Guidance for Healthcare Professionals on COVID-19

The Research Society for the Study of Diabetes in India has released guidance for healthcare professionals on COVID-19.

In China, where most cases have occurred so far, people with diabetes had much higher rates of serious complications and death than people without diabetes—and generally, we believe that the more health conditions someone has (for example, diabetes and heart disease), the higher their chance of getting serious complications from COVID-19.

The problem people with diabetes face is primarily a problem of worse outcomes, not a greater chance of contracting the virus.

People with Diabetes and COVID-19

People with diabetes do face a higher chance of experiencing serious complications from COVID-19:

• In general, people with diabetes are more likely to experience severe symptoms and complications when infected with a virus. If diabetes is well-managed, the risk of getting severely sick from COVID-19 is about the same as the general population.
• When people with diabetes do not manage their diabetes well and experience fluctuating blood sugars, they are generally at risk for a number of diabetes-related complications. Having heart disease or other complications in addition to diabetes could worsen the chance of getting seriously ill from COVID-19, like other viral infections, because your body's ability to fight off an infection is compromised. But if glucose control is poor, the severity of viral illness and risk of complications will increase because of impairment of immunity.
• Viral infections can also increase inflammation, or tissue oedema in people with diabetes. This is also caused by above-target blood sugars, and both could contribute to more severe complications.
• People with diabetes do face an increased risk of DKA (diabetic ketoacidosis) and/or hypoglycemia. DKA is commonly experienced by people with type 1 diabetes.

COVID-19 Risk for People with Type 1 versus Type 2 Diabetes

• In general, we don't know of any reason to think COVID-19 will pose a difference in risk between type 1 and type 2 diabetes.
• More important is that people with either type of diabetes vary in their age, complications, and how well they have been managing their diabetes.
• People who already have diabetes-related health problems are likely to have worse outcomes if they contract COVID-19 than people with diabetes who are otherwise healthy, whichever type of diabetes they have.

Infection Prevention and Control Measures

At Triage

• Give suspect patient a triple layer surgical mask and direct patient to a 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 contact with respiratory secretions.

Apply Droplet Precautions

• Droplet precautions prevent large droplet transmission of respiratory viruses.
• Use a triple layer surgical 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 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.
• Avoid contaminating environmental surfaces that are not directly related to patient care (e.g., door handles and light switches). Ensure adequate room ventilation.

Precautions for Diabetics

• Advise patients to drink lots of fluids. If the patient is having trouble or pain in swallowing, advise them to have small sips every 15 minutes or so throughout the day to avoid dehydration.
• Patients should be advised for frequent self-monitoring of blood glucose to prevent hypoglycemia as well as to identify glycemic excursions. Specific instructions should be given about hypoglycemia management, e.g., to eat 15 grams of simple carbohydrates (like honey, jaggery, jam, or hard candy) and about modification in their drug or insulin dose according to physician advice if hypoglycemia occurs.
• Patients, particularly type 1 diabetes patients, should be advised to check urine ketones when there is sustained hyperglycemia with two readings of random blood sugar above 250mg/dl. If urine ketones are trace or small, they should be advised for adequate hydration and rechecking ketones in a few hours. If urine ketones are moderate or large or persistently small or there are symptoms of DKA (abdominal pain, nausea, vomiting), they should immediately consult a physician or emergency department of a nearby hospital.
• Patients should be instructed about personal hygiene like regularly washing hands, avoiding touching face, and cleaning injection/infusion sites & finger-stick sites with soap and water or rubbing alcohol.
• Patients with diabetes, particularly those with poor glycemic control, as they are at increased risk of complications, should be instructed about warning symptoms and need for hospitalization if they develop such symptoms.
• Apart from these, patients should be instructed to follow social isolation to prevent the spread of infection to others.
• Always be in touch with your personal doctor in such situations.

Investigations

Laboratory Markers in COVID-19 Patients

Most Frequent

• Decrease lymphocyte count
• Decrease albumin
• Decrease hemoglobin levels
• Increase C-reactive protein (CRP)
• Increase Erythrocyte Sedimentation Rate (ESR)
• Increase Lactate Dehydrogenase (LDH)
• Increase D-dimer

In Severe COVID-19

• Decrease lymphocyte count
• Decrease albumin
• Decrease hemoglobin levels
• Increase C-reactive protein (CRP)
• Increase Erythrocyte Sedimentation Rate (ESR)
• Increase Lactate Dehydrogenase (LDH)
• Increase D-dimer
• Increase Neutrophil count
• Increase Alanine Aminotransferase (ALT)
• Increase Aspartate Aminotransferase (AST)
• Increase Cardiac biomarkers (e.g., cardiac troponins)
• Increase Procalcitonin

Specimen Collection

Responsibilities

• The clinician should decide the necessity for collection of clinical specimens for laboratory testing of 2019-nCoV only after following the case definition as given by the health authorities, Government of India.
• Appropriate clinical samples need to be collected by laboratory personnel/health care workers trained in specimen collection in the presence of a clinician.
• By following all biosafety precautions and using personal protective equipment (PPEs), clinical samples need to be sent to the designated laboratories as approved by the Government of India, by following standard triple packaging.

Selection of Patient

• The ICMR has revised the strategy for testing of COVID-19 on 21/03/2020. According to this recommendation, the following have been included for testing:
• All asymptomatic individuals who have undertaken international travel in the last 14 days
• All symptomatic contacts of laboratory-confirmed cases
• All symptomatic healthcare workers
• All hospitalized patients with Severe Acute Respiratory illness (Fever and cough and/or shortness of breath)
• Asymptomatic direct and high-risk contacts of a confirmed case should be tested between day 5 and day 14 coming in/her contact

Specimen Labelling and Processing

• Personal protective equipment (apron, hand gloves, face shield, N95 Masks, etc.) need to be used and all biosafety precautions should be followed so as to protect individuals and the environment.
• Proper labelling (name/age/gender/specimen ID) needs to be done on the specimen container and other details of the sender (name/address/phone number) on the outer container by mentioning "To be tested for 2019-nCoV".
• Diagnosis by PCR is available from imported kits and now we have an Indian kit available for diagnosis (ICMR recommended and approved by DCGI).

Treatment

• The only approved treatment as of today is social distancing, quarantine, and in affected cases, symptomatic treatment only.
• A number of treatment regimens including HCQS, Azithromycin, etc. have been used so far but they are not validated by RCTs.