GUIDELINES FOR SETTING UP PRIVATE FEVER CLINIC AND RESPIRATORY CLINIC

Following guidelines should be followed in setting up Private Fever clinic and Respiratory Clinic.
 Separate spacious building with facilities for OP room, Lab, Sample Collection, Nurse Duty room,
Doctor Duty room and other facilities should be available.
 Easy access for entry and exit to be maintained.
 At entry point and exit point hand washing facilities with tap and soap to be provided.
 Spacious, well ventilated waiting hall with chairs placed two meters apart to be arranged in order to
maintain social distancing and avoid crowding.
 At the reception, the desk person with adequate protection (wearing mask) should register the
name, age, sex address and contact number of the client.
 Each patient should be issued with a face mask.
 Temperature of the patients to be recorded by non-touch thermometer.
 Only one patient to be allowed into the Doctors examination room after wearing a mask.
 Each consultant to sit in separate, spacious, well ventilated, well illuminated, non AC cubicles.
 Doctor and Client should sit in chairs and tables placed two meters apart.
 Doctor should be adequately protected with mask and gloves.
 Depending on the clinical condition and for all ILI cases COVID 19 test to be performed.
 Samples must be sent to the nearest Govt. / Pvt. microbiological lab.
 The line list of cases and treatment details to be shared to deputy director of health services and to
the common Govt. Portal @ www.dphpm.com .
 All consultants and other health care providers to be trained in SOP for personal protection,
management of COVID 19 Cases, collection of samples and reporting.
 Universal Precaution measures should be adopted in day to day functioning of these clinics.

 The Govt. of India guidelines for rational use of PPE is enclosed for reference.
 The Disinfection Protocol for surfaces relating to spread of infection such as hand rails, door
handles, patient’s chair, table, examination couch, floor and sample collection area to be followed
as per guidelines. (frequency of disinfection and type of disinfectant).
 Biomedical waste generated including mask and PPE used to be handled and disposed as per BMW
Management Rules without any deviation.
 The whole campus to be disinfected and sanitized every day to avoid amplification of the epidemic.

Dr. S. Gurunathan
State Appropriate Authority
Tamil Nadu Clinical Establishment Act
 Ministry of Health and Family Welfare
Directorate General of Health Services
[Emergency Medical Relief]

Novel Coronavirus Disease 2019 (COVID-19): Guidelines on rational use of Personal Protective
Equipment

1. About this guideline

This guideline is for health care workers and others working in points of entries (POEs), quarantine
centers, hospital, laboratory and primary health care / community settings. The guideline uses setting
approach to guide on the type of personal protective equipment to be used in different settings.

2. Introduction

Coronaviruses are a large family of viruses, some causing illness in people and others that circulate
among animals, including camels, cats and bats. Rarely, animal coronaviruses can evolve and infect
people and then spread between people such as has been seen with MERS and SARS.

The outbreak of Novel coronavirus disease (now named COVID-19) was initially noticed from a
seafood market in Wuhan city in Hubei Province of China in mid-December, 2019, has spread to
more than 185 countries/territories worldwide including India.
The causative agent for COVID-19, earlier termed provisionally as novel Coronavirus has been
officially named as SARS-CoV-2.

3. Mode of transmission

There is clear evidence of human-to-human transmission of SARS-CoV-2. It is thought to be

transmitted mainly through respiratory droplets that get generated when people cough, sneeze, or
exhale. SARS-CoV-2 also gets transmitted by touching, by direct touch and through contaminated
surfaces or objects and then touching their own mouth, nose, or possibly their eyes. Healthcare
associated infection by SARS-CoV-2 virus has been documented among healthcare workers in many
countries.

The people most at risk of COVID-19 infection are those who are in close contact with a
suspect/confirmed COVID-19 patient or who care for such patients.

4. Personal Protective Equipment (PPE)

Personal Protective Equipments (PPEs) are protective gears designed to safeguard the health of
workers by minimizing the exposure to a biological agent.

4.1 Components of PPE

Components of PPE are goggles, face-shield, mask, gloves, coverall/gowns (with or without aprons),
head cover and shoe cover. Each component and rationale for its use is given in the following
paragraphs:
4.1.1 Face shield and goggles

Contamination of mucous membranes of the eyes, nose and mouth is likely in a scenario of droplets
generated by cough, sneeze of an infected person or during aerosol generating procedures carried out
in a clinical setting. Inadvertently touching the eyes/nose/mouth with a contaminated hand is another
likely scenario. Hence protection of the mucous membranes of the eyes/nose/mouth by using face
shields/ goggles is an integral part of standard and contact precautions. The flexible frame of
goggles should provide good seal with the skin of the face, covering the eyes and the surrounding
areas and even accommodating for prescription glasses.

4.1.2 Masks

Respiratory viruses that includes Coronaviruses target mainly the upper and lower respiratory tracts.
Hence protecting the airway from the particulate matter generated by droplets / aerosols prevents
human infection. Contamination of mucous membranes of the mouth and nose by infective droplets
or through a contaminated hand also allows the virus to enter the host. Hence the droplet
precautions/airborne precautions using masks are crucial while dealing with a suspect or confirmed
case of COVID-19/performing aerosol generating procedures.

Masks are of different types. The type of mask to be used is related to particular risk profile of the
category of personnel and his/her work. There are two types of masks which are recommended for
various categories of personnel working in hospital or community settings, depending upon the work
environment:

1. Triple layer medical mask

2. N-95 Respirator mask

4.1.2.1 Triple layer medical mask

A triple layer medical mask is a disposable mask, fluid-resistant, provide protection to the wearer
from droplets of infectious material emitted during coughing/sneezing/talking.

4.1.2.2. N-95 Respirator mask

An N-95 respirator mask is a respiratory protective device with high filtration efficiency to airborne
particles. To provide the requisite air seal to the wearer, such masks are designed to achieve a very
close facial fit.

Such mask should have high fluid resistance, good breathability (preferably with an expiratory
valve), clearly identifiable internal and external faces, duckbill/cup-shaped structured design that
does not collapse against the mouth.

If correctly worn, the filtration capacity of these masks exceeds those of triple layer medical masks.
Since these provide a much tighter air seal than triple layer medical masks, they are designed to
protect the wearer from inhaling airborne particles.

4.1.3 Gloves

When a person touches an object/surface contaminated by COVID-19 infected person, and then
touches his own eyes, nose, or mouth, he may get exposed to the virus. Although this is not thought
to be a predominant mode of transmission, care should be exercised while handling objects/surface
potentially contaminated by suspect/confirmed cases of COVID-19.

Nitrile gloves are preferred over latex gloves because they resist chemicals, including certain
disinfectants such as chlorine. There is a high rate of allergies to latex and contact allergic dermatitis
among health workers. However, if nitrile gloves are not available, latex gloves can be used. Non-
powdered gloves are preferred to powdered gloves.

4.1.4 Coverall/Gowns

Coverall/gowns are designed to protect torso of healthcare providers from exposure to virus.
Although coveralls typically provide 360-degree protection because they are designed to cover the
whole body, including back and lower legs and sometimes head and feet as well, the design of
medical/isolation gowns do not provide continuous whole-body protection (e.g., possible openings in
the back, coverage to the mid-calf only).

By using appropriate protective clothing, it is possible to create a barrier to eliminate or reduce

contact and droplet exposure, both known to transmit COVID-19, thus protecting healthcare
workers working in close proximity (within 1 meter) of suspect/confirmed COVID-19 cases or their
secretions.

Coveralls and gowns are deemed equally acceptable as there is a lack of comparative evidence to
show whether one is more effective than the other in reducing transmission to health workers.
Gowns are considerably easier to put on and for removal. An apron can also be worn over the gown
for the entire time the health worker is in the treatment area. Coveralls/gowns have stringent
standards that extend from preventing exposure to biologically contaminated solid particles to
protecting from chemical hazards.

4.1.5 Shoe covers

Shoe covers should be made up of impermeable fabric to be used over shoes to facilitate personal
protection and decontamination.

4.1.6. Head covers

Coveralls usually cover the head. Those using gowns, should use a head cover that covers the head
and neck while providing clinical care for patients. Hair and hair extensions should fit inside the
head cover.

The specifications for all the PPEs are at Annexure-A.

5. Rational use of PPE

The PPEs are to be used based on the risk profile of the health care worker. The document describes
the PPEs to be used in different settings.

5.1. Point of Entry

S. No. Setting Activity Risk Recommended Remarks

PPE
1 Health Desk Provide Low risk Triple layer medical Minimum distance
information to mask of one meter needs
travellers to be maintained.
Gloves
2 Immigration Provide services Low risk Triple layer medical Minimum distance
counters, to the passengers mask of one meter needs
customs and to be maintained.
airport security Gloves
3 Temperature Record Low risk Triple layer medical
recording Temperature with mask
station hand held thermal
recorder. Gloves
4 Holding area/ Interview & Moderate N-95 masks
Isolation Clinical Risk
facility of examination by Gloves
APHO/ PHO doctors/ nurses
5 Isolation Clinical Moderate N-95 masks
facility of management Risk
APHO (doctors, nurses) Gloves

Attending to High risk Full complement of When aerosol

severely ill PPE generating
passenger procedures are
anticipated
5 Sanitary staff Cleaning Moderate N-95 mask
frequently risk
touched surfaces/ Gloves
Floor/ cleaning
linen
6 Administrative Providing No risk No PPE No contact with
staff administrative patients of COVID-
support 19. They should not
venture into areas
where suspect
COVID-19 cases are
being managed.
5.2. Hospital Setting

5.2.1. Out Patient Department (Respiratory Clinic / Separate screening area)#

S. No Setting Activity Risk Recommended Remarks

PPE
1 Triage area Triaging patients Moderate N 95 mask Patients get masked.
risk
Provide triple Gloves
layer mask to
patient.
2 Screening area Provide Moderate N-95 mask
help desk/ information to risk
Registration patients Gloves
counter
3 Temperature Record Moderate N 95 mask
recording temperature with Risk
station hand held thermal Gloves
recorder
4 Holding area/ Nurses / Moderate N 95 mask Minimum distance
waiting area paramedic Risk of one meter needs
interacting with Gloves to be maintained.
patients
5 Doctors Clinical Moderate N 95 mask No aerosol
chamber management Risk generating
(doctors, nurses) Gloves procedures should
be allowed.
6 Sanitary staff Cleaning Moderate N-95 mask
frequently risk
touched surfaces/ Gloves
Floor/ cleaning
linen
7 Visitors Support in Low risk Triple layer medical No other visitors
accompanying navigating various mask should be allowed to
young children service areas accompany patients
and elderlies in OPD settings. The
visitors thus allowed
should practice hand
hygiene

# All hospitals should identify a separate triage and holding area for patients with Influenza like
illness. If there is no triage area / holding area for patients due to resource constraints, such hospitals
will follow the above guidance for general OPD.

5.2.2. In-patient Services

S. No. Setting Activity Risk Recommended Remarks

PPE
1 Individual Clinical Moderate N 95 mask Patient masked.
isolation rooms/ management risk Gloves Patients stable. No
cohorted aerosol generating
isolation rooms activity.
2 ICU/ Critical Critical care High risk Full complement of Aerosol generating
 care management PPE activities performed.
3 ICU /critical Dead body High risk Full complement of
care packing PPE
4 ICU/ Critical Dead body Low Risk Triple Layer medical
care transport to mask
mortuary
Gloves

5 Sanitation Cleaning Moderate N-95 mask

frequently risk
touched surfaces/ Gloves
floor/ changing
linen
6 Other Non- Attending to Risk as PPE as per hospital No possibility of
COVID infectious and per infection prevention exposure to COVID
treatment areas non-infectious assessed control practices. patients. They
of hospital patients profile of should not venture
patients into COVID-19
treatment areas.
7 Caretaker Taking care of the Low risk Triple layer medical The caretaker thus
accompanying admitted patient mask allowed should
the admitted practice hand
patient hygiene, maintain a
distance of 1 meter

5.2.3. Emergency Department

S.No Setting Activity Risk Recommended Remarks

PPE
1 Emergency Attending Moderate N 95 mask When aerosol
emergency cases risk generating
Gloves procedures are
anticipated
2 Attending to High risk Full complement of Aerosol generating
severely ill PPE activities performed.
patients of SARI

5.2.4. Pre-hospital (Ambulance) Services

S. No. Setting Activity Risk Recommended Remarks

PPE
1 Ambulance Transporting Moderate N-95 mask
Transfer to patients not on risk
designated any assisted Gloves
hospital ventilation
Management of High risk Full complement of When aerosol
SARI patient PPE generating
while transporting procedures are
anticipated
Driving the Low risk Triple layer medical Driver helps in
ambulance mask shifting patients to
Gloves the emergency
5.2.5. Other Supportive/ Ancillary Services

S. No. Setting Activity Risk Recommended Remarks

PPE
1. Laboratory Sample collection High risk Full complement
and transportation of PPE
Sample testing High risk Full complement
of PPE

2 Mortuary Dead body Moderate N 95 mask No aerosol generating

handling Risk Gloves procedures should be
allowed.
No embalming.

While performing High Risk Full complement No post-mortem

autopsy of PPE unless until specified.
3 Sanitation Cleaning Moderate N-95 mask
frequently risk
touched surfaces/ Gloves
Floor/ cleaning
linen in COVID
treatment areas
4 CSSD/Laundry Handling linen of Moderate N-95 mask
COVID patients risk
Gloves
5 Other Administrative No risk No PPE No possibility of
supportive Financial exposure to COVID
services Engineering patients. They should
Security, etc. not venture into
COVID-19 treatment
areas.

5.3. Health Workers in Community Setting

S. No. Setting Activity Risk Recommended Remarks

PPE
1 ASHAs/ Field Surveillance Low Risk Triple layer mask Maintain distance of
Anganwadi one meter.
and other field Gloves Surveillance team to
staff carry adequate triple
layer masks to
distribute to suspect
cases detected on
field surveillance
2 Doctors at Field surveillance Medium N 95 mask
supervisory Clinical risk
level examination. Gloves.
conducting field
investigation
5.4 Quarantine facility

S. No. Setting Activity Risk Recommended Remarks

PPE
1 Persons being Low Risk Triple layer mask
quarantined
2 Healthcare staff Health monitoring Low Risk Triple layer mask
working at and temperature
quarantine recording Gloves
facility
Clinical Moderate N-95 masks
examination of Risk
symptomatic Gloves
persons
3 Support staff Low Risk Triple layer mask

Gloves

5.5 Home Quarantine

S. No. Setting Activity Risk Recommended Remarks

PPE
1 Persons being Low Risk Triple layer mask
quarantined
2 Designated Taking care of Low Risk Gloves While cleaning
family member person being commonly touched
quarantined surfaces or handling
soiled linen
3 Other family No Risk No PPE required Maintain a distance
of at least 1 meter
from person under
home quarantine.
Senior citizens in the
household should
stay away from such
persons under home
quarantine.

Points to remember while using PPE

1. PPEs are not alternative to basic preventive public health measures such as hand
hygiene, respiratory etiquettes which must be followed at all times.
2. Always (if possible) maintain a distance of at least 1 meter from
contacts/suspect/confirmed COVID-19 cases
3. Always follow the laid down protocol for disposing off PPEs as detailed in infection
prevention and control guideline available on website of MoHFW.
 Annexure A

Personal Protection Equipment (PPE) - Specifications

(for Contact & Airborne precautions)

1. PPE Kit
1.1 Gloves
• Nitrile
• Non-sterile
• Powder free
• Outer gloves preferably reach mid-forearm (minimum 280 mm total length)
• Different sizes (6.5 & 7)
• Quality compliant with the below standards, or equivalent:
a. EU standard directive 93/42/EEC Class I, EN 455
b. EU standard directive 89/686/EEC Category Ill, EN 374
c. ANSI/SEA 105-2011
d. ASTM D6319-10

1.2 Coverall (medium and large)*

• Impermeable to blood and body fluids
• Single use
• Avoid culturally unacceptable colors e.g. black
• Light colors are preferable to better detect possible contamination
• Thumb/finger loops to anchor sleeves in place
• Quality compliant with following standard
a. Meets or exceeds ISO 16603 class 3 exposure pressure, or equivalent

1.3 Goggles
• With transparent glasses, zero power, well fitting, covered from all sides with
elastic band/or adjustable holder.
• Good seal with the skin of the face
• Flexible frame to easily fit all face contours without too much pressure
• Covers the eyes and the surrounding areas and accommodates for prescription glasses
• Fog and scratch resistant
• Adjustable band to secure firmly so as not to become loose during clinical activity
• Indirect venting to reduce fogging
• May be re-usable (provided appropriate arrangements for decontamination are in
place) or disposable
• Quality compliant with the below standards, or equivalent:
a. EU standard directive 86/686/EEC, EN 166/2002
b. ANSI/SEA Z87.1-2010
1.4. N-95 Masks
• Shape that will not collapse easily
• High filtration efficiency
• Good breathability, with expiratory valve
• Quality compliant with standards for medical N95 respirator:
a. NIOSH N95, EN 149 FFP2, or equivalent
• Fluid resistance: minimum 80 mmHg pressure based on ASTM F1862, ISO 22609,
or equivalent
• Quality compliant with standards for particulate respirator that can be worn with
full- face shield

1.5. Shoe Covers

• Made up of the same fabric as of coverall
• Should cover the entire shoe and reach above ankles

1.6. Face Shield

• Made of clear plastic and provides good visibility to both the wearer and the patient
• Adjustable band to attach firmly around the head and fit snuggly against the forehead
• Fog resistant (preferable)
• Completely covers the sides and length of the face
• May be re-usable (made of material which can be cleaned and disinfected)
or disposable
• Quality compliant with the below standards, or equivalent:
a. EU standard directive 86/686/EEC, EN 166/2002
b. ANSI/SEA Z87.1-2010

3. Triple Layer Medical Mask

• Three layered medical mask of non-woven material with nose piece, having
filter efficiency of 99% for 3 micron particle size.
a. ISI specifications or equivalent

4. Gloves
• Nitrile
• Non-sterile
• Powder free
• Outer gloves preferably reach mid-forearm (minimum 280mm total length)
• Different sizes (6.5 & 7)
• Quality compliant with the below standards, or equivalent:
1. EU standard directive 93/42/EEC Class I, EN 455
2. EU standard directive 89/686/EEC Category Ill, EN 374
3. ANSI/SEA 105-2011
4. ASTM D6319-10
5. Body Bags - Specifications

1) Impermeable
2) Leak proof
3) Air sealed
4) Double sealed
5) Disposable
6) Opaque
7) White
8) U shape with Zip
9) 4/6 grips
10) Size: 2.2 x 1.2 Mts
11) Standards:
a) ISO 16602:2007
b) ISO 16603:2004
c) IS016604:2004
d) ISO/DIS 22611:2003

All items to be supplied need to be accompanied with certificate of analysis from national/
international organizations/labs indicating conformity to standards

All items: Expiry 5 years

* Due to scarcity of coveralls, and risk versus benefit, that as an emergency temporary measure in
larger public interest, in present given circumstances, the fabric that cleared/passed ‘Synthetic
Blood Penetration Resistance Test’ (ISO 16603) and the garment that passed ‘Resistance to
penetration by biologically contaminated solid particles (ISO 22612:2005) may be considered as the
benchmark specification to manufacture Coveralls.” The Coveralls should be taped at the seams to
prevent fluid/droplets/aerosol entry.

The test for these two standards (ISO 16603 and ISO 22612:2005), which can be performed in
Indian laboratories are as per WHO Disease Commodity Package (Version 4.0)