmission-based precautions (including isolation) and release from COVID-19 care pathway as follows
1 Criteria for discharging patients from isolation (i.e discontinuing transmission-based precautions) without requiring retesting:
• For symptomatic patients: 10 days after symptom onset, plus at least 3 additional days without symptoms (including without fever and without respiratory symptoms)
• For asymptomatic cases: 10 days after positive test for SARS-CoV-2
Patients can be released from isolation based on the duration of their symptoms For instance, if a patient experiences symptoms for 2 days, they may be discharged 13 days after symptom onset (10 days plus an additional 3 days) In cases where symptoms persist for 14 days, the discharge would occur 17 days post-symptom onset (14 days plus 3 days) Similarly, a patient with symptoms lasting 30 days can be released 33 days after the onset of symptoms (30 days plus 3 days).
Countries have the option to maintain testing as a component of their release criteria, with the initial guideline suggesting the requirement of two negative PCR tests spaced at least 24 hours apart.
4 Some patients may experience symptoms beyond the period of infectivity See Chapter 24 Care of COVID-19 patients after acute illness
Countries must clearly define clinical pathways to monitor each patient through to full recovery, ensuring discharge criteria consider the patient's condition, disease experience, and other relevant factors.
Release from the COVID-19 care pathway differs from clinical discharge from a facility or ward, as some patients may need continued rehabilitation or care based on their clinical needs If release from the COVID-19 care pathway aligns with clinical discharge, it is essential to consider various clinical factors, including medication reconciliation, follow-up plans with healthcare providers, and a review of routine immunization status.
7 See scientific brief Criteria for releasing COVID-19 patients from isolation for more details (80)
Immediate implementation of appropriate infection prevention and control measures
This guidance consolidates infection prevention and control (IPC) technical recommendations established since the onset of the COVID-19 pandemic The IPC guidelines are presently undergoing a review, with an updated version expected to be released shortly.
For additional information please see the following links:
1 Infection prevention and control during health care when coronavirus disease (COVID-19) is suspected or confirmed (81)
2 Infection prevention and control in the context of coronavirus disease (COVID-19): A living guideline (in MAGICapp)
IPC measures for patients with suspected or confirmed COVID-19:
Health facilities must implement essential WHO-recommended infection prevention and control (IPC) measures, including proper respiratory etiquette and hand hygiene, as well as precautions for contact, droplet, and airborne transmission It is crucial to maintain thorough environmental cleaning and disinfection, ensure adequate ventilation, and provide isolation facilities for COVID-19 patients Additionally, whenever possible, a physical distance of at least 1 metre should be maintained among individuals in healthcare settings, particularly in indoor environments, with the goal of increasing this distance whenever feasible.
Apply standard precautions for all patients
To ensure safety during diagnostic and care services, it is essential to apply standard precautions based on risk assessment for all patients at all times These precautions encompass hand and respiratory hygiene, proper use of personal protective equipment (PPE), and universal masking in areas with known or suspected SARS-CoV-2 transmission Additionally, standard precautions involve appropriate patient placement, thorough environmental cleaning, prevention of needle-stick or sharps injuries, and effective waste management.
To ensure effective hand hygiene, frequently use an alcohol-based hand rub (ABHR) and wash hands with soap and water when visibly dirty, drying them with disposable towels It is essential to perform hand hygiene before and after using personal protective equipment (PPE) and whenever necessary during patient care, following the WHO's Five Moments for Hand Hygiene guidelines.
To ensure patient safety, use disposable or dedicated medical equipment such as stethoscopes, blood pressure cuffs, pulse oximeters, and thermometers If sharing equipment is necessary, it must be thoroughly cleaned and disinfected between each use Healthcare workers should avoid contaminating non-patient care surfaces, like door handles and light switches, and should not touch their face with potentially contaminated hands Routine cleaning and disinfection of all surfaces, particularly high-touch areas and those visibly soiled or contaminated with blood and bodily fluids, is essential.
Best practices for safely managing health care waste, including waste related to surgeries and obstetric care, should be followed
Screen for early recognition of suspected COVID-19 patients and rapid implementation of source control measures
Screen all persons at first point of contact in health facility to allow for early recognition followed by immediate isolation/separation
Patients suspected or confirmed to have COVID-19 should wear a medical mask and be placed in a separate, well-ventilated area, preferably an isolation room It is crucial to maintain a distance of at least 1 meter between patients All individuals must cover their nose and mouth with a tissue or their elbow when coughing or sneezing, dispose of tissues safely, and practice hand hygiene after contact with respiratory secretions In areas experiencing community transmission of COVID-19, visitor access should be limited to essential individuals, such as parents of pediatric patients and caregivers, who should also wear masks.
National regulations typically govern the necessary ventilation rates in healthcare facilities Effective environmental and engineering controls are essential for minimizing the concentration of infectious respiratory aerosols in the air, as well as for reducing contamination on surfaces and inanimate objects.
Mask use in health care facilities
The World Health Organization (WHO) advises the use of face protection as part of a comprehensive infection prevention and control (IPC) strategy to mitigate the spread of SARS-CoV-2 It is essential for national policies and health facilities to implement and sustain IPC measures, which should include an established IPC program or a designated, trained IPC focal point Key components of these measures involve engineering, environmental, and administrative controls, as well as standard and transmission-based precautions Additionally, effective screening and triage are crucial for the early identification of COVID-19 cases, alongside ongoing surveillance and vaccination efforts for health workers For detailed recommendations on mask usage in healthcare settings, please refer to the official guidelines.
Infection prevention and control in the context of coronavirus disease (COVID-19): A living guideline (in MAGICapp)
Isolate and cohort patients with suspected or confirmed COVID-19
Where possible, designate a team of health workers to care for patients with suspected or confirmed COVID-19 and restrict their contact with COVID-19 patients
For optimal safety, it is recommended to place all COVID-19 patients in well-ventilated single rooms whenever possible If single rooms are unavailable or the bed occupancy rate is expected to exceed 100%, suspected, probable, or confirmed cases should be cohorted in adequately ventilated spaces, ensuring that beds are at least 1 meter apart to minimize the risk of transmission.
Limit patient movement within the institution and ensure that patients wear medical masks when outside of their care area (e.g when being transported)
To ensure safety in healthcare settings, it is crucial to implement transmission-based precautions, including contact, droplet, and airborne measures, as necessary Before entering the room of a patient suspected or confirmed to have COVID-19, healthcare workers should utilize contact and droplet precautions In situations where aerosol-generating procedures (AGP) are conducted on such patients, these procedures must take place in well-ventilated areas, and appropriate personal protective equipment (PPE) such as N95 respirators or FFP2 masks should be worn.
Universal and targeted continuous masking
In areas of known or suspected community or cluster SARS-CoV-2 transmission, universal masking is recommended (very low certainty evidence) in health care facilities:
In healthcare facilities where non-COVID-19 patients are treated, it is essential for all personnel—including healthcare workers, community health workers, caregivers, staff, visitors, outpatients, and service providers—to consistently wear a well-fitting medical mask This guideline applies in all areas of the facility, including common spaces such as cafeterias and staff rooms, unless otherwise specified for specific procedures like aerosol-generating procedures (AGP).
Inpatients are generally not required to wear medical masks unless they cannot maintain a physical distance of at least 1 metre, such as during examinations or bedside visits Additionally, masks are necessary when patients are outside their care area, like during transportation, as long as they can tolerate wearing a mask and have no medical contraindications.
For full recommendations and additional details, see: Infection prevention and control in the context of coronavirus disease
(COVID-19): A living guideline (in MAGICapp)
In areas of known or suspected sporadic SARS-CoV-2 transmission, targeted continuous medical mask use is recommended (very low certainty evidence) in health care facilities:
In clinical settings for non-COVID-19 patients, health workers, including community health workers and caregivers, must consistently wear a well-fitting medical mask throughout their entire shift, except in specific situations such as during aerosol-generating procedures (AGPs) or while eating and drinking.
In non-patient areas, staff are not required to wear a medical mask during routine activities if they have no patient contact
For full recommendations and additional details, see: Infection prevention and control in the context of coronavirus disease (COVID-19): A living guideline (in MAGICapp)
Health workers are advised to wear a respirator or medical mask, along with additional personal protective equipment (PPE) such as gowns, gloves, and eye protection, prior to entering a room with a patient suspected or confirmed to have COVID-19.
For full recommendations and additional details, see: Infection prevention and control in the context of coronavirus disease (COVID-19): A living guideline (in MAGICapp)
Respirators should be worn in the following situations:
• In care settings where ventilation is known to be poor* or cannot be assessed, or the ventilation system is not properly maintained
• Based on health workers' values and preferences and on their perception of what offers the highest protection possible to prevent SARS-CoV-2 infection
Health workers involved in aerosol-generating procedures (AGP) on suspected or confirmed COVID-19 patients should consistently wear a respirator, along with other personal protective equipment (PPE) This is particularly crucial in settings like intensive care units, semi-intensive care units, and emergency departments where AGP are routinely performed.
*PPE includes gown, gloves, eye protection
For full recommendations and additional details, see: Infection prevention and control in the context of coronavirus disease (COVID-19): A living guideline (in MAGICapp).
Screening, triage and clinical assessment: early recognition of patients with COVID-19
The main goal of the global response to COVID-19 is to reduce transmission rates, identify and isolate suspected cases, and ensure timely and appropriate care for patients The location for treatment will vary based on the epidemiological situation, which may include designated COVID-19 health facilities, community centers, or home care when necessary For more information, refer to the WHO guidelines.
Operational considerations for case management of COVID-19 in health facility and community (1)
We recommend screening all persons at the first point of contact with the health system in order to identify individuals that have suspected or confirmed COVID-19
Screening for health conditions can be conducted in various settings, including emergency units, outpatient departments, community health clinics, and through telemedicine, while maintaining a safe distance of over 1 meter It is essential to utilize a straightforward set of questions based on the WHO case definition and to implement screening protocols at all health access points and during contact tracing efforts Special attention should be given to older adults and immunosuppressed individuals, as they may exhibit atypical symptoms such as fatigue, reduced alertness, decreased mobility, diarrhea, loss of appetite, delirium, and absence of fever Therefore, screening questions may need to be tailored to specific environments and guided by epidemiological factors.
Individuals exhibiting symptoms that align with the case definition for suspected COVID-19 should promptly enter the COVID-19 care pathway They must be provided with a medical mask and isolated in a single room If a single room is unavailable, patients with similar clinical diagnoses and epidemiological risk factors should be grouped together, ensuring at least 1 meter of spatial separation between them It is crucial that suspected cases are not placed in the same cohort as confirmed cases, as detailed in Chapter 7 on infection prevention and control (IPC).
In regions where endemic infections like malaria, dengue, and tuberculosis are prevalent, it is essential to screen febrile patients according to established protocols, regardless of any respiratory symptoms This approach is crucial as there is a possibility of co-infection with COVID-19.
When the influenza virus is suspected to be in circulation, it is essential to include it in the screening process for patients presenting with fever and influenza-like symptoms, following local testing protocols It is also important to consider the possibility of co-infection with COVID-19.
Large outbreaks of COVID-19 have been reported in long-term care facilities (LTCFs), necessitating the activation of the COVID-19 care pathway for all residents who are contacts of confirmed cases This includes immediate isolation, testing, and treatment as required The primary focus in LTCFs should be on safeguarding residents' well-being and protecting healthcare workers, alongside implementing clinical management and infection prevention and control (IPC) measures tailored to individual conditions and prognoses, such as screening visitors for COVID-19.
Existing prognostic models are reviewed in a living systematic review, available at https://www.covprecise.org/living-review/
Available prognostic models need to be validated in other populations
Community health workers must adhere to established protocols for identifying and treating common illnesses and warning signs while implementing the COVID-19 care pathway for suspected cases It is essential to consult the guidance provided by WHO, IFRC, and UNICEF on community-based healthcare, which includes outreach efforts and campaigns during the COVID-19 pandemic.
At a health facility, it is essential to screen and isolate patients suspected of having COVID-19, followed by triaging them with a standardized tool like the WHO/IFRC Interagency Integrated Triage Tool This process includes evaluating the patient to assess the severity of the disease.
• Initiate timely care for the acutely ill using a systematic approach, as described in WHO/ICRC Basic emergency care (93)(94)
Following the initial assessment and stabilization of the patient, it is essential to refer them to the appropriate COVID-19 care destination based on their medical needs This may involve transferring the patient to a critical care unit or ward within the same health facility, directing them to a different health facility, utilizing a community facility, or sending them home, all in accordance with established COVID-19 care pathways.
Patients with mild to moderate illness typically do not need emergency interventions or hospitalization; however, isolation is essential for all suspected or confirmed cases to prevent virus transmission The choice to monitor a suspected case in a healthcare facility, community setting, or at home should be individualized, taking into account the patient's clinical presentation, need for supportive care, potential risk factors for severe disease, and the home environment, particularly the presence of vulnerable individuals Additionally, in cases where tuberculosis may be present, further specific measures may be required.
Early identification of patients at risk for severe COVID-19 enables prompt initiation of optimized supportive care and ensures safe, swift referral to specialized facilities within the COVID-19 care pathway, where access to oxygen and respiratory support is available.
Risk factors that contribute to rapid deterioration, severe disease, and increased mortality include older age (over 60 years) and non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, chronic lung disease, cancer, and cerebrovascular disease Patients with these risk factors should be closely monitored for any signs of deterioration, ideally within a healthcare facility The decision regarding monitoring location—whether in a health facility, community center, or home—should be individualized based on clinical presentation, need for supportive care, risk factors, and home conditions, especially the presence of other vulnerable individuals In pregnant women, risk factors for severe disease encompass advanced maternal age, high body mass index (BMI), non-white ethnicity, pre-existing health conditions, and pregnancy-related issues like gestational diabetes and pre-eclampsia.
4 Some patients develop severe pneumonia and require oxygen therapy, and a minority progress to critical disease with complications such as respiratory failure or septic shock (see Table 6.3) (97)(98)
5 COVID-19 confirmation needs to be made prior to determining severity; particularly in children, for whom the differential diagnosis for respiratory distress is particularly important
Children suspected or confirmed to have COVID-19 should be cared for alongside their caregivers, provided the caregivers also have the virus It is essential to create child-friendly environments that address the unique medical, nursing, nutritional, and mental health needs of these children.
For patients with COVID-19 of varying severity in clinical or hospital settings, we recommend using clinical judgment, taking into account patients' values, preferences, and applicable local and national policies, to inform management decisions regarding hospital and ICU admissions This approach is favored over existing prediction models for prognosis, given the very low certainty associated with them.
Clinical judgment and established policies, whether at the local or national level, play a crucial role in determining the admission of COVID-19 patients to hospitals and intensive care units (ICUs) These judgments and policies often incorporate ethical considerations related to the allocation of resources and care.
Laboratory diagnosis
This guidance brings together diagnostic technical guidance developed and published since the beginning of the COVID-19 pandemic
1 Antigen-detection in the diagnosis of SARS-CoV-2 infection (109)
2 Use of SARS-CoV-2 antigen-detection rapid diagnostic tests for COVID-19 self-testing (110); and
3 Diagnostic testing for SARS-CoV-2 interim guidance regarding specimen collection, processing and laboratory testing and the diagnostic algorithm (111)
We recommend, for all suspect COVID-19 cases, at minimum the collection of respiratory specimens for nucleic acid amplification testing (NAAT) for example reverse transcription polymerase chain reaction (RT-PCR)
Repetitive testing of the upper and lower respiratory tracts may be necessary for accurate COVID-19 diagnosis Additional diagnostic samples, such as validated faecal specimens, can also be useful In cases involving deceased individuals, postmortem specimens should be collected Furthermore, testing for other respiratory viruses and bacteria should be conducted as per local clinical guidelines when indicated.
SARS-CoV-2 antibody tests are not recommended for diagnosis of current infection with COVID-19
When collecting specimens, it is essential to wear the correct personal protective equipment (PPE) to ensure safety and compliance with infection prevention and control (IPC) guidelines For upper respiratory tract (URT) specimens, implement droplet and contact precautions, while airborne precautions are necessary for lower respiratory tract (LRT) specimens Always refer to the latest IPC guidelines, including chapter 5, for the most current recommendations.
In the initial week after symptom onset, high viral loads are typically detected in upper respiratory tract (URT) specimens For optimal URT sample collection, we recommend obtaining nasopharyngeal and oropharyngeal specimens using viral swabs made of sterile Dacron or rayon, avoiding cotton When performing nasopharyngeal swabbing, it is essential to use a swab with a long, flexible shaft specifically designed for this purpose For detailed guidance on proper URT sampling techniques, refer to the Clinical Care for Severe Acute Respiratory Infection Toolkit.
COVID-19 adaptation (94) Unless specified differently by the receiving laboratory, transport sample in viral transport media
LRT samples are more likely to yield positive results after the first week of illness, so if URT samples are negative but clinical suspicion persists, it's advisable to collect specimens from the LRT, such as expectorated sputum or endotracheal aspirate/bronchoalveolar lavage in ventilated patients Clinicians may choose to focus solely on LRT samples when they are readily available, particularly in mechanically ventilated patients It is important to avoid sputum induction due to the heightened risk of aerosol transmission.
In cases of COVID-19, particularly when pneumonia or severe illness is present, a single negative upper respiratory tract (URT) sample does not rule out the diagnosis; therefore, additional URT and lower respiratory tract (LRT) samples are advised For hospitalized patients with confirmed COVID-19, repeated sampling of URT and LRT can be performed as clinically necessary, although such testing is no longer required for the cessation of COVID-19 precautions.
4 NAAT testing is the reference method for the diagnosis of COVID-19 However, antigen testing can be used to diagnose current
In situations where NAAT is unavailable or turnaround times are prolonged, COVID-19 antigen testing can be crucial for timely diagnosis For detailed guidance on the effective use of antigen tests for diagnosing SARS-CoV-2 infection, refer to the interim guidelines on antigen detection.
When utilizing antigen testing for COVID-19, it is crucial to follow the manufacturer's instructions for sample collection and testing, ensure that staff are properly trained, and integrate quality assurance within a national testing program Antigen rapid diagnostic tests (Ag-RDTs) can also be employed for self-testing by individuals A positive result from a self-test indicates a likely COVID-19 infection, whereas a negative result does not eliminate the possibility of infection For further information, refer to the interim guidance on the use of SARS-CoV-2 antigen-detection rapid diagnostic tests for self-testing.
In cases where a patient strongly suspected of having COVID-19 receives repeated negative NAAT/RT-PCR results, it is advisable to collect paired serum specimens—one during the acute phase and another 2–4 weeks later during the convalescent phase This approach is effective only if validated (semi) quantitative serology assays and trained personnel for interpretation are available in the laboratory Analyzing these paired samples can help determine seroconversion or an increase in antibody titres, thereby reinforcing the likelihood of recent COVID-19 infection despite negative NAAT results.
Depending on the local epidemiology and clinical symptoms, test for other potential etiologies (e.g influenza, malaria, dengue fever, typhoid fever) as appropriate
Patients should be tested for various respiratory pathogens as per local clinical management guidelines, which may include viral infections such as influenza A and B, respiratory syncytial virus, parainfluenza viruses, rhinoviruses, adenoviruses, enteroviruses like EVD68, human metapneumovirus, and endemic coronaviruses (HKU1, OC43, NL63, 229E) Additionally, bacterial pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, and atypical respiratory pathogens like Legionella pneumophila and Coxiella burnetii should also be considered based on epidemiological and clinical factors.
Chlamydia psittaci or pneumoniae, Mycoplasma pneumoniae) URT and LRT specimens are generally suitable for viral respiratory pathogens For bacterial culture sputum or other LRT specimens are required
Dual infections with various respiratory pathogens—viral, bacterial, and fungal—have been observed in COVID-19 patients, indicating that a positive test for a non-COVID-19 pathogen does not exclude the possibility of COVID-19 infection Additionally, certain microbes identified in respiratory cultures may either be pathogenic or part of the normal flora of the mouth and respiratory tract Therefore, it is crucial to assess whether a detected microorganism represents a co-infection or is simply a component of the normal flora on a case-by-case basis.
In malaria-endemic regions, patients presenting with fever should undergo testing for malaria and other potential co-infections using validated rapid diagnostic tests (RDTs) or thick and thin blood films Additionally, arbovirus infections such as dengue and chikungunya should be considered, especially in cases of undifferentiated febrile illness accompanied by thrombocytopenia It is important to note that co-infection with the COVID-19 virus can occur; therefore, a positive dengue test does not rule out the need for COVID-19 testing If tuberculosis (TB) is suspected, sputum samples should be collected in a well-ventilated area, preferably outside, to minimize transmission risk, and staff should maintain a safe distance during the collection process.
When the influenza virus is suspected or confirmed in the community, it is crucial to test patients with severe illness or those at high risk, including young children and postpartum women, using rapid molecular tests that provide results within 24 hours Delays in testing can diminish the effectiveness of clinical management, so it is essential to initiate empiric treatment without waiting for test results.
For COVID-19 patients with severe or critical disease, also collect blood cultures, ideally prior to initiation of antimicrobial therapy (107)
If blood cultures cannot be taken timely before the administration of antimicrobial therapies, indicate the details of administered antibiotics on the laboratory request
COVID-19 self-testing, using SARS-CoV-2 Ag-RDTs, should be offered in addition to professionally administered testing services (low to moderate certainty evidence)
For full recommendations and additional details, see: Use of SARS-CoV-2 antigen-detection rapid diagnostic tests for COVID-19 self- testing (110)
COVID-19 self-testing is a personal choice that enhances access to testing, allowing individuals to make informed decisions regarding their health and the well-being of their families and communities It is essential that self-testing remains voluntary and free from stigma or discrimination Individuals must receive adequate guidance on when to test and their responsibilities following a test Those unsure of their results should seek professional testing options as per national guidelines Additionally, countries should reevaluate consent policies to facilitate COVID-19 self-testing for adolescents and mature minors, ensuring they can access testing without parental consent when necessary.
The implications of COVID-19 test results are influenced not only by their sensitivity and specificity but also by the prevalence of SARS-CoV-2 in the tested population In high pre-test probability environments, such as areas with active community transmission or among individuals at high risk of exposure, the positive predictive value of self-testing is elevated, indicating that a positive result is likely to be accurate Conversely, in low pre-test probability scenarios, such as testing asymptomatic individuals with no known exposure, the positive predictive value decreases, resulting in a higher likelihood of false positives However, in these low-risk situations, the negative predictive value remains high, significantly reducing the chances of false negatives.
Effective implementation of COVID-19 self-testing relies on health worker and community awareness and engagement As local epidemiological conditions evolve, it is essential to provide context-specific, accurate, clear, concise, and age-appropriate information about self-testing Messaging should clarify when self-testing is prioritized or deprioritized for particular populations or settings, explain the implications of positive or negative results, and outline recommended follow-up actions While messages may differ based on local circumstances, they must align with national policies to ensure consistency.