National Dmat

Guidance on the clinical management of 2019 NCoV

Training Manual

February 7 ,2020

THIS TRAINING MANUAL WAS PREPARED BY NATIONAL DMAT. February 07, 2020
Contents
Preface......................................................................................................................................................................................................................... 3
Authors........................................................................................................................................................................................................................ 4
Introduction –Prepared by Dr. Yared........................................................................................................................................................................... 5
2019-nCoV infection Pre- hospital case management - Prepared by Dr. Assefu..........................................................................................................6
IPC measures........................................................................................................................................................................................................... 7
PP equipment.......................................................................................................................................................................................................... 8
Triage and treatment format suspected of 2019-nCoV infection..........................................................................................................................11
Emergency department management - Prepared by Dr. Hayot and Yared................................................................................................................12
PATIENT FLOW....................................................................................................................................................................................................... 12
CASE MANAGEMENT............................................................................................................................................................................................. 18
Equipment required in the treating areas..............................................................................................................................................................22
ICU Management for 2019-nCov case - Prepared by Dr. kirubel,Pr. Aklilu, Dr, Aschalew..........................................................................................24
ICU Setup............................................................................................................................................................................................................... 24
Admission Criteria.................................................................................................................................................................................................. 24
Specific management............................................................................................................................................................................................. 27
Ethical considerations for the 2019 NCoV – Dr. Eyob,Dr. Sesen, Sr. Selam................................................................................................................35
Preface

This manual is designed for 2019 Novel Corona Virus preparedness and clinical management. Training programmed for DMAT members and
stakeholders. It aims at assisting in training DMAT and stakeholders in different levels to enable them to prepare for 2019 NCoV management
plans, respond in both in pre hospital and facility level. It also provides guidance on effective communication, coordination, collaboration and
cooperation in performing roles and responsibilities in times of disaster in order to build community resilience and ensure that impacts are
minimized by an efficient and effective disaster response.

The manual is organized into 05 modules. Module One is on the introduction. The second module focuses on prehospital preparedness and
response for the 2019 NCoV. The third module deals with emergency facility preparedness and response for the 2019 NCoV. Module Four is on
the critical care approach to the preparedness and response for the 2019 NCoV. The fifth module is on ethical issues regarding the 2019 NCoV.
Authors

Modules Authors: Email:

First document prepared by Dr. WoldesenbetWaganew woldegessam@gmail.com

Module 1: Introduction Dr. Yared Boru

Module 2: Prehospital Dr. Assefu W/Tsadik Assefu2000@gmail.com

Module 3: Emergency facility Dr. Yared Boru yaredboru@gmail.com

Dr. Hywet Engida hywtengida@gmail.com

Module 4: Critical Care Pr. Aklilu akliluem@gmail.com

Dr. Kirubel Abebe kirunel4@gmail.com
Dr.Aschalew
Module 5: Ethical Issues Dr. Eyob Zeryihun e.zerbz@gmail.com
Dr. Sesen Tsegaye sesentsegaye@gmail.com
Sr. Selam Tigistu selyob@gmail.com
Module 1: Introduction
Severe acute respiratory infection remains one of the leading causes of mortality around the world . A recent cluster of pneumonia
cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). It has been recognized as
global public health emergency by WHO after cases had started to be seen outside china. Ethiopia is listed by WHO under countries
with high risk of acquiring the infection due to frequent flight from affected area. This will further worsen countries situation to handle
the burden once case is identified. It is critical that countries step up their readiness and in particular put in place effective screening
mechanisms at airports and other major points of entry. (WHO)

After the report of the first case in Wuhan City, Hubei Province, China on December 31, 2019, new cases are being reported from
different area around the world. Resulting in, 31,481 confirmed cases and 638 deaths to date. (7th Feb2020, CDC). To minimize the
exposure to and transmission of 2019-ncov, infection prevention and control measures should be implemented systematically based on
the standard, contact, and droplet precautions. Effective initial screening of patients by visual triaging has a crucial role in isolating
patients that can potentially transmit infections to other patients or healthcare professionals.

This treatment guideline encompasses principles of infection prevention and control, starting from the scene up to patient discharge
and safe burial system if patient died. Management of critically ill patients, in wards and ICU has been discussed as per guideline.
Ethical considerations regarding safety of health professionals and bioethics have been included. Due to limited information available
about 2019-nCoV regarding the diagnosis, duration of shedding, disease severity and transmission, the guide line will be revised and
updated as more information becomes available. All healthcare facilities must ensure that health professionals are well trained and
able to implement infection control procedures and disease management.
Module 2 :2019-nCoV infection Pre- hospital case management
EOC, Emergency dispatch: Pre hospital emergency care involves activation of the EOC or Dispatch center, and these centers should
have three digit or four digit communication devices for the public access and cell phones or Walky-talky for communication with
ambulance crew. Health education on how, when to use this communication system should give regularly and continuously.The EOC
pre-hospital focal person or the dispatcher completes the dispatch documentation using pre prepared format and if the information
given fulfills the case definition, he/she contacts the BLS or ALS ambulance crew according the severity of case, and gives order
where to take the case, and subsequently informs the receiving health facility on the incoming suspect or case. The EOC should have
separate dedicated ambulances for the cases, and equip the ambulances with IPC, supportive and resuscitation equipment and supplies
according the ambulance level and IPC protocol.

Ambulance crew:The ambulance crew, maintains PPE&IPC, at all times, (before, during and after handling of cases or suspects).
Conducts triage and treatment at the scene and during transportation. Every care and treatment given should be documented on the
triage &treatment format, when necessary he/she should contact the designated receiving health facility for help or to update the
condition of the case. Finally the ambulance crew should handover patients with verbal and written communication and maintains
documents properly and report as per the national guideline. When suspected patient is transported to quarantine or designated
hospital the hand over should be with precaution so, for this purpose:

 Pre arrival communication should made, then

 well prepared with use of PPE, staff approaches the ambulance
 patient handover with verbal & written document
 ambulance crew remains in the ambulance
 proper discard or disinfect all used PPE (mask, gown, face or eye covers, gloves )before going out of ambulance
 disinfect the ambulance
Triage: use PPE at all times.Give suspect or patient a medical mask and when there is more than one suspectdirect patient to
separate area, an isolation room if available. Keep at least 1 meter distance between suspected patients and other patients. Instruct all
patients to cover nose and mouth during coughing or sneezing with tissue or flexed elbow for others. Perform hand hygiene after every
contact with respiratory secretions.

Transportation: Prepare ambulance equipment for every shift and following every use, handle equipment according IPC, Check
Equipment using checklist following every use, Continue patient treatment and care during transportation and Handover to receiving
institution with Verbal and Written format.

Governance: at the EOC there should be a prehospital focal person that lead and monitor the activities are going according the
guideline.

M& D: all cases handled with suspicion of corona virus will have proper documentation at all level; (dispatch or EOC, ambulance
service)and handover to health facilities. 24hrs activity report will be submitted to the pre hospital EOC focal person

IPC measures

1. Hand hygiene according IP protocol (use hand sanitizer before and after touching of cases, hand washing with soup for at least
20min), avoid touching doors, equipment, with used gloves
2. Proper uses of PPE –
2.1 Droplet precautions: Use a medical mask if working within 1-2 meters of the patient. Place patients in single rooms, or
group together those with the same etiological diagnosis. If an etiological diagnosis is not possible, group patients with similar
clinical diagnosis and based on epidemiological risk factors, with a spatial separation. When providing care in close contact
with a patient with respiratory symptoms (e.g. coughing or sneezing), use eye protection (face-mask or goggles), because
sprays of secretions may occur. Limit patient movement within the institution and ensure that patients wear medical masks
when outside their rooms.
2.2 Airborne precautions:when performing an aerosol generating procedure; i.e. open suctioning of respiratory tract,
Intubation, CPR) use PPE, including gloves, long-sleeved gowns, eye protection, and N95.
 2.3 Contact precautions: transmission from contact with contaminated surfaces or equipment (i.e. contact with contaminated
oxygen tubing/interfaces). Use PPE (medical mask, eye protection, gloves and gown) when entering room/ambulance and
remove PPE when leaving. If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood pressure cuffs
and thermometers). If equipment needs to be shared among patients, clean and disinfect between each patient use. Ensure that
you and your colleagues refrain from touching eyes, nose, and mouth with potentially contaminated gloved or ungloved hands.
Avoid contaminating environmental surfaces that are not directly related to patient care (e.g. door handles and light switches).
Ensure adequate room/ambulance ventilation. Avoid movement of patients or transport. Perform hand washing regularly.
3. Disinfection of reusable contaminated materials
3.1 Disinfect reusable equipment’s such as Bag Valve Mask, Laryngoscop, magil forceps, BP apparatus with 10%
sedexberekina
3.2 Cover o2 cylinder and gage with plastic and dispose after every use in collecting bag
3.3 Disinfect the ambulance with chemical spray and ventilate

4. waste management
4.1 There should be waste disposal center for every contaminated material
4.2 keep every contaminated material in plastic bag
4.3 keep sharp materials separate in safety box
4.4 Disinfect and clean the ambulance after every use

PP equipment

Item Purpose How to use How/ when to dispose

N 95 mask Droplet infection prevention 1for every case

Safety Goggle Droplet infection prevention 1for every case

Plastic Face Droplet infection prevention 1for every case

shield

Isolation gown Prevention from body fluids 1for every case

Surgical head Prevention from secretion of 1for every case

cover body fluids

Boots Prevention from body fluids Disinfect

Surgical glove Prevention from body fluids 1for every case

Hand sanitizer Prevention of cross infection

Safety box

Waste disposal
plastic
Waste disposal
points

Supportive &Resuscitation equipment &supplies

Item Specification Quantity How to handle &dispose

O2 cylinder 2for each ambulance

O2 gage 2for each ambulance

O2 flow meter 2for each ambulance

O2 delivery face 10,000

mask

O2 delivery nasal 10,000

cannula

Ambu bag (BVM) 2for each ambulance Some Ambu bags can be
different size, with sterilized in an autoclave at
different face 134° C or 272° F.
masks Otherwise, it must be
sterilized through the use
of the
recommended disinfectan
t solution. Glutaraldehyde
2% is an appropriately
high-level disinfectant;
the bag must be immersed
in the solution for at least
20 minutes.

NIV- CPAP/BiPAP 2for each ambulance Recommended disinfecta

with tight feting nt solution.
mask &strips Glutaraldehyde2% is an
appropriately high-
level disinfectant; at least
20 minutes.

Manual/ electrical 2for each ambulance

suction machine

Suction tube 10,000 Discard

different size

Transportation MV 2for each ambulance

Oro-pharyngeal 10,000 Recommended disinfecta

airway nt solution. Glutaraldehyde
2% is an appropriately
 high-level disinfectant;at
least 20 minutes.

Naso-pharyngeal 10,000 recommended disinfectan

airway t solution. Glutaraldehyde
2% is an appropriately
high-level disinfectant;at
least 20 minutes.

Automated ECG 2for each ambulance Clean after every use the
monitor surface using antiseptics
with(BP,P,Sao2,
ECG, ECO2, T,RR)

Laryngoscop with 2 box for each ambulance

different size blades

ETT different size 1000

Bugi 2for each ambulance

Stylet 2for each ambulance

Adhesive plaster 2for each ambulance

Bandage 2 packs for each ambulance

Gauze 2 packs for each ambulance

Syringe different 20 for each ambulance

size

IV canola 20 for each ambulance

Antipyretic drugs

Triage and treatment format suspected of 2019-nCoV infection

1. Date …………., time…………… service given

2. Name of the patient …………………………………….
3. Age ………………., sex……………………….
4. Does the patient have acute respiratory infection symptoms? Yes……., no……
5. If yes select from the listed below
 4.1 Fever,
4.2 Cough,
4.3 sneezing
6. Does the patient have travel history? Yes………, No…….., If yes

a. Close contact with a confirmed or probable case of 2019-nCoV in the 14 days prior to illness onset, Yes
……………., No…………………..
b. visiting or working in a live animal market in Wuhan, Hubei Province, China in the 14 days prior to symptom
onset, Yes……………….., No………………
c. Worked or attended a health care facility in the 14 days prior to onset of symptoms where patients with hospital
associated 2019-nCov infections has been reported.
7. Suspect corona virus with any acute respiratory illness AND at least one of the above
8. Apply all IPC precautions for corona virus
9. VS: BP……………………, P……………….., RR…………………, Sao2………………, T………………,
10. Treatmentgiven……………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………..
11. Pre arrival call to receiving institution: yes …………………, No……………….
12. Time ………..and date …………………..transfer to ……………………..health facility/ quarantine area
13. Handover by ………………………………, signature ………………..
14. Accepted by …………………………………….., signature …………….

Module 3: Emergency department management

PATIENT FLOW
1.1 Non Quarantine health facility ED
1.1.2 Pre triage screening :
  Pre triage screening area: Recognize and sort all patients with SARI at first point of contact with health care
system and Consider nCOV as a possible etiology of SARI under certain conditions (see Table 1). Follow the
algorithm 1 for every patient.
 Every health facility should have a pre triage screening area to screen out basic things with history while taking
vital sign and feel up a proper format.( format should be prepared and available in each facility)
 Immediate implementation of appropriate IPC measures
 IPC is a critical and integral part of clinical management of patients and should be initiated at the point of
entry of the patient to hospital. Standard precautions should always be routinely applied in all areas of
health care facilities. Standard precautions include hand hygiene; use of PPE to avoid direct contact with
patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin. Standard
precautions also include prevention of needle-stick or sharps injury; safe waste management; cleaning and
disinfection of equipment; and cleaning of the environment.
 At pre-triage screening area give suspect patient a medical mask and direct patient to an isolation room.
Keep at least 1 meter distance between suspected patients and other patients. Instruct all patients to cover
nose and mouth during coughing or sneezing with tissue or flexed elbow for others. Perform hand hygiene
after contact with respiratory secretions.

 Design of the area

 Equipment for this area
 Human capacity and dressing code

SARI

An ARI with history of fever or measured temperature ≥38 C° and cough; onset within the last ~10 days; and
requiring hospitalization.5 However, the absence of fever does NOT exclude viral infection.6
 A. Patients with severe acute respiratory infection (fever, cough, and requiring admission to hospital), AND with
no other etiology that fully explains the clinical presentation1 AND at least one of the following:
 A history of travel to or residence in the city of Wuhan, Hubei Province, China in the 14 days prior to
symptom onset, or
 Patient is a health care worker who has been working in an environment where severe acute respiratory
infections of unknown etiology are being cared for.

Surveillance case B. Patients with any acute respiratory illness AND at least one of the following:
definitions for 2019-  Close contact2 with a confirmed or probable case of 2019-nCoV in the 14 days prior to illness onset, or
nCoV*  Visiting or working in a live animal market in Wuhan, Hubei Province, China in the 14 days prior to
symptom onset, or
 Worked or attended a health care facility in the 14 days prior to onset of symptoms where patients with
hospital-associated 2019-nCov infections have been reported.

Table 1. Definitions of patients with SARI, suspected of nCoV*

*See https://www.who.int/health-topics/coronavirus for latest case definitions

1. Testing should be according to local guidance for management of community-acquired pneumonia. Examples of other etiologies
include Streptococcus pneumoniae, Haemophilus influenza type B, Legionella pneumophila, other recognized primary bacterial
pneumonias, influenza viruses, and respiratory syncytial virus.
2. Close contact’ is defined as:
 Health care associated exposure, including providing direct care for nCoV patients, working with health care workers infected
with nCoV, visiting patients or staying in the same close environment of a nCoV patient.
 Working together in close proximity or sharing the same classroom environment with a with nCoV patient
 Traveling together with nCoV patient in any kind of conveyance
 Living in the same household as a nCoV patient
 The epidemiological link may have occurred within a 14-day period before or after the onset of illness in the case under
consideration.
1.1.3 Isolation Triage at non quarantine hospital
 Triage the patient and start treatment based on the severity (refer to early supportive therapy monitoring) while calling for
PHEM for transporting the suspected patient and close contact to Quarantine areas.
 Dead body ?????

Table 2. Clinical syndromes associated with nCoV infection

Uncomplicated Patients with uncomplicated upper respiratory tract viral infection, may have non-specific symptoms such as fever,
illness cough, sore throat, nasal congestion, malaise, headache, muscle pain or malaise. The elderly and immunosuppressed
may present with atypical symptoms. These patients do not have any signs of dehydration, sepsis or shortness of
breath.
Mild pneumonia Patient with pneumonia and no signs of severe pneumonia.
Child with non-severe pneumonia has cough or difficulty breathing + fast breathing: fast breathing (in breaths/min): <2
months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40 and no signs of severe pneumonia.
Severe Adolescent or adult: fever or suspected respiratory infection, plus one of respiratory rate >30 breaths/min, severe
pneumonia respiratory distress, or SpO2 <90% on room air (adapted from [1]).
Child with cough or difficulty in breathing, plus at least one of the following: central cyanosis or SpO2 <90%; severe
respiratory distress (e.g. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign:
inability to breastfeed or drink, lethargy or unconsciousness, or convulsions. Other signs of pneumonia may be present:
chest indrawing, fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40.2 The diagnosis is
clinical; chest imaging can exclude complications.
Acute Onset: new or worsening respiratory symptoms within one week of known clinical insult.
Respiratory Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by effusions,
Distress lobar or lung collapse, or nodules.
Syndrome7-9 Origin of oedema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective
assessment (e.g. echocardiography) to exclude hydrostatic cause of oedema if no risk factor present.
Oxygenation (adults):
• Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cmH2O,7 or non-ventilated8)

• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cmH2O,7 or non-ventilated8)
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cmH2O,7 or non-ventilated8)
• When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)
Oxygenation (children; note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2):
• Bilevel NIV or CPAP ≥5 cmH2O via full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤264
• Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5
• Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3
• Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3

Sepsis Adults: life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection,
with organ dysfunction*. Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low
oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin
mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.

Children: suspected or proven infection and ≥2 SIRS criteria, of which one must be abnormal temperature or white
blood cell count.

Septic shock Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and
serum lactate level >2 mmol/L.

Children (based on [12]): any hypotension (SBP <5th centile or >2 SD below normal for age) or 2-3 of the following:
altered mental state; tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in
children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or
petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia.
 Abbreviations: ARI, acute respiratory infection; BP, blood pressure; bpm, beats/minute; CPAP, continuous positive airway pressure;
FiO2, fraction of inspired oxygen; MAP, mean arterial pressure; NIV, noninvasive ventilation; OI, Oxygenation Index; OSI,
Oxygenation Index using SpO2; PaO2, partial pressure of oxygen; PEEP, positive end-expiratory pressure; SBP, systolic blood
pressure; SD, standard deviation; SIRS, systemic inflammatory response syndrome; SpO2, oxygen saturation. *If altitude is higher
than 1000m, then
correction factor should be calculated as follows: PaO2/FiO2 x Barometric pressure/760.
* The SOFA score ranges from 0 to 24 and includes points related to 6 organ systems: respiratory (hypoxemia defined by low
PaO2/FiO2), coagulation (low platelets), liver (high bilirubin), cardiovascular (hypotension), central nervous system (low level of
consciousness defined by Glasgow Coma Scale), and renal (low urine output or high creatinine).
Sepsis is defined by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score13 of ≥2 points. Assume
the baseline score is zero if data are not available.

Table 3. How to implement infection prevention and control measures for patients with suspected or confirmed nCoV
infection 14,15

Apply droplet Droplet precautions prevent large droplet transmission of respiratory viruses. Use a medical mask if
precautions working within 1-2 metre s of the patient. Place patients in single rooms, or group together those with the
same etiological diagnosis. If an etiological diagnosis is not possible, group patients with similar clinical
diagnosis and based on epidemiological risk factors, with a spatial separation. When providing care in close
contact with a patient with respiratory symptoms (e.g. coughing or sneezing), use eye protection (face-mask
or goggles), because sprays of secretions may occur. Limit patient movement within the institution and
ensure that patients wear medical masks when outside their rooms.
Apply contact Droplet and contact precautions prevent direct or indirect transmission from contact with contaminated
precautions surfaces or equipment (i.e. contact with contaminated oxygen tubing/interfaces). Use PPE (medical mask,
eye protection, gloves and gown) when entering room and remove PPE when leaving. If possible, use either
disposable or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers). If equipment
needs to be shared among patients, clean and disinfect between each patient use. Ensure that health care
workers refrain from touching their eyes, nose, and mouth with potentially contaminated gloved or
ungloved hands. Avoid contaminating environmental surfaces that are not directly related to patient care
 (e.g. door handles and light switches). Ensure adequate room ventilation. Avoid movement of patients or
transport. Perform hand hygiene.
Apply airborne Ensure that healthcare workers performing aerosol-generating procedures (i.e. open suctioning of
precautions when respiratory tract, intubation, bronchoscopy, cardiopulmonary resuscitation) use PPE, including
performing an aerosol gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or
generating procedure higher level of protection). (The scheduled fit test should not be confused with user seal check before each
use.) Whenever possible, use adequately ventilated single rooms when performing aerosol-generating
procedures, meaning negative pressure rooms with minimum of 12 air changes per hour or at least 160
litres/second/patient in facilities with natural ventilation. Avoid the presence of unnecessary individuals in
the room. Care for the patient in the same type of room after mechanical ventilation commences
Remark: Any suspected case identified within the hospital should be given a medical mask and immediately evacuate the patient to an
isolation room. Keep at least 1meterdistance between suspected patients and other patients. Instruct all patients to cover nose and
mouth during coughing or sneezing with tissue or flexed elbow for others. Perform hand hygiene after contact with respiratory
secretions.

1.2 Quarantine health facilities

1.2.1 Reception area

 Continue the treatment initiated elsewhere and re-triage the patient and dispose to the subsequent areas.
 Mild to moderate to general wards.
 Sever to ICU.
 Dead body to designated morgue

1.2.2 General wards

 Pediatrics
 Adult
 Male
 Female
CASE MANAGEMENT

2.1 Early supportive therapy and monitoring

 Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxaemia, or shock.
Remarks: Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥90% in non-pregnant
adults and SpO2 ≥92-95 % in pregnant patients.1,2 Children with emergency signs (obstructed or absent
breathing, severe respiratory distress, central cyanosis, shock, coma or convulsions) should receive oxygen
therapy during resuscitation to target SpO2 ≥94%; otherwise, the target SpO2 is ≥90%. Use contact precautions
when handling contaminated oxygen interfaces of patients with nCoV infection.
 Use conservative fluid management in patients with SARI when there is no evidence of shock.
Remarks: Patients with SARI should be treated cautiously with intravenous fluids, because aggressive fluid
resuscitation may worsen oxygenation, especially in settings where there is limited availability of mechanical
ventilation.16
 Give empiric antimicrobials to treat all likely pathogens causing SARI. Give antimicrobials within one hour of initial
patient assessment for patients with sepsis.
Remarks: Although the patient may be suspected to have nCoV, administer appropriate empiric antimicrobials
within ONE hour of identification of sepsis.17 Empiric antibiotic treatment should be based on the clinical
diagnosis (community-acquired pneumonia, health care-associated pneumonia [if infection was acquired in
healthcare setting], or sepsis), local epidemiology and susceptibility data, and treatment guidelines. Empiric
therapy includes a neuraminidase inhibitor for treatment of influenza when there is local circulation or other risk
factors, including travel history or exposure to animal influenza viruses.18 Empiric therapy should be de-
escalated on the basis of microbiology results and clinical judgment.
 Do not routinely give systemic corticosteroids for treatment of viral pneumonia or ARDS outside of clinical trials
unless they are indicated for another reason.
 Remarks: A systematic review of observational studies of corticosteroids administered to patients with SARS reported
no survival benefit and possible harms (avascular necrosis, psychosis, diabetes, and delayed viral clearance).19 A
systematic review of observational studies in influenza found a higher risk of mortality and secondary infections with
corticosteroids; the evidence was judged as very low to low quality due to confounding by indication.20 A subsequent
study that addressed this limitation by adjusting for time-varying confounders found no effect on mortality.21 Finally, a
recent study of patients receiving corticosteroids for MERS used a similar statistical approach and found no effect of
corticosteroids on mortality but delayed lower respiratory tract (LRT) clearance of MERS-CoV.22 Given lack of
effectiveness and possible harm, routine corticosteroids should be avoided unless they are indicated for another reason.
See section 6 for the use of corticosteroids in sepsis.

 Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly progressive respiratory failure
and sepsis, and apply supportive care interventions immediately.
Remarks: Application of timely, effective, and safe supportive therapies is the cornerstone of therapy for
patients that develop severe manifestations of nCoV.
 Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and appreciate the
prognosis. Communicate early with patient and family.
Remarks: During intensive care management of SARI, determine which chronic therapies should be continued
and which therapies should be stopped temporarily. Communicate proactively with patients and families and
provide support and prognostic information. Understand the patient’s values and preferences regarding life-
sustaining interventions.

1.3 Special considerations for pregnant patients

 Pregnant women with suspected or confirmed nCoV should be treated with supportive therapies as described above,
taking into account the physiologic adaptations of pregnancy.
  The use of investigational therapeutic agents outside of a research study should be guided by individual risk-benefit
analysis based on potential benefit for mother and safety to fetus, with consultation from an obstetric specialist and
ethics committee.
 Emergency delivery and pregnancy termination decisions are challenging and based on many factors: gestational age,
maternal condition, and fetal stability. Consultations with obstetric, neonatal, and intensive care specialists (depending
on the condition of the mother) are essential.

2.3 Specific anti-Novel-CoV treatments and clinical research

 There is no current evidence from RCTs to recommend any specific anti-nCoV treatment for patients with suspected or
confirmed nCoV.
 Unlicensed treatments should be administered only in the context of ethically-approved clinical trials or the
Monitored Emergency Use of Unregistered Interventions Framework (MEURI), with strict monitoring.
https://www.who.int/ethics/publications/infectious-disease-outbreaks/en/
 Clinical characterization protocols are available, including the SPRINT-SARI https://isaric.tghn.org/sprint-sari/
and WHOISARIC forms available at https://isaric.tghn.org/protocols/severe-acute-respiratory-infection-data-
tools/. Contact oubreak@who.int for additional questions.

2. COLLECTION OF SPECIMENS FOR LABORATORY DIAGNOSIS ( to be revised by laboratory)

WHO guidance on specimen collection, processing, and laboratory testing, including related biosafety procedures, is
available.23
 Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally before antimicrobial therapy. DO NOT delay
antimicrobial therapy to collect blood cultures.
 Collect specimens from BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower respiratory
tract (LRT; expectorated sputum, endotracheal aspirate, or broncho-alveolar lavage) for nCoV testing by RT-PCR. Clinicians
may elect to collect only LRT samples when these are readily available (for example, in mechanically ventilated patients).
 Serology for diagnostic purposes is recommended only when RT-PCR is not available.23
 Remarks: Use appropriate PPE for specimen collection (droplet and contact precautions for URT specimens; airborne
precautions for LRT specimens). When collecting URT samples, use viral swabs (sterile Dacron or rayon, not cotton)
and viral transport media. Do not sample the nostrils or tonsils. In a patient with suspected novel coronavirus,
especially with pneumonia or severe illness, a single URT sample does not exclude the diagnosis, and additional URT
and LRT samples are recommended.23 LRT (vs. URT) samples are more likely to be positive and for a longer
period.23 Clinicians may elect to collect only LRT samples when these are readily available (for example, in
mechanically ventilated patients). Sputum induction should be avoided due to increased risk of increasing aerosol
transmission.
Remarks: Dual infections with other respiratory viral infections have been found in SARS and MERS cases. At this
stage we need detailed microbiologic studies in all suspected cases. Both URT and LRT specimens can tested for other
respiratory viruses, such as influenza A and B (including zoonotic influenza A), respiratory syncytial virus,
parainfluenza viruses, rhinoviruses, adenoviruses, enteroviruses (e.g. EVD68), human metapneumovirus, and endemic
human coronaviruses (i.e. HKU1, OC43, NL63, and 229E). LRT specimens can also be tested for bacterial pathogens,
including Legionella pneumophila.
 In hospitalized patients with confirmed nCoV infection, repeat URT and LRT samples should be collected to demonstrate viral
clearance. The frequency of specimen collection will depend on local circumstances but should be at least every 2 to 4 days until
there are two consecutive negative results (both URT and LRT samples if both are collected) in a clinically recovered patient at
least 24 hours apart. If local infection control practice requires two negative results before removal of droplet precautions,
specimens may be collected as often as daily.

Equipment required in the treating areas

 All areas where patients with SARI are cared for should be equipped with pulse oximeters, functioning oxygen systems
and disposable, single-use, oxygen-delivering interfaces (nasal cannula, simple face mask, and mask with reservoir
bag).


 Pre triage screening area

Suspected Non- suspected

To designated
isolation area triage

Call PHEM and send

to quarantine

Figure A pre triage screening algorithm

Figure B pre triage screening format
Module 4: ICU Management for 2019-nCov case
ICU Setup
1.1. Room
 Six beds
 Well ventilated (preferably negative pressured room)
 Area for a single bed should cover at least 20 m2
 Adequate power source & adequate plugs (6-8)
 Adequate water supply (which support dialysis) & sink
 Appropriate store room
 Staff counter should be separate
1.2. Drugs, equipment’s & Supplies-see annex 1,2 & 3
1.3. Human Resources
 Physicians: Intensivist, Anesthesiologist, pulmonary critical care or emergency medicine specialist or trained physician
 Nursing: Short or long term EMCC trained nurses practicing in ICU led by formally trained EMCC nurse. (1:1 or more)
 Porter(runner), Guard, janitor, Biomedical technician

Admission Criteria
1.4. General principle: unstable patients who will benefit most from the ICU and patients with high risk of deterioration are
prioritized for ICU admission.
1.5. Unstable and deteriorating patients -Requires intensive treatment and monitoring that cannot be provided outside of
theCritical care unit including:
 Mechanical ventilatory support (excluding mask continuous positive airway pressure (CPAP) or non-invasive (eg, mask)
ventilation)
 Possibility of a sudden, precipitous deterioration in respiratory function requiring immediate endotracheal intubation and
mechanical ventilation
 Need for vasoactive drugs to support arterial pressure or cardiac output
 Support for circulatory instability due to hypovolemia from any cause which is unresponsive to modest volume
replacement.
  Requires invasive monitoring and may potentially need immediate intervention. E.g. a patient with chronic co-morbid
conditions who develops acute severe medical or surgical illness get priority.
1.6. Criteria based on V/s and other assessment for calling intensive care admission
 Threatened airway
 All cardio respiratory arrests
 Respiratory rate ⩾40 or ⩽8 breaths/min
 Oxygen saturation <90% on ⩾50% oxygen, If there is ABG:Rising arterial carbon dioxide tension with respiratory
acidosis
 Pulse rate <40 or >140 beats/min
 Systolic blood pressure <90 mm Hg
 Sudden fall in level of consciousness (fall in Glasgow coma score >2 points)
 Repeated or prolonged seizures
 Other organ failures and metabolic, electrolyte and acid base disturbances: Indications for considering renal replacement
therapy and significant electrolyte/ABG and biochemical disturbances
 Special judgment by clinicians
2. General management
 3-Give emperic broad spectrum antimicrobials to trea

Give antimicrobials within one hour of initial patient assessment for patients with sepsis Emperic therapy should be de-escalated on the basis of mi
 4-Closely monitor patients with SARI for signs of clinical
deterioration and apply supportive care interventions
immediately

5-Understand the patient’s co-morbid condition(s) to tailor

the management of critical illness

6-Communicate early with patient and family

Specific management
 Severe pneumonia

Adolescent/Adult Child with cough/difficulty in

Fever or suspected Respiratory breathing +
infection +one of: at least one of the following: The diagnosis is clinical, chest
Respiratory rate>30/min Central cynosis/SpO2<90% radiograph may exclude
Severe respiratory distress Severe respiratory distress complications
SpO2<90% on room air Signs of severe pneumonia with
danger signs
 Acute Respiratory Distress Syndrome

mild
Onset ARDS:200<PaO2/FiO2<300mmHg(wit
new/worsening respiratory h PEEP/CPAP >5cmH2O, or non- Oxygenation
symptoms within one week ventilated (children:OI=Oxygenation Index and
Chest imaging moderate ARDS: OSI=Oxygenation Index Using SpO2)
bilateral opacities 100mmHg<PaO2/FiO2<200mmHg Bilevel NIV/CPAP>5cmH2O via full
origin of edema with PEEP>5cmH2O, or non- facemask:PaO2/FiO2<300mmHg or
respiratory failure not fully ventilated SpO2/FiO2<264
expalined by cardiac failure or fluid Severe ARDS: PaO2/FiO2<100mmHg Mild/moderate/severe
overload with PEEP>5cmH2O, or non- ARDS(ventilated invasively)
It can be mild/moderate/severe ventilated
When PaO2 is not available,
SpO2/FiO2<315 suggests ARDS

Management of hypoxemic respiratory failure and ARDS

1-Oxygen via face mask with reservoir bag-flow rates 10-15l/min

2-HFNO/NIV should only be used in selected patients without comorbidities and non-pregnant

3-Monitor closely for one hour and invasive ventilation if acutely deteriorate or no improvement

4-MV setting-low tidal volume (4-8MI/KG), low inspiratory pressure, high PEEP

5-If no improvement consider prone ventilation, respiratory paralysis or ECMO.

 Sepsis

Signs of organ dysfunction:

altered mental status
difficult or fast breathing
low O2 saaturation
reduced urine output Children:
Adults fast heart rate suspected or proven infection and
life-threatening organ dysfunction weak pulse >/= 2SIRS criteria, of which one
with suspected orproven infection cold extremities must be abnormal temperature or
low blood pressure WBC COUNT
skin mottling or
laboratory evidence of
coagulopathy,
thrombocytopenia,acidosis, high
lactate or hyperbilirubinemia
 Septic Shock

Children:
(based on any hypotension or 2-3 of the following)
altered mental status
tachycardia or bradicardia(HR 160bpm in infants,
Adult: 150bpm in children
persisting hypotension despite volume resuscitation, prolonged capilary refill(>2sec) or warm vasodilation
requiring with bounding pulses
vasopressors to maintatin MAP>/=65mmHg and tachypnea
Serum lactate level >2mmol/L mottled skin.petechial/purpuric rash
increased lactate
oliguria
hyper/hypothermia

Management of Sepsis/septic shock

Recognize and treat within one hour:

1-Antimicrobial therapy

2-Fluid loading

Adults: 30ml/kg isotonic crystalloid in the first 3hours

Children: 20ml/kg as rapid bolus

40-60ml/kg in the first hour

 Follow for improvement, JVP and signs of pulmonary edema

If no improvement, raised JVP or pulmonary edema reduce fluid

3-Vasopressors (norepinephrine, epinephrine, vasopressin, and dopamine are safe for use

Annex 1 -ICU inventory

Items Item number per ICU (six beds)

Ventilators 8

Connections 60

Nebulizer 6

Test lungs 2

Humidifier (Adult) 6

Blood warmer 2

Catheter mount 500

IBP Module 100

IBP cables 50
Pulse oxymeter 3

ECG machine 2

Torch 10

Glucometer 10

Shaving set 1

Tongue depressor 1 box

Minor set 6

Stethoscope 6

Knee hammer 6

Tuning fork 6

Cricothyroid set 2

Stillets 6

Laryngoscope(ordinary) 6

Ambu bag’s (adult) 6

Cordless phone 1

Bath basins 1

Double stands 12
O2 trolly’s 6

Wheel chair 1

Fumigation pump 1

Room heater 3

Monitor 6

ETCO2 Module 6

Temp probes 6

Otoscope 3

Defibrillator 1

Feeding cup 6

Steel kidney trays 12

Plastic kidney trays 6

Hot water bag 6

mattress 6

Enema can 6

Bed pan 6

Urinal 6
 Shoe racks 40

Office chair 6

Couch (staff resting bed) 2

Bed side trolley 6

IV stand steel 6

Suction unit 6

Fridges 1

Computers 2

Pillows 10

ABG GEM machine 1

Wall clock 1

Infusion Pump 12

US 1

Portable x-ray 1

Dialysis machine 2

UPS 8

Annex 2-Drugs
Module 5: Ethical considerations for the 2019 NCoV
1. Obligations of governments and the international community

Governments can play a critical role in preventing and responding to infectious disease outbreaks by improving social and
environmental conditions, ensuring well-functioning and accessible health systems, and engaging in public health surveillance and
prevention activities.

Together, these actions can substantially reduce the spread of diseases with epidemic potential. In addition, they help assure that an
effective public health response will be possible if an epidemic occurs. Governments have an ethical obligation to ensure the long-
term capacity of the systems necessary to carry out effective epidemic prevention and response efforts.

Ensuring the sufficiency of national public health laws —certain public health interventions that might be necessary during an
infectious disease outbreak (e.g. restrictions on freedom of movement). Public health laws should be reviewed to ensure that they give
the government sufficient authority to respond effectively to an epidemic while also providing individuals with appropriate human
rights protections.

2. Involving the local community

All aspects of infectious disease outbreak response efforts should be supported by early and ongoing engagement with the affected
communities. In addition to being ethically important in its own right, community engagement is essential to establishing and
maintaining trust and preserving social order.

Involving communities fully in infectious disease outbreak planning and response efforts such as community level IP and burial
process is important.

The media will play an important role in any infectious disease outbreak response effort. In turn, the media has a responsibility to
provide accurate, factual, timely and balanced reporting. This is a crucial component of media ethics.
3. Allocating scarce resources

Infectious disease outbreaks can quickly overwhelm the capacities of governments and health-care systems, requiring them to make
difficult decisions about the allocation of limited resources. Some of these decisions may arise in the context of allocating medical
interventions, such as hospital beds, medications, and medical equipment. Others may relate to broader questions about how public
health resources should be utilized. For example, how should limited resources be allocated between activities such as surveillance,
health promotion, and community engagement? Should human resources be devoted to contact tracing at the possible expense of
patient management? Should limited funds be spent improving water and sanitation facilities or building quarantine facilities?

Governments, health-care facilities, and others involved in response efforts should prepare for such situations by developing
guidelines on the allocation of scarce. Such guidelines should be developed through an open and transparent process .

Focus should be on balancing, health related consideration i.e life year saved, need of vulnerable population, Providing supportive and
palliative care to persons unable to access lifesaving resources, & consistent application.

4. Restrictions on freedom of movement

Restrictions on freedom of movement include isolation, quarantine, travel advisories or restrictions, and community based measures to
reduce contact between people (e.g. closing schools or prohibiting large gatherings). These measures can often play an important role
in controlling infectious disease outbreaks, and in these circumstances, their use is justified by the
ethical value of protecting community wellbeing.

Moreover, all such measures impose a significant burden on individuals and communities, including direct limitations of fundamental
human rights, particularly the rights to freedom of movement and peaceful assembly.

No restrictions on freedom of movement should be implemented without careful attention to the following considerations;

 Justifiable basis for imposing restrictions

 Least restrictive means
 Addressing financial and social consequences
  Equitable application

Quarantine Regulations of Ethiopia: Council of Ministers Regulations No. 4/1992, Ensures the legal ground for quarantine
and isolation of ill patients to prevent the spread of infection, control of hazardous exposure to the community in case of
emergencies and disasters reduction.

5. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease

Individuals offered medical interventions for the diagnosis, treatment, or prevention of an infectious pathogen should be informed
about the risks, benefits, and alternatives, just as they would be for other significant medical interventions. The presumption should be
that the final decision about which medical interventions to accept, if any, belongs to the patient.

In exceptional situations, there may be legitimate reasons to override an individual’s refusal of a diagnostic, therapeutic, or preventive
measure that has proven to be safe and effective and is part of the accepted medical standard of care. Decisions on whether to override
a refusal should be grounded in the following considerations: Public health necessity of the proposed intervention, Existence of
medical contraindications to the proposed intervention, unwilling patient (just isolate) and impact on community trust (overriding
refusal may end up in community distrustful)

6. Emergency use of unproven interventions outside of research

There are many pathogens for which no proven effective intervention exists. For some pathogens there may be interventions that have
shown promising safety and efficacy in the laboratory and in relevant animal models but that have not yet been evaluated for safety
and efficacy in humans. But further testing is ongoing to apply on human.
Considering the high mortality of the outbreak it can be ethical to offer patients experimental intervention on emergency provided;

 no proven effective treatment exists;

 it is not possible to initiate clinical studies immediately;
 data providing preliminary support of the intervention’s efficacy and safety are available, at least from laboratory or animal
studies.
 the relevant country authorities, as well as an appropriately qualified ethics committee, have approved such use;
 adequate resources are available to ensure that risks can be minimized;
 the patient’s informed consent is obtained;
 the emergency use of the intervention is monitored and the results are documented and shared in a timely manner with the
wider medical and scientific community.

7. Frontline response workers’ rights and obligations

 Individuals should not be expected to take on risky work assignments during an infectious disease outbreak unless they are
provided with the training, tools, and resources necessary to minimize the risks to the extent reasonably possible.
 Health insurance should be secured
 Priority access to highest health care even for family members who become ill through contact
 Appropriate payment
 Support for reintegrating into the community; to reduce impact of stigma providing job placement and relocation can be
done by government.
 The health professionals are obliged to follow the standard IP precautions on their return to community and family.

8. Facilities ethical issues

  Hospitals should have their own newly established isolation center to which suspected cases arrive before getting to ER
triage which significantly decrease the burden at Emergency. The isolation room at ER should be ready for cases and quick
transfer should be facilitated.
 Any quarantined individual can contact family member only via cell phone.
 Whenever a case of NCoV arrives latter on the patient as well contact persons should be disclosed for further approach.
 Facility should provide food/drink/cloth to patients.
 Patient’s condition to family members should be communicated by the treating physician.
 Establish an Ethical Committee that monitor the death care, disinfection of equipments for reuse and other ethical issues at
the hospital.

Special consideration in pregnancy and neonate

Pregnant women with suspected or confirmed 2019-nCoV infection should be treated with supportive therapies as described above,
taking into account the physiologic adaptations of pregnancy. The use of investigational therapeutic agents outside of a research study
should be guided by individual risk-benefit analysis based on potential benefit for mother and safety to fetus, with consultation from
an obstetric specialist and ethics committee. Emergency delivery and pregnancy termination decisions are challenging and based on
many factors: gestational age, maternal condition, and fetal stability. Consultations with obstetric, neonatal, and intensive care
specialists (depending on the condition of the mother) are essential.

Despite the recent figures that are suggesting that neonate victims are few, nevertheless standardized preparedness and response effort
shall be implemented. Hence, there should be well equipped area for neonates containing the standard neonatal ICU facilities along
with the standard application of WHO precautions for IPC.

Dead body handling

While deceased is in bed/ nurses

1. Adhere to standard precautions and use appropriate personal protective equipment (PPE) at all times.
2. After the physician declares death, perform the following tasks to prevent exposure to blood and body fluid during
transportation to protecting morgue personnel:
a. Remove all disposable tubes and lines appropriately.
 b. Dress all wounds with impervious material to prevent oozing of body fluids or bleeding from wounds or previous catheter
sites.
c. Request an appropriately sized body bag and place the body in the bag.
3. Follow the proper identification of the body, transportation, and documentation in the morgue.
4. Patients with known infectious diseases should have body tags labeled with the appropriate category.
5. The nurse in charge or dedicated personnel will inform the morgue supervisor if the deceased was known to harbor an
infectious agent. (This information will also be confirmed in writing on the identification tag.)

Morgue Staff

1. All morgue staff and especially body washers must be oriented and attend in-service training annually regarding the proper
infection control practices (i.e., hand hygiene, modes of disease transmission, and the importance of PPE) and how to apply
these practices.
2. Always use standard precautions and use appropriate personal protective equipment (PPE) at all times. a. Avoid direct contact
with blood and body fluids.
3. Use PPE (mask, goggles, latex/vinyl gloves, boots, waterproof full-length apron) to prevent splashing and contamination with
body fluids. a. Remove disposable PPE and discard immediately after the task is completed.

Staff handling dead bodies of unknown category

Staff such as Food and Environmental Hygiene Department (FEHD) may need to handle dead bodies of unknown categories.
For example, dead bodies found on board conveyances from land, sea or air, with unclear history or suspected infectious
disease.
 1. Dead body care
2. 2.1. When handling of dead bodies:

(a) Avoid direct contact with blood or body fluids from the dead body.
(b) Observe strict personal hygiene and put on appropriate personal protective equipment (PPE) including gloves, water
resistant gown / plastic apron over water repellent gown, and surgical masks. Use goggles or face shield to protect eyes, if
there may be splashes.
(c) Make sure any wounds are covered with waterproof bandages or dressings.
(d) Do NOT smoke, drink or eat. Do NOT touch your eyes, mouth or nose.

2.2. Place the dead body in a robust and leak-proof opaque plastic bag of not less than 150 μm thick, which should be
zippered closed. Pins are NOT to be used. (The bagged body should be placed in another opaque body bag if the deceased
was suspected to be suffering from highly infectious diseases).

2.3. Attach an appropriate identity label to the body bag before transport to public mortuary as the case may warrant.

2.4 body is then placed in 4 degrees freezer or put in a coffin for burial.
2.5. Remove personal protective equipment after handling of the dead body. Then, wash hands with liquid soap and water
immediately.

**** viewing of body possible with proper PPE appliances and after placement of body in a 1st body bag.

3. Environmental control
3.1. Make sure that supply of disposable gloves, protective equipment, alcohol-based hand rub and disinfectant such as
household bleach is readily available.
 3.2. After use, the disposable items such as gloves and protective clothing should be disposed of in a plastic bag.
3.2. Linen contaminated with blood or body fluids should be laundered in a washing machine with hot washing cycle
(>70oC), otherwise, they should be soaked in freshly prepared “1 in 49 diluted household bleach” (mixing 1 part of 5.25%
bleach with 49 parts of water) for 30 minutes before washing.
3.4. All surfaces may be contaminated should be wiped with “1 in 49 diluted household bleach” (mixing 1 part of 5.25%
bleach with 49 parts of water), leave it for 15-30 minutes, and then rinse with water. Metal surfaces could be wiped with
70% alcohol.
3.5. Surfaces visibly contaminated with blood and body fluids should be wiped with “1 in 4 diluted household bleach”
(mixing 1 part of 5.25% bleach with 4 parts of water), leave it for 10 minutes, and then rinse with water.

Burial

Burial is the preferred disposal method.

Burial site

Burial site should be determined through consultation with the affected community and local authority. Graveyard should be located
at least 50m from ground water sources used for drinking water and at least 500m from the nearest habitable building. Covering of
soil of 1m recommended. Base of any grave 15m above the ground water table to minimize contamination.