COVID-19 Clinical Practice Guidelines Hadhramout Initiative Against Corona Group (HIAC Group)

Abdulla A. Baradwan, Khalid H. Ba-Msahell, Iman A. Ba-Saddik, Ibrahim Albakri, Hassan O. Batis, Ahmed Babiqai, Ahmed Al habshi, Shaker Bajaber, Ahmed M. Badheeb (HIAC Clinical Scientific Committee) Abstract Hadhramout Initiative Against Corona (HIAC ) formed a working group of clinicians relevant to the management of COVID-19 to formulate clinical practice guidelines (CPG) for clinicians caring for the patients infected with COVID-19 in Yemen. The regional guidelines on the management of COVID-19 were thoroughly reviewed and its applicability was assessed for Yemen. HIAC’s recommendations covered (2) sections: the first one is the diagnosis, including case definition, risk stratification of the affected cases, investigations (prioritization of reverse transcription-polymerase chain reaction (RT-PCR) testing, D-dimer, chest x-ray, and chest computed tomography, while the second part covers the treatments (mainly Favipiravir, Remdesivir, Hydroxychloroquine, and Glucocorticoid, Anticoagulants, and Supportive measures).


Introduction
On March 11th, 2020, the World Health Organization (WHO) declared CoronaVirus Disease 2019 (COVID-19) a pandemic. Given the current global public health threat and economic impact, it is of paramount importance to urgently move and work towards rapid diagnosis, therapeutic measures, and management on discharge. In Yemen, the identification of public health risks and prioritization of resources are still uncertain, a few public hospitals and medical wards together with isolation units have been designated to receive patients. Fear is increasing among healthcare staff due to the lack of personal protective equipment and the massive shortage of equipment and medicines. This article is presented as a possible cost-effective guideline designed for Yemen, aiming to standardize the management of the COVID-19 patients based on the best available evidence. • Strict Home isolation for 10 days after onset of symptoms, plus at least 3 days without symptoms (fever and respiratory symptoms). • High-risk group patients should be monitored closely and may require hospitalization due to the risk of rapid clinical deterioration. • Adequate nutrition and appropriate hydration.
• Symptomatic treatment: Paracetamol is the preferred antipyretic agent for fever and pain. • Azithromycin can be used as an immune-modulatory agent for only 5 days duration.
• Other Antibiotics are not recommended for therapy or prophylaxis in patients with mild or moderate COVID-19 unless there is a clinical suspicion of a bacterial infection.

PCR Confirmed Cases
Asymptomatic patient Individuals who test positive for SARS-CoV-2 by using a molecular diagnostic test (e.g. polymerase chain reaction) or antigen test, but have no symptoms.
• Strict Home isolation for 10 days after a proven positive test.
• Adequate Nutrition and Appropriate Hydration.
• No need for specific treatment.

Mild to Moderate infected patient
Patient with any of the various symptoms and signs of COVID 19 but without dyspnea and SpO2 ≥ 94% on room air at sea level but does not require O2 supplementation.
Symptomatic meeting the case definition for COVID-19, but do not require O2 supplementation.
▪ Strict home isolation for 10 days after symptom onset, plus at least 3 days without fever and respiratory symptoms.
▪ Unless High-risk group patients should be monitored closely and may require hospitalization due to the risk of rapid clinical deterioration.
▪ Adequate Nutrition and Appropriate Hydration. ▪ Symptomatic treatment: o Paracetamol is the preferred antipyretic agent for fever and pain ( o Azithromycin is used as an immune-modulatory agent for only 5 days duration. o Other Antibiotics are not recommended as therapy or prophylaxis for patients with mild or moderate COVID-19 unless there is clinical suspicion of bacterial infection.

Severely infected patients
• Symptomatic patient meeting the case definition for COVID-19, with ≥ 1 of the following signs: Respiratory rate ≥30/min (adults), ≥40/min (children < 5 years), Oxygen saturation 'SpO2' < 94%, Partial pressure of oxygen/Fraction of inspired oxygen (PaO2/FiO2) ratio < 300 mmHg and/or Lung infiltrates >50% and requires O2 supplementation. • Strict Hospital Isolation and decision for Intensive Care Unit (ICU) admission taken by ICU team. • Oxygen supplementation either by nasal prong, face mask, venturi mask, or face mask with reservoir bag to reach target SpO2 ≥ 94%. Once the patient is stable, target 'SpO2' is > 90%; while in pregnant women target oxygen saturation is ≥ 92 -95%. • Consider an awake prone position for a spontaneously breathing patient.
• Adequate Nutrition and Appropriate Hydration.
• Symptomatic treatment: Paracetamol is the preferred antipyretic agent for fever and pain (Adjust the dose in patients with hepatic impairment).  Criteria for high-risk patients at risk for developing cytokine storm: 1 or more of the following: ▪ Serum IL-6 ≥ 3 x upper normal limit ▪ Ferritin > 300ug/L with double the level within 24 hours. ▪ Ferritin > 600ug/L at presentation and LDH > 250. ▪ Elevated D-dimer (>1 mcg/mL). Do not stop Angiotensin-converting enzyme inhibitors/Angiotensin receptor blockers ACEI/ARBs or aspirin in a patient who is already on its use Anticoagulant: Thromboprophylaxis Recommendations: • All admitted patients should be evaluated upon admission, and daily thereafter for both risks of thrombosis and bleeding. • Laboratory evaluation and monitoring: Baseline CBC, PT, aPTT on admission'' and CBC should be done serially twice weekly.
• If the patient is on heparin infusion, then it is advised to do aPTT according to the given protocol. • Direct oral anticoagulant (DOAC) is an alternative therapy for patients who do not prefer to use injections, especially those who are treated on an outpatient basis. • Antiplatelet medications are not recommended to be used as prophylaxis.
• Thromboprophylaxis should be continued until the time of discharge or if the patient becomes asymptomatic. • Patients with Heparin-induced thrombocytopenia (HIT), please follow HIT standard institutional protocol for alternative anticoagulation. • D-Dimer is not currently available in Hadhramout public governorate hospitals and with quite an expensive cost price of the test in private health care centers; thus the following advice is adopted to be undertaken locally.

Tocilizumab
Early use of IL6 in cytokine storm equipment such as intensive care unit beds, oxygen, ventilators, personal protective equipment, essential medicines, laboratory supplies, and reagents.
In response to the above gaps, HIAC deployed a technical team to support the local health authority to enhance the clinical management practices in the country. Several virtual scientific meetings were held for physicians working in isolation units taking care of COVID-19 patients as well as on infection prevention and control measures. The trainees work at different departments, including intensive care units and emergency and internal medicine departments in all designated locations of the southern governorates. The discussion was based on regional and international CPGs and recommendations, as well as preparing for the discussion of the readiness for the different waves of the pandemic.
Challenges remain in the areas of surveillance, laboratory testing, reporting, community engagement, and case management, due to a long-standing conflict in the country. After 3 months of the weekly meetings, the group ended up with this protocol for the COVID-19, which will be submitted to the national COVID-19 task force before disseminating this CPGs to all health care workers.

Conclusions
HIAC guidelines are following the current evidence and cost-effective management to improve the outcome of Covid's victims, so as to safeguard and protect health in low-income countries.