MINISTRYOFHEALTH

InterimGuidanceonProvisionofServicesforNoncommunicableDiseases(NCDs)

DuringtheCOVID-19Pandemic

July2020

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ContentsForeword.....................................................................................................................................................................iiListofAbbreviationsandAcronyms...........................................................................................................................ivCHAPTER1:Introduction.............................................................................................................................................1

1.1 COVID-19:Abriefbackground.......................................................................................................................11.2 ImpactonNCDs.............................................................................................................................................11.3 PurposeoftheGuidance...............................................................................................................................11.4 GeneralmanagementofNCDS......................................................................................................................21.5 Universalinfectionpreventionandcontrol(IPC)strategies/measures........................................................2

CHAPTER2:ManagingDiabetesDuringCOVID-19Pandemic.....................................................................................32.1 Introduction...................................................................................................................................................32.3 SpecificpointsrelatingtodiabetesmellitusandCOVID-19infection...........................................................42.4 RecommendedserviceprovisionduringCOVID-19period...........................................................................8

Chapter3:CANCER....................................................................................................................................................103.1 Introduction.................................................................................................................................................103.2 Cancerprevention.......................................................................................................................................103.3 Cancerscreening.........................................................................................................................................113.4 Cancerdiagnosis..........................................................................................................................................153.5 Cancertreatment........................................................................................................................................153.6 ImprovingStaffPreparedness.....................................................................................................................173.7 Palliativecare..............................................................................................................................................18

Chapter4:CardiovascularDiseases..........................................................................................................................204.1 Introduction.................................................................................................................................................204.2 ManagementofCVDpatientswithandwithoutCOVID-19infection.........................................................214.3 Specificrecommendationsforhealthcareproviders..................................................................................224.5 Specificrecommendationsonuseofpersonalprotectiveequipment(PPE)forHCPandpatients............244.6 CareforAcuteCoronarySyndromeandStroke..........................................................................................26

Chapter5:SickleCellDisease....................................................................................................................................295.1 ManagingSickleCellDisordersDuringtheCOVID-19pandemic.................................................................295.2 ReducingtheriskofCOVID-19inPLWSCD..................................................................................................295.3 ShieldingforPLWSCD..................................................................................................................................295.4 HealthandWellness....................................................................................................................................295.6LivingwithOthers...........................................................................................................................................305.8 SickleCellTrait.............................................................................................................................................315.10RoutineSickleCellDisorderintheContextofCOVID-19.............................................................................315.11 RecommendedserviceprovisionduringCOVID-19period.......................................................................33

ListofContributors....................................................................................................................................................35

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Foreword

Evidence shows that persons living with Non Communicable Diseases (NCDs) are more

Susceptible to COVID-19 infection, havemore severe COVID 19 infection and have higher

case fatality rates.Additionally, thepandemichas resultedtodelays indiagnosisofNCDs

resulting in more advanced disease stages while those previously diagnosed are

experiencingincompleteorinterruptedtherapy.

Thisguideservestoinformtheclinicalteamsandallotherstakeholderscountrywideonthe

approaches to ensure continuity of key Non Communicable Diseases: Diabetes, Cancer,

CardiovascularandSickleCellDiseasesservicesacrossthecontinuumofcare.Thisismeant

tominimizedisruptionofservicesandenablethehealthcareteamstoprotectthemselves

and their clients during the period of this pandemic. As the pandemic evolves, we will

continue to provide further Guidance on Provision of Services for Non communicable

Diseases(NCDs)inKenya.

Dr.PatrickAmothAg.DirectorGeneralforHealthMinistryofHealth

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Acknowlegements

Many individuals and organizations have made insightful guidance and contributions onprovisionofservicesfornon-communicablediseases(NCD)duringtheCovid-19pandemic.

SpecialmentiongoestothedepartmentofNon-communicablediseasesleadby:Dr.WaqoEjersa, Dr. Ephantus Maree, Dr. Gladwell Gathecha, Dr. Mary Nyangasi, Dorcas Kiptui,ZachariaNdegwa,JoanPaulMalenya,Dr.NasirumbiMagero,Dr.ValerianMwendaandDr.StephenMutiso.

The team is grateful to Dr. Benard Gitura, Dr. Benard Samia and Dr. LilianMbau (KenyaCardiacSociety),Dr.OrenOmbiro(PATH).FurthermorewearethankfultoDr.ZipporahAli(KEPHCA), Samuel Mbunya and Prof. Anne Greist (Indiana University), Dr. Eric Njenga(KDSGandAghaKhanUniversity),Prof.JessieGithanga(UniversityofNairobi).

Dr.PacificaOnyancha

Ag.DirectorMedicalServices/Preventive&Promotivehealth

MinistryofHealth

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ListofAbbreviationsandAcronyms

ACS AcuteCoronarySyndrome

BSE Breastself-examination.

CBE Clinicalbreastexamination.

CBE Clinicalbreastexamination.

COVID-19 Coronavirusdisease-2019.

CVDs CardiovascularDiseases

DNA Deoxyribonucleicacid

FOBT Fecaloccultbloodtest.

HPV Humanpapillomavirus.

IPC Infectionpreventionandcontrol.

MOH MinistryofHealth.

NCDs Non-CommunicableDiseases

PPE Personalprotectiveequipment.

SHS Second-HandTobaccoSmoke

UON UniversityofNairobi

VIA Visualinspectionwithaceticacid.

VILI Visualinspectionwithlugol’siodine.

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CHAPTER1:Introduction

1.1 COVID-19:AbriefbackgroundCoronavirusdisease2019(COVID-19)isanovelinfectioncausedbyacoronavirustypethathaspreviouslynotbeenseeninhumans.ItwasfirstidentifiedinWuhan,Chinatowardstheendof2019.TherapidspreadofCOVID-19globallyhasgreatimpactsonthesocio-economicenvironment and on health systems. While most people infected with the Coronavirusexperiencemild tomoderate respiratory illness and recoverwithout needing specializedtreatment, it has been reported that persons aged 60 years and above, and thosewithunderlying NCDs are at higher risk of developing severe forms of the illness. The virusspreadsmainlythroughrespiratorydropletsfromaninfectedpersonthroughcoughingorsneezing.TherearecurrentlynovaccinesorspecifictreatmentsforCOVID-19.Preventionorslowingdownoftransmissionthroughsimplehygienemeasuresremainsthebestapproachtothediseaseatthistime.

1.2 ImpactonNCDsCovid-19 poses new challenges for the NCD agenda globally and in Kenya. It has beenshownthattheinfectionspreadsfastandthattheseverityandoutcomesareworseamonghigh-risk persons, including older persons and those with NCDs such as diabetes,cardiovascular diseases, respiratory conditions, or NCD risk factors exist, such as obesityandsmoking.Inaddition,themitigatingactionsandresponsestotheoutbreakjeopardizeaccesstoandqualityofessentialhealthservicesforNCDsanddisruptlifestyleapproachesfor NCD prevention & control. Supply of medicines and commodities is also disrupted,while the re-prioritizing of funding, including donor funds, may affect the continuity ofNCDsresponsesbothlocallyandinternationally.Furthertothis,thereisahigherprevalenceofmentalhealthconditionsbeingreported.

1.3 PurposeoftheGuidanceCOVID-19posesnewchallengestoNCDservicedeliveryacrossthecontinuumofcare.Theinfectionhasbeenshowntospreadfastwithworseoutcomesinpersonswithpre-existingconditions includingcancer. Theabilitytomaintaindeliveryofessentialhealthservices inCOVID-19 will depend on the local COVID-19 transmission scenario (no cases, sporadic,clusters or community transmission) and the health system capacity as the pandemicevolves. This guide seeks to propose strategies to optimize diagnosis and care of NCDpatientswhile at the same timeofferingpotential options to alleviate theburden to the

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healthcaresystemwhenresourcesmayneedtobedivertedtothedirectcareofpatientsaffected by COVID-19. These recommendations are intended for use as a guide to beapplied through apatient-centered approach and should thereforenot substitute clinicaljudgement.Theyshouldbeadaptedwithconsiderationofthesituationoftheoutbreakandimpact on the health system in respective counties at different points in time.Once theCOVID-19 outbreak is contained, patients should again be managed as per the currentdiseasespecificscreeningandtreatmentguidelines.

1.4 GeneralmanagementofNCDS• IncreaseawarenessofpatientswithNCDsabouttheirheightenedsusceptibilityto

COVID-19andwaystoreducetheriskoftransmissionandrecognizeCOVID-19symptoms:thisactivityshouldalsoincludeinformationregardingtheimplicationsforself-managementofNCDs.

• Createself-managementplans,andsupportself-monitoringofdisease,ifappropriate,thatisbackedupbyhealthcareworkersusingalternativedeliverymechanisms

• Increase home supplies ofmedication and stocks ofmonitoring devices. Patientsshouldhaveaminimumofone-monthsupply

• Modifyroutineclinicalreviews(e.g.frequency,meansofdelivery),asappropriate• WhentreatingpatientsaffectedbyNCDsandCOVID-19, it iscriticaltomonitorthe

side-effectsandinteractionsofmedicines

1.5 Universalinfectionpreventionandcontrol(IPC)strategies/measuresThebasicprinciplesofIPCandstandardprecautionsshouldbeappliedinallhealthcarefacilitiesasoutlined in the existing MOH Interim Infection Prevention and Control Recommendations forCoronavirus Disease 2019 (COVID-19) in Health Care Settings (3-27-2020) – In particular,recommendationsforOutpatientCareandforrationaluseofPPEs.

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CHAPTER2:ManagingDiabetesDuringCOVID-19Pandemic

2.1 IntroductionPeople livingwithdiabetesmellitus (PLWDM)areat increased riskofserious illness fromCOVID-19. Understanding this risk and the best ways to mitigate it is key to enablingpatients,caregivers,andhealthcareprofessionalstomakeinformedchoicesaboutwaystomanagePLWDMduringtheCOVID-19pandemic.PLWDMshouldbealertedontheIllnessesmost likely to have an effect on blood glucose levels (especially if these conditions arefollowedbyafeverorhightemperature):

• Commoncoldorflu,includingCOVID-19• Sorethroat• Urinarytractinfections• Bronchitisorchestinfections• Stomachupsetsanddiarrhea• Skininfectionssuchasabscesses

2.2 ReducingtheriskofCOVID-19inPLWD

PLWD should be advised follow general guidance on risk reduction, including socialdistancing,coughinghygieneandhandwashing.TheyshouldalsoensurethattheypracticegoodglycaemiccontrolduringtheCOVID-19pandemicasitmayhelpinreducingtheriskofinfectionandseverity.

PlanningAheadPeople livingwithdiabetes, their caregivers,andparentsof children livingwithdiabetesshouldworkwith theirhealthcare teamtomakean illnessplan. Theyshoulddiscuss thefollowingaspectsofcare:

• Theirtargetbloodsugargoalduringthestayathomeperiod• Howtoadjusttheirmedicines(forexamplehowtoadjusttheir insulindosageand

whentotakeinsulin)?• Whentocontacttheirhealthcareteamforhelp• Howoftentochecktheirbloodsugarandketonelevels.

WhentocontactahealthcareproviderPeoplelivingwithdiabetesshouldcontacttheirhealthcareteam:

• Iftheyarenotsurewhattodo

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• Iftheyvomitrepeatedly(notabletoholddownanyfoodordrinkformorethansixhours),astheycanquicklybecomeverydehydrated

• Iftheirbloodglucosestayshighformorethan24hours• If they develop symptomswhich could be indicative of their developing diabetic

ketoacidosis. Such symptoms are Vomiting, Rapid breathing with fruity-smellingbreath,AbdominalpainandReducedlevelofconsciousness(drowsiness)

ThefollowingIndividualswithdiabetesareconsideredmostvulnerable:

• Thosewithinadequatelycontrolleddiabetesmellitus,specificallywithaHBA1creading>7.6%orthosewithrecentlyfluctuatingsugars.

• Patientsmorethan55yearsofage.• Patients with diabetes and concomitant comorbidities such as heart failure,

hypertension, chronic obstructive pulmonary disease, chronic kidney disease, cancerand HIV who are already known to have a significant impairment in their immunefunction.

2.3 SpecificpointsrelatingtodiabetesmellitusandCOVID-19infection• It is importanttonotethatthosepatientslivingwithdiabeteswhoarewellcontrolled

with no significant comorbidities have a significantly lower risk of developing severecomplications of COVID-19 and their risk is comparable to that of the generalpopulation.

• TheriskassociatedwithCOVID-19infectionissimilarinindividualswhohaveeithertype1ortype2diabetesexcludingotherriskfactorssuchasage,microandmacrovascularcomplications,comorbiditiesandglycemiccontrol.

• COVID-19infectioninindividualswhohaveeithertype1ortype2diabetescanputthemat a higher risk of developing diabetic ketoacidosis. The same standard treatmentprotocol for managing diabetic ketoacidosis as outlined by the American diabetesassociation (ADA) is used to treat patients with diabetes who develop diabeticketoacidosissecondarytoCOVID-19infection.

3 RoutineDiabetesintheContextofCOVID-19

Outpatientcare• Sensitizationofpatientswithdiabetesfortheimportanceofoptimalmetaboliccontrol• Optimizationofcurrenttherapyifappropriateandensuringthatthepatientshaveadequate

supplyofessentialdrugs(3months’supply)• Caution with discontinuation of established therapy without consulting the health care

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provider• Where possible, utilization of Telemedicine and Community Health Workers strategy to

maintainmaximalself-containment• CounselingofhealthydietsandphysicalactivitybeprovidedtoallPLWD• Toensuremaximumsocialdistancing

o Establishseparateconsultationareasforpeoplelivingwithdiabetes.o ProvidePPEstohealthcareworkersandpatientso Thequeuingsystemshouldensurethatpatientsareatleast2metersfromeachother

InpatientcareIt is important to Monitor all new patients for new onset diabetes in infected patients andManagement of infected patients with diabetes to be done in the ICUwhere possible. It is alsoimportanttomonitorPlasmaglucose,electrolytes,pH,bloodketonestoruleoutDKAorHHSDiabetesemergenciesintheinpatientDiabeticKetoAcidosis(DKA)Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetescharacterizedbyhyperglycemia,ketoacidosis,andketonuriaManagementofDKACheckforclinicalsignsofDKAinclude:Dehydration,tachycardia,tachypnea,deepsighingrespiration,breathsmellsofacetone,nauseaand/orvomiting,abdominalpain,blurryvison,confusion,drowsiness,progressivedecreaseinlevelofconsciousnessand,eventually,lossofconsciousness(coma).Confirmthediagnosis

• Capillarybloodglucosetest>15mmol/L• Urinaryorplasmaketones• PH<7.3orbicarbonate<15mmol/L

Investigations• Blood

§ Urea/electrolytes§ Glucose§ Bicarbonate§ Liverfunctiontests§ Fullbloodcount

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§ Arterial/venousbloodgases§ Cardiacenzymes§ Bloodcultures

• Chestradiograph(CXR)-preferablyportable• Electrocardiogram(ECG)• Cultures: Mid-stream urine (MSU) and other appropriate cultures e.g. cerebrospinal fluid

(CSF)ifmeningitissuspectedManagementofDKA

• FluidsareacriticalpartoftreatingDKA.AdultswithDKAgenerallyneedanaverageof6Lrehydration.Keepafluidbalancechart±urinarycatheterifoutputpoor.ConsiderCVPiffluidstatusdifficulttoassessclinicallyorlikelytoneedICUsupport.

• Insulinisneededtohelpswitchfromacatabolictoananabolicstatewhichwillresultinuptakeofglucoseintotissuesandthereductionofgluconeogenesis.Theendresultistoswitchofftheproductionoffreefattyacidandketones.

• Potassium replacement: Hypo and hyperkalaemia are potentially life-threateningconditionsduringthetreatmentofDKA.CheckK+after2hoursandat4,8,12,16and24hoursoruntiltransfertosubcutaneousinsulin.Checkmagnesiumlevelsat12-24hours.

• Oxygen:shouldbegivenandoxygensaturationsmonitored(aimfor>96%).• Nasogastric tube should be inserted as gastric dilation commonwith increased risk of

aspiration• Conscious level. If GCS reduced, position patient in recovery position and consider

intubationforairwayprotection(lessthan8intubate)• Antibioticsifinfectionsuspected(seeantibioticprotocol)• Heparinprophylaxis

DiabeticHyperosmolarHyperglycemicStateHyperosmolarHyperglycemicState(HHS)ischaracterizedbytheslowdevelopmentofmarkedhyperglycemia (usually >30mmol/L or 540 mg/dl) and usually reading ‘unrecordable’ on theglucometer), dehydration and pre-renal azotemia (elevated blood urea and creatinine).Ketonuriamaybeslightorabsent.Two-thirdsofcasesare inpreviouslyundiagnosedcasesofdiabetesTreatmentInitial treatment is the sameas forDiabeticKetoacidosis; butusually insulin requirements arelower than in DKA and individuals respond well to rehydration. Owing to its high mortality,immediate referral for relevant specialist care is recommended. ECG should be done and

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Heparin/anti-thromboticagentsshouldbegivenintheabsenceofcontraindications.HypoglycemiaHypoglycemia isamedicalemergencyandshouldbetreatedpromptly ifseriouscomplicationsaretobe avoided. It is characterized by blood glucose levels <4 mmol/L. Some patients mightexperience hypoglycemic symptoms at higher blood glucose levels and clinicians shouldindividualizecare.ManagementofHypoglycemia

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2.4 RecommendedserviceprovisionduringCOVID-19periodCategoryofservice DescriptionofservicesEssential Services to bemaintained

InpatientDiabetesSupport• Tomaintainpatientsafetyandpatientflowasabove• Includingsupportfordiabetesfootemergencies

Virtual support (use of CHWs, Peer educators or telephonehelplines)

- Foradmissionpreventionbyprovidingsafetyadvice- Proactivesupportforhighriskgroupsinthecommunity

o Recurrenthospitaladmissionso Recurrentseverehypoglycaemiao HbA1cover11%

- ProvisionofsupportfollowingdischargeDiabetesfootclinics(Forpreventionofamputation)Antenataldiabetesservices

- Tomaintainsafetyforsimilarlyhighriskgroups–shouldbevirtualappointmentswhereverpossible

Urgentfacetofacereviews- Newdiagnosistype1diabetes- Urgentinsulinstart(wherealternativemedicationcannotbe

used)o Patientissymptomatico Ketonesareelevatedo HbA1cabove10%

- UrgenttrainingforglucosemonitoringOtherBloodtestmonitoringisessential

- Decliningrenalfunction- Significanthyponatraemia- Significanthyperkalaemia

Services to be put onhold or provide spacedconsultations

- Allfacetofacestructurededucation- Allnon-urgentdiabetesreviews

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2.5 References1. MinistryofHealthKenya, 2018:KenyaNationalClinicalGuidelines forManagementof

DiabetesMellitus2. DiabetesUK2020:MaintainingAcuteDiabetesServicesinresponsetoCOVID193. InternationalDiabetesFederation2020:Howtomanagediabetesduringanillness“SICK

DAYRULES”4. JosephI.Wolfsdorfetal2017:DiabeticKetoacidosisandHyperglycemicHyperosmolar

State: A Consensus Statement from the International Society for Pediatric andAdolescentDiabetes

5. Stefan R Bornstein et al 2020: Practical recommendations for the management ofdiabetesinpatientswithCOVID-19

6. Press release. ‘AmericanDiabetesAssociation®UpdateonCOVID-19andADAEvents.’March13,2020.Arlington,Virginia.

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Chapter3:CANCER

3.1 IntroductionApproximately70-80%ofcancerpatientsinKenyaareusuallydiagnosedattheadvanced

stagesduetolowawarenessofsignsandsymptoms,inadequatescreening,pooraccessto

diagnosticandtreatmentservices.TheCOVID-19pandemichashadsignificanteffectson

demandandcapacitytodelivercancerservicesacrossthecarecontinuum.Healthworkers

acrossalllevelsofcareshouldcontinuetoprioritizecancersymptomrecognitionand

referralsfordiagnosisandmanagementwhileimplementingtheCOVID-19infection

preventionmeasures.

3.2 CancerpreventionHealthcare providers should advise the public that they should continue taking thefollowingmeasurestoreducetheircancerrisk:

• Avoidingtobaccoinallitsforms,includingexposuretosecondhandsmoke.• Havingahealthydiet:Reduceyourconsumptionof saturated fatand redmeat,which

may increasetheriskofcoloncancerandamoreaggressive formofprostatecancer.Increaseyourconsumptionoffruits,vegetables,andwholegrains.

• Exercisingregularly.Physicalactivityhasbeen linkedtoareducedriskofcoloncancer.Exercise also appears to reduce a woman's risk of breast and possibly reproductivecancers.Exercisewillhelpprotectyouevenifyoudon'tloseweight.

• Maintain healthy body weight:Obesity increases the risk of many forms of cancer.Calories count; if you need to slim down, take in fewer calories and burnmorewithexercise.

• Limitalcohol intake: Excessalcohol increases the riskof cancersof themouth, larynx(voicebox),esophagus(foodpipe),liver,andcolon;italsoincreasesawoman'sriskofbreastcancer.

• Avoid unnecessary exposure to radiation.Get medical imaging studies only when youneedthem.Protectyourself fromultraviolet radiation insunlight,which increases theriskofmelanomasandotherskincancers.

• Avoidexposuretoindustrialandenvironmentaltoxinssuchasasbestosfibers,benzene,aromaticamines,andpolychlorinatedbiphenyls(PCBs).

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3.3 CancerscreeningThe covid-19 situation has negatively affected health-seeking behavior among thegeneralpopulation.It isthereforeessentialtoincreaseawarenesscampaignsthroughmediaandotherfeasiblemeanstoencouragethegeneralpublictoseekconsultationiftheyhavepossiblesymptomsofcancer.

3.3.1Breastcancerscreeningservices

Breast health awareness and education are important in the early detection of breastcancer and can be emphasized at community and primary healthcare level within thecontextofCOVID-19.Althoughmammographyistherecommendedmodeofbreastcancerscreening,breastself-examination(BSE),clinicalbreastexamination(CBE)andultrasoundare complementary to mammography and aid in early diagnosis of breast cancer andshould therefore be used for breast cancer screening and early diagnosis wheneverpossible.

• Asymptomaticwomen:Breastcancerscreeningisanotconsideredurgentforwomenwhoareasymptomaticandthereforemammographyscreeningservicesforthisgroupofwomen shouldbe temporarily suspended.Asymptomaticwomen should thereforebe advised to wait for between 3 to 6 months, or until the pandemic situation iscontained. Clients with appointments should be contacted and informed of thepostponement of their appointments and later on be informed of their newappointmentdateswhenservicesresume.

• Symptomaticwomen:Womenwhohavebreastcancersymptomsshouldbeattendedtoandreferredappropriatelyfortripleassessment(clinicalbreastexamination,biopsyand a diagnostic mammogram) in line with the National Cancer Treatment Protocols2019, but taking into consideration the necessary precautions against COVID-19. Pre-triagingsymptomaticpatientstoscreenforrespiratorysymptomsthroughtelemedicineortelephoneconsultationshouldbeconsideredasappointmentsaremade.

• Over 80% of breast cancer cases in Kenya occurs in women in the average riskpopulation (womenwithout a family history of breast cancer) and recommendationsperagecategoryforwomenwithaverageriskareastabulatedbelow:

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Source:NationalCancerScreeningGuidelines,2018

3.3.2CervicalCancerScreening

Anywomanwhohaseverhadsexualintercourseiseligibleforscreeningbutthetargetagegroup for population-based screening is women aged between 25 to 49 years. Womenaged50to65yearsarestillatriskofcervicalcancerandcanreceivescreeningeveryfiveyears. The Human Papilloma Virus (HPV) test is recommended as the gold standardscreeningmethod although, Visual Inspectionwith Acetic acid (VIA) alone, or combinedwithVisual InspectionwithLugol’s iodine (VILI) andPap smear tests canalsobeusedasprimaryscreeningmethodswherefacilitiesforHPVtestingarenotavailable.

Theguidanceforcervicalcancerscreeningisasfollows:

• Continuationof routinecervicalcancerscreeningserviceswilldependonthestageoftheoutbreakinrespectivecountiesatdifferentpointsintime,asrecommendedintheMOH Interim Guidance on Continuity of Essential Health Services During the Covid-19Outbreak,asfollows:a) Scenario1:Ongoingcommunitytransmissionbutwithfewpredominantlymildcases

inkeyhotspots(noevidenceofwidespreadcommunityCOVID-19infections)In this case, ensure that any woman who comes to the health facility seekingcervical cancer screening services receives the screening services and, asmuch asthisispossible,isnotturnedback.

b) Scenario 2: Rising number of cases in counties (widespread community covid-19infections)

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As thenumberofCOVID-19cases rise, routinecervical cancer screeningshouldbestrategically adapted to allow safe service delivery. The following specificadaptationsshouldbeundertaken:

• Encourageself-samplingforHPVtesting,whereHPVtestingservicesareavailable.CommunityHealthWorkersandHealthCareWorkerscanbetrainedtoofferappropriatecounselingandproperinstructionsoncervicalsamplecollectiontotheclientstoallayanyfearsandensurecollectionofagoodqualitysample.

• Promote appropriate and adequatemanagement of clientswith a positivescreening test and use of telephone communication to relay negativescreeningtestresultstoclients.

• Employa single-visit approach to screeningand treatmentofprecancerouslesions,wherethecapacityexistsandservicescanbesafelydelivered.

• PrioritizeaccesstoscreeningforallwomenlivingwithHIV.

The outbreak situation should be monitored regularly in the county, with a view toreversetheadaptationsandtransitionto restorationofactivitiesasbefore.However,someadaptationsmaybecontinuedforalimitedtime,whileothersthatareseentobeeffective,safeandfavorablecanbeintegratedintoroutinepracticeafterthepandemic.Campaigns can also be organized after the outbreak to make up for missedopportunities.

• Treatment for premalignant cervical lesions should be provided while implementingappropriateinfectionpreventionmeasures.

• ProcessingofHPVDNA&Papsmearsamples:LaboratoriesshouldcontinueprocessinganyHPVandPap smear samples they receiveand to relay the results to the relevanthealthproviders.

• Defer any cervical cancer screening outreaches but consider expansion of access totheseserviceswithinthefacilitythroughintegratedcareapproaches.

Symptomaticwomen:Ensurethatanywomanwithsymptomsofcervicalcancer(suchaspervaginalbleedingduringsexualintercourse,bleedingbetweenperiods,postmenopausalbleeding, abnormal foul-smelling discharge) is counseled and referred appropriately in atimelymannerforcolposcopyandbiopsyfordiagnosisandfurthermanagement.

o At referral, ensure communicationwith the receiving facility to avoid patientsbeingturnedback.

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o Ensurefollow-up&linkagestocareforallclientswhoarefoundtohaveinvasivecancer before the onset or during the COVID-19 pandemic to ensure earlydiagnosis and treatment for better outcomes. Follow-up appointments shouldbescheduledinsuchawayastoavoidcrowdingatthehealthfacility.

3.3.3Colorectalcancerscreening

Thefollowingrisk-stratifiedapproachisrecommendedforcolorectalcancerscreening:

• Average-riskpopulation:Screeningshouldbeinitiatedfrom45yearsofagewithannualfecaloccultbloodtest(FOBT)orcolonoscopyevery10yearswhereavailable.

• Increased-riskpopulation(familyhistoryofcolorectalcancer)andhigh-riskpopulation(hereditary/geneticpredispositionorinflammatoryboweldisease):Screeningshouldbeinitiatedearlierevery5-10years.Colonoscopyistherecommendedscreeningmodality.

InAsymptomaticclients,itisrecommendedthat:• Routinescreeningproceduresshouldbesuspendedandpostponedtoalaterdate• Clients with booked appointments for follow up on benign conditions should be

rebooked.Allattemptsshouldbemade including throughtheuseof tele-medicine toensurepatientsarenotlosttofollowup.

• Clientson followup fordiagnosticproceduresor review formalignancyor suspectedmalignancy shouldbeevaluated in a timelymannerby agastroenterologist/ surgeon,andmanagedthroughamulti-disciplinaryteamapproach.

SymptomaticclientsshouldbereferredappropriatelyforcolorectalcancerscreeningusingcolonoscopyorFOBTonacasebycasebasis.However,pre-screeningofpatientsthroughtelephoneinterviewforrespiratorysymptomsisadvised.

3.3.4Retinoblastoma

HealthcareworkersattheMaternalandChildHealthclinicsarerequestedtoappropriatelyfill theretinoblastomasection in theMCHbookletaftereyeexaminationfordetectionofwhitereflex/cat’seyereflex,squintorproptosisinallchildrenlessthan5yearspresentingat theMCH clinics. Thosewith any abnormalities should be referred immediately to thenextlevelofcarewithanophthalmologistforfurthermanagement.

TheMOHGuidelinesonManagementofPaediatricPatientsDuringCovid-19Pandemic(March,2020) recommends that routine pediatric services should continue countrywide whileensuringthatriskoftransmissionofCoronavirusinfectiontochildren,theircaregiversand

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healthcareworkersisminimized,throughpreferentialuseofsmallerlesscrowdedlevels2and 3 facilities, set up separate space akin to an out-reach post service at high volumefacilities,useofspecificscheduledappointments,etc.

Referral to an Eye Clinic: The child should be referred to the nearest eye clinic forevaluation, accompanied by a referral letter (*in certain cases where eye clinicsin countyhospitals have been shut down in response to the COVID-19 pandemic, the child should bereferredtothenearestopeneyeclinic).Asfaraspossible,thehealthcareworkerreferringthepatientshouldestablishpriorlinkagewithreferralfacilityinformingthemofthereferralandadvisetheparent/guardianonmeasurestominimizeexposureofthechildtoCOVID-19diseasebyfollowingtheMOHguidelinesonIPC.

3.4 Cancerdiagnosis• Thereiscurrentlynoevidencetowithholdcancerdiagnosisanddelayingdiagnosiscan

havenegativeeffectsforcancerpatients.• Increasecampaignstoencouragethegeneralpublictoseekconsultationanddiagnosis

forpossiblesymptomsofcancer.• In a patient newly diagnosed with cancer, it may be reasonable to limit staging

procedures and pretreatment evaluation only to those that are most necessary toinformdevelopmentoftheinitialcareplan.

• Adoption of virtual consultations is encouraged for patients not requiring a physicalexam, or in-office diagnostics. This includes routine surveillance in patientswhohavecompletedtreatmentorthoseonactivesurveillanceconsideredtobeatrelativelylowriskofrecurrenceordiseaseprogression,andthosewhoareasymptomaticduringthefollow-upperiod.

• In the context of COVID-19, facilities are encouraged to establish digital diagnosticplatforms to allow for telepathology and telereporting of pathology specimens tomitigate against longer waiting times for cancer diagnosis that may worsen shouldcancerdiagnosticservicesbehalted.Itshouldbenotedthatalready,majorityofcancerpatients in Kenya are diagnosed late leading to poor treatment outcomes and highmortality rate. Telepathology, therefore, offers an innovative solution for promptdiagnosis,knowledgeexchangeandsharingamongtherelevantpathologistsandinthesettingofthemultidisciplinaryteammeetings.

3.5 CancertreatmentThefollowingcancerpatientsareatahigherriskofhavingseverediseaseif infectedwiththenovelSARS-COV2virus:

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• Thosewhoareundergoingactivechemotherapy, immunotherapy,targetedcancertreatmentsorradiotherapy

• Thosewithcancersofthebloodorbonemarrowsuchas leukaemia, lymphomaormyelomaatanystageoftreatment

• Thosewhohavehadrecentsurgery,bonemarroworstemcelltransplants• Thosetakingimmunosuppressiondrugs.• Thoseadvancedinage(ageover60years)• Thosewithpre-existingcardiovascular,respiratoryorkidneydiseases.

There iscurrentlynoevidencetowithholdcancertreatmentanddelayingtreatmentscanhave negative effects for cancer patients. These guidelines should not replace clinicaljudgement and individualized decision-making is encouraged. Kenya is currentlyexperiencingarisingnumberofCOVID-19casesincounties(widespreadcommunitycovid-19 infections). Although the guidance for this scenario is evolving, the following arerecommended:

1. Incountieswithhighcommunitytransmission,anyclinicvisitsforfollow-uppatientsthatcanbepostponedwithoutanyrisktothepatientshouldbepostponed.

2. Ensure follow-up patients are aware of where and how to access telehealth oronline services for monitoring and self-care. Where clinic visits are absolutelynecessary, ensure proper timing of appointments to reduce time spent at thefacility.

3. Prioritize care for newly diagnosed cancer patients, patients on active treatmentandpatientswithlife-threateningconditionsorclinicallyunstablepatientsincludingthosewithoncologicalemergencies.

4. Forthosewhoneedtoattendparticularlyfortreatment,scheduleappointmentstoreducewaitingtimes.Encouragepatientsnottoarrivetooearly.

5. Consider systemic therapies that can be given in alternative regimens, differentlocationsorviaothermodesofadministrationincluding:

• Changing intravenous treatments to subcutaneous or oral if there arealternatives.

• Selectingregimensthatareshorterinduration.• Considerusing4-weeklyimmunotherapyregimens• Dispensinglongerperiodsfororalmedications.

6. For patients undergoing radiotherapy continue treatment to completion andexploreoptionsforhypo-fractionationwherepossible

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7. Developoncologycareplansandconsiderreferringpatientstotheirnearestcountycancercenterforcarethatcanbeprovidedtheretoreduceunnecessarytravel.

8. Considerhomedeliveryoforalmedicationwherepossible9. UseofGCSForempiricalantibioticsasprimaryprophylaxistoprotectpatientsatrisk

ofneutropeniaandreduceadmissionratesisencouragedwhereappropriate.10. Cancer patients with active COVID-19 infection: Consider withholding all

immunosuppressive oncology treatment until after recovery. Treatment mayresumeafteranegativeCOVID-19result.

11. Cancer patient with suspected COVID-19 infection: consider delayingimmunosuppressivetreatmentfor14daysandprioritizeCOVID-19testing.

Cancer patient with known COVID-19 exposure without symptoms: Consider delayingtreatmentfor14days,requestforaCOVID-19testandallowself-isolationasperguidelines.Routine COVID-19 testing for all cancer patients 48-72 hours before immunosuppressivetherapymaybeconsideredwherefeasible.

3.6 ImprovingStaffPreparedness• EnsureoncologyclinicstaffsreceiveadditionalCOVID-19trainingtoscreenpatients

forpossibleCOVID-19infection.• DevelopStandardOperatingProceduresfor isolatingpotentially infectedstaffand

patientsinconsultationwiththehospital’sCOVID-19surveillanceteam.• EnsureadequatesuppliesofPPEsfortheOncologyclinic.• Staff working at high risk areas such as those performing aerosol generating

proceduresespeciallyforheadandneckcancersorbronchoscopywillneedtodonfullPPE.

• Establish a triage desk. At every appointment, screen patients and ask questionsaboutoverallhealthandrecenttravel.

• Allpersonsattheclinicshouldwearamaskandpracticesocialdistancing.• Patients may be asked to reschedule until they are feeling better if they have

respiratorysymptoms.• Frequently clean and disinfect surfaces with 0.5% chlorine throughout the clinics.

Makesuretodiscardanyremainingdisinfectingsolutionwithin24hours.• Provide“sanitationstations”atallentrances.Thesestationsshouldhavesoapand

water,tissues,handsanitizerwith60%alcohol,andprovisionofamask,ifpossible.

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3.7 PalliativecareThefollowingshouldguidepalliativecaretocancerpatientsduringthisperiod:

• Palliativecareshouldcontinuetobeavailabletocancerpatientsatallstagesoftheirillness.

• Increasepsychosocialsupportforcancerpatientsandtheircaregiversduringthisdifficultperiod.

• Attendtothenutritionalneeds,symptoms&psychological/spiritualneedsofthepatientaswell.

� Identifythosewhoneedtoreceiveinformationaboutthepatient'sillnessaswellashowandwhereyouwilldeliverinformation.

� Ensureappropriate&promptmanagementofdistressingsymptomsandmaintainpatientconfidentiality.

� Makesureyoudebrief-attendtoyourownmental,physicalandspiritualhealth.� BothCOVID-19andnon-COVID-19conditions(forexample,advancedlungcancer,

lymphangitis,carcinomatosis,etc)maycauseseverebreathlessness/distresstowardendoflife.Opiates(morphine)mayreducetheperceptionofbreathlessness.Theyshouldbeprescribedonthetreatmentchartandthetimingofdoseswritteninthechart.

� Innovativesolutionscanbeadoptedtoovercomehealthsystemchallengesduringthisperiodincludingusingtelemedicine,homedrugdelivery,encouragingphonecommunicationbetweenclients,familiesandstaff,allowingpatientrelativestopickupprescriptionsforopioidsforalongerperiodoftimeandgivingsocialsupportfortherelativesbyphone.

� Palliativecareneedsforcancerpatientscanbeassessedandprovidedatthecommunitylevel.

� CancerpatientswithactiveCOVID-19infection:patientswhoareolder,withadvanceddiseaseandsignificantco-morbiditiesinneedofmechanicalventilationwillusuallyhavedismaloutcomes.Proactivediscussionsshouldthereforebeginwiththepalliativecarespecialistsongoalsofcareandadvancedcareplanning.Optimizeprovisionofend-of-lifecareandbereavementservicesforcancerpatientsandtheircaregiverswithincapabilitiesinaccordancewithCOVID-19infectionpreventionmeasures.

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3.8References

1. SocietyofGynecologicOncology-GynecologicOncologyConsiderationsduringtheCOVID-19Pandemic;March23,2020:https://www.sgo.org/clinical-practice/management/covid-19-resources-for-health-care-practitioners/gyn-onc-considerations-during-covid-19/

2. GastroenterologySocietyofKenya-GuidelinesonGastrointestinalEndoscopicProcedures,April2020.

3. MOHInterimGuidanceonContinuityofEssentialHealthServicesDuringtheCovid-19Outbreak.

4. MOHGuidelinesonManagementofPaediatricPatientsDuringCovid-19Pandemic(March2020).

5. MOHInterimInfectionPreventionandControlRecommendationsforCoronavirusDisease2019(COVID-19)inHealthCareSettings(3-27-2020)

6. SurgicalSocietyofKenya-COVID-19:SSKstatementonrecommendationsforsurgicalproceduresandoutpatientclinics;16thMarch2020https://www.ssk.or.ke/wp-content/uploads/2020/03/SSK-covid-19-statement.pdf

7. InterimInfectionPreventionandControlRecommendationsforCoronavirusDisease2019(COVID-19)inHealthCareSettings

8. TheKenyaNationalCancerScreeningGuidelines,20189. TheKenyaNationalCancerTreatmentProtocols,201910. WorldHealthOrganization:CancerPrevention.Availableat

https://www.who.int/cancer/prevention/en/.AccessedonMay5,2020.11. CentersforDiseaseControlandPrevention.InterimInfectionPreventionandControl

RecommendationsforPatientswithSuspectedorConfirmedCoronavirusDisease2019(COVID-19)inHealthcareSettings.Availableathttps://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html.AccessedJune15,2020.

12. AmericanSocietyofClinicalOncology(ASCO):COVID-19Provider&PracticeInformation.Availableathttps://www.asco.org/asco-coronavirus-information/provider-practice-preparedness-covid-19.AccessedonMay19,2020.

13. WorldHealthOrganization(WHO)(2018).Integratingpalliativecareandsymptomreliefintotheresponsetohumanitarianemergenciesandcrises:AWHOguide.Retrievedfrom:https://apps.who.int/iris/bitstream/handle/10665/274565/9789241514460-eng.pdf?sequence=1&isAllowed=y.AccessedonMay5,2020.

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Chapter4:CardiovascularDiseases

4.1 IntroductionTheanalysisofepidemiologiccharacteristicsamong theearlycases inChinashowedthatolder individuals, and people who have serious chronic medical conditions likecardiovasculardiseaseareatriskofsevereillnessonceinfectedbyCOVID-19(WHF,2020).Globally, there is a high prevalenceof cardiovascular disease, >7% of patients experiencemyocardial injury from the infection and up to 22% of critically ill patients have a CVD(ClerkinKevinJ.etal.,2020).

ConsiderationsformanagementofPatientwithCVDduringCOVID19Pandemic:

• Patients with underlying conditions are at higher risk for complications ormortality—up to 50% of hospitalized patients have a chronic medical illness (40%cardiovascularorcerebrovasculardisease)3.

• Individuals with CVDs and associated risks such as hypertension, diabetes andsmokingareathigherriskofseverediseaseanddeath2,3.

• Covid-19 infection has been associated with multiple direct and indirectcardiovascular complications including acute myocardial injury, myocarditis,arrhythmiasandvenousthromboembolism1.

• WiththeincreaseinfocustowardsresponsetoCOVID-19,potentialforcompromisein the rapid triage of non-COVID-19 patients with cardiovascular conditions mayresult2.

• Cardiovascular health care workers are at the frontline of managing COVID-19infected patients and thereforemeasures should be put in place tominimize thisrisk2.

• COVID-19 infection may have longer-term implications for overall cardiovascularhealth however long-term follow-up data concerning the survivors of respiratoryvirusepidemicsarescarce3.

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Figure1:RiskfactorsandpotentialCVsequelaewhichmayresultfromCOVID-19infection2

Specifically,thisguidanceprovidesrecommendationsforthefollowing:

I. ManagementofCVDPatientswithandwithoutCOVID-19infectionII. Use of personal protective equipment (PPE) for HCP and patients Provision of

cardiacproceduresIII. SafeProvisionofcardiacprocedures(Echocardiography,Cardiaccatheterization)IV. County preparedness for the provision of CVD services during the COVID-19

Pandemic

4.2 ManagementofCVDpatientswithandwithoutCOVID-19infectionSpecificrecommendationsforpreventionofinfectioninCVDPatients

a) Continuetakingyourmedicationandensureyouhaveenoughdrugstolastamonthormore.

b) Measureyourbloodpressureregularlyathomeandcontactyourhealthproviderincaseofelevatedbloodpressure.

c) Alwayswearamaskwheninpublicplacesorincontactwithotherpeopled) Keepadistanceofatleastonemeterwheninpublicplaces.e) Avoidtouchingyoureyes,nose,andmouthwithunwashedhands.f) Avoidclosecontactwithothers(atleast2meterssocialdistance)especiallythose

whoaresick.g) Cleananddisinfectfrequentlytouchedsurfacesdaily.Thisincludestables,

doorknobs,lightswitches,countertops,handles,desks,phones,keyboards,toilets,

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faucets,andsinks.Ifsurfacesaredirty,cleanthemusingdetergentorsoapandwaterpriortodisinfection.

h) ImmediatelycontactahealthcareworkerorthenearesthealthfacilityifyouhavebeenexposedtoCOVID-19anddevelopafeverandsymptoms,suchascoughordifficultybreathing

i) Eatinghealthydiets,withplentyoffruitsandvegetables(MOH)j) Washyourhandsoftenwithsoapandwateroralcohol-basedsanitizerforatleast20

seconds.k) Beawareofyourhealthstateandifyouexperiencesymptoms,visitthenearest

hospital.l) Avoidfoodshighinsaltandeatabalanceddiet.m) Keepphysicallyactive–undertakeregularexercises,walkaround,andstretchat

homen) Avoidunnecessaryvisits.o) Donotattendpublicgatherings.p) Getintouchwithfriendsandfamilyovertelephone.q) Ifpossible,sendotherstoshopforyourfood,medicine,andotherrequirements.r) Avoidalcoholandsmoking(Ref:WHO,WHF)s) Incaseyouexperiencedifficultyinbreathing,headache,swellingofthelegs,face

puffiness,dizziness,increasedheartbeat,chestpain,alteredspeechandgeneralweakness,callthehealthfacilityorhealthcareprovider

t) FollowanyadditionalinstructionsfromtheMinistryofHealth

4.3 Specificrecommendationsforhealthcareprovidersa) Minimizenon-essential/non-urgentin-personprovider-patientinteractionsasmuchas

possible.

b) Considertemperaturescreeningbeforeclinic/facilityentry.

c) Reviewcurrentschedulesdaysinadvancewithagoalofidentifyingestablishedpatientsthat:

a. Canbesafelyrescheduled>3months

b. Canbeseenvirtually(e.g.telephone,telemedicine)foractiveissues

c. Mustbeseenface-to-face(traditionalvisit)

d) Staggerorspaceoutappointmentsforthosewhomustbeseenface-to-facetoreducethenumberofpatientsintheofficeandwaitingareas.

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e) Utilizetelemedicineore-visitstoconsultandtriagepatientsespeciallythosewithpre-existingCVDwhoarehigherrisk.ThiswillbeminimizingexposureofpatientsandHCPs(especiallyelderly)topotentialinfection.

f) ItisimportantforpatientswithCVDtoremaincurrentwithvaccinations,includingthepneumococcalvaccinegiventheincreasedriskofsecondarybacterialinfectionwithCOVID-19.

g) Limitelectivecardiacproceduressuchascardiaccatheterization,operations,andechocardiographytoonlythosethatarenecessary.

h) Forproceduresthatarenecessary,numbersofpersonnelshouldbekeptatminimal.

i) TriageofpatientswithCOVID-19shouldtakeintoconsiderationunderlyingcardiovasculardiseaseaswellasothercomorbiditiessuchasdiabetes,cancer,respiratoryandrenal.

j) ConsideringtheanticipatedincreaseinnumbersofpatientinfectedwithCOVID-19,hospitalprotocolsshouldbedevelopedforthecareofacuteandchronicCVpatientswithandwithoutCOVID-19consideringthestretchedresources

Figure2belowsummarizesthekeyconsiderationswhenmanagingCVDpatientswithandwithoutCOVID-19infection.

Figure2:KeyconsiderationsformanagementofpatientswithandwithoutCVD1

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4.5 Specificrecommendationsonuseofpersonalprotectiveequipment(PPE)forHCPandpatients

a) Patients with suspected/probable or confirmed infection should wear disposablesurgicalmaskswheninaroomwithotherpersons

b) CVD patients accessing diagnostic or therapeutic services ay the health facilitiessurgicalmaskstoprotectthemselves

c) ThelevelofprotectionofHCPdependsonpatientriskstatus,settingandprocedureperformed.Thisisclearlyoutlinedinthetablebelow.

d) Every health facility should triage patients and categorize them as eitherprobable/suspected or not probable/suspected or negative case. For the former,HCPsshoulduselevelIIprotectionswhileforthelatter,levelI.

e) Patientsadmittedinthecardiologywardshouldbeconsideredpossibleinfectedandmanaged with level II or III protection as they await test results. They shouldpreferablybemanagedinadedicatedarea/ward.

f) It is recommended that confirmed/probable and suspected cases have dedicatedequipment including BP cuffs, stethoscopes, and thermometers. If this is notpossible,theequipmentshouldbeappropriatelydisinfected.

g) BeforeprovidingconsultationintheED, ifpossible,performquicktriageonphoneandestablishofthepatienthassuspectedCOVID-19symptomsorriskfactors.Iftheconsult is urgent and there is not time to wait for the results, the HCP shouldconsider the patient positive and se Level II protection (Level III is performingaerosol generatingprocedure.Otherwise, theother EDpatients canbe seenwithlevelIprotection.

h) CatheterizationLaboratoryi. Allpatientaccessingthisshouldhavesurgicalmasksii. ST-Segment Elevation Myocardial Infarction (STEMI): Due to urgency, immediate

reperfusion strategy shouldbe implementedwithprecautions forCOVID infectionuntil provenotherwise. Facilities that are able to doprimary PCI should offer thistreatment while Pharmacoinvasive approach with thrombolysis and latercatheterization and PCI can be used in those not getting primary PCI. Eitherstrategy/procedure should be performed even before results of the tests areavailable.Wherecommunity transmission ishigh,assumeallpatientsareCOVID-19positiveanduseappropriatePPE.

iii. Non-ST-SegmentElevationMyocardialInfarction–:Ifhighrisk,manageasSTEMI.Allothersshouldhaveaswabdoneimmediatelyandkeptinadedicatedarea.When2tests are negative and there are no suspicious symptoms, perform coronary

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angiographyandPCIinacatheterizationlaboratoryforCOVID-19negativepatients.If the test is positive and an invasive approach is required, use a dedicatedlaboratory.Performasmanyroutineproceduresatthebedsidebeforetransportingthepatient to the laboratory.Minimize the staff in the laboratory andhave themwearLevelIIorIIIPPE.

iv. Transesophageal Echocardiography, Continuous Positive Airway Pressure andOrotrachealIntubationPatients:ThesepatientsshouldbetestedforCOVID-19andiftherearetwonegativetestsandnosuspicioussymptoms,theprocedureshouldbeperformedusing standard protocols. For positive COVID-19 patients, performing afocusedultrasound(POCUS)examatthebedsideifpreferred.

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Table1:SummaryofCOVID-19PersonalProtectionManagement6

4.6 CareforAcuteCoronarySyndromeandStroke1) MaintainemergencycaresystemsandprotocolsformanagingACSandstroke.2) ModifyACSandstrokenetworks(hubandspoke+differentiatedpathways),

accordingtopatient’sCOVID-19status.3) Maintaintime-sensitiveinterventions(e.g.thrombolysis,thrombectomy).4) Developsafeoptionsforrehabilitationduringinpatientcare.5) Recognizepotentialmedicineinteractionsandcardiovasculartoxicitiesofseveral

off-labelmedicinesusedforCOVID-19treatment.6) Prioritizefollow-upconsultationswithstrokesurvivorsbecausetheyareathigher

riskofpneumonia.4.7Specificrecommendationsforcountyhealthfacilitiespreparedness

• Healthsystemmanagersshouldensurethatthefollowingstepsaretakenduringpreparation.

• AdequateSuppliesandCommodities• CountiesneedtomapsuppliesandsupplychainsforCVDessentialmedicines,and

otherhealthproductsandtechnologies.• Theyshouldensurethatforecastingandquantificationofessentialdrugsand

nutritioncommoditiestoensureminimaldisruptionofessentialservices.

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• AdequatelyquantifyandmakeavailablesuppliesofPPEs,sanitizers,soapanddisinfectantsforthePrimarycarefacilitiesisdone.

4.8ReorganizationofPatientFlow

• Organizepatientflowtoensurephysicaldistancing,andprovideguidanceforpatientsandstaffe.g.throughdrawingsofclearareas

• Changeprotocolsforkeygroupstoallowforreducedpatient-doctorcontacte.g.biggerprescriptionsforCVDpatients.

4.9Referralsystems

• Thereshouldbeaneffectiveandreadilyavailablereferralsystem/protocolfortheCardiovascularDiseasepatients.

• SeparateambulanceservicessothatvehiclesusedforCOVID-19responsearenotusedforotherresponses

SensitizationandTrainingofallStaffonmanagementofcardiovasculardiseasepatients,whotestedpositiveforCOVID-19.

TherearevariousvirtualtrainingscurrentlyrunningattheNationallevelthroughtheMinistryofhealth,andstakeholdersfromotherprofessionalassociations.

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4.10References

1. CDC.AreYouatHigherRiskforSevereIllness|CDC[Internet]?[cited2020Mar22].Available from: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html

2. Driggin E,MadhavanMV, Bikdeli B, Chuich T, Laracy J, Bondi-Zoccai G, Brown TS,NigoghossianCD,ZidarDA,HaytheJ,BrodieD,BeckmanJA,KirtaneAJ,StoneGW,Krumholz HM, Parikh SA, Cardiovascular Considerations for Patients, Health CareWorkers, and Health Systems During the Coronavirus Disease 2019 (COVID-19)Pandemic, Journal of the American College of Cardiology (2020), doi:https://doi.org/10.1016/j.jacc.2020.03.031

3. Tian-YuanXiong,SimonRedwood,BernardPrendergast,MaoChen.Coronavirusesand the cardiovascular system: acute and long-term implications,European HeartJournal,ehaa231,https://doi.org/10.1093/eurheartj/ehaa231

4. America College of Cardiology. COVID-19 Clinical Guidance For the CardiovascularCare Team. https://www.acc.org//~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/2020/02/S20028-ACC-Clinical-Bulletin-Coronavirus.pdf

5. Fry E. COVID-19 Operational Considerations - American College of Cardiology[Internet]. 2020 [cited 2020Mar 22].Available from:https://www.acc.org/latest-in-cardiology/articles/2020/03/20/10/42/covid-19-coronavirus-operational-considerations

6. EuropeanSocietyofcardiology.ESCGuidancefortheDiagnosisandManagementofCVDiseaseduringtheCOVID-19Pandemic.2020;1–115.

7. World Health Organisation. Maintaining essential health services: operationalguidancefortheCOVID-19context

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Chapter5:SickleCellDisease

5.1 ManagingSickleCellDisordersDuringtheCOVID-19pandemicPeople living with Sickle Cell Disorders (PLWSCD) are at increased risk of serious illnessfromCOVID-19.Understandingthisriskandthebestwaystomitigateit iskeytoenablingpatients,caregivers,andhealthcareprofessionalstomakeinformedchoicesaboutwaystomanagePLWSCDduringtheCOVID-19pandemic.

5.2 ReducingtheriskofCOVID-19inPLWSCDPLWSCDshouldbeadvisedfollowgeneralguidanceonriskreduction,includingsocialdistancing,coughinghygieneandhandwashing.Hereisanoverviewofthetypesofguidanceandwhotheyapplyto:

• Foreveryone:Stayingalertandsafe(socialdistancing)–thisincludesanyonewithsicklecelltrait(sicklecellcarriers)

• Forallpatientswithasicklecelldisorder(e.g.HbSS,HbSBetathalassaemia,HbSC,HbSD,HbSO)-shielding(seebelow)

5.3 ShieldingforPLWSCDShieldingisameasuretoprotectclinicallyextremelyvulnerableindividualsbyminimisinginteractionbetweenthosewhoareclinicallyextremelyvulnerableandothers.Thisincludesallpatientswithsicklecell(e.g.HbSS,HbSBetathalassaemia,HbSC,HbSD,HbSO).• Strictlyavoidcontactwithsomeonewhoisdisplayingsymptomsofcoronavirus

(COVID-19)–hightemperatureand/ornewandcontinuouscough• Donotleaveyourhouseforanyunnecessaryvisit• Donotattendanygatherings(includinggatheringsoffriendsandfamiliesinprivate

spacesforexamplefamilyhomes,weddingsandreligiousservices)• Donotgooutforshopping,leisureortravel• Keepintouchusingremotetechnologysuchasphone,internet,andsocialmedia

5.4 HealthandWellnessGiventheveryunusualcircumstancesthatshieldingcreates,itisimportanttobeawareofwaystokeeponeselfasfitandhealthyaspossible.FoodsthatcontainVitaminDsuchasoilyfishandeggsareimportantasVitaminDdeficiencyisverycommonnotonlyinthegeneralpopulationbutalsoinsicklecelldisorderandmayexacerbatebonepain.Sunlight

30

onbareskinisagoodwaytoincreaseVitaminDintakesoeveryopportunityshouldbetakentobenefitfromthesun,ifonlyatanopenwindoworonabalcony,ifsittinginagardenisnotfeasible.

Takingregularmoderateexerciseisnotonlygoodforphysicalhealthbutalsoimprovesgeneralmoodandhelpsoverallmentalhealth.Veryrigorousexercisingisnotrecommendedinsicklecelldisordersandiftheweatherishotcareshouldbetakentodrinkplentyoffluids.

5.6LivingwithOthersForpeoplelivingwithotherstheremaybeconcernsabouthowtoeffectivelyshieldoneselfwhilstsharinglivingquarters.Belowisguidanceifyouhaveasicklecelldisorderandyoulivewithotherpeople.Althoughtheotherpeopleyoulivewithdonotneedtofollowshieldingguidelines(unlesstheyalsofallintoaclinicallyextremelyvulnerablecategory),everyoneinthehouseshoulddowhattheycantosupportyouinshieldingandstrictlyfollowthespecificadvicebelowandgeneralsocialdistancingadvice.• Trytominimizethetimespentwithotherpeopleinsharedspaces(kitchens,

bathrooms,sittingareas)• Keepsharedspaceswellventilated• Aimtokeep2metersdistancebetweenhouseholdmembers,andsleepinaseparate

bedwherepossible• Ifpossible,useaseparatebathroomfromtherestofthehousehold• Ifyoudoshareatoiletandbathroomwithothers,itisimportantthattheyaresanitized

aftereveryuse.• Ifyoushareakitchenwithothers,avoidusingitwhiletheyarepresent5.7HospitalAppointments

• Healthfacilityappointmentsshouldbescheduled,andconfirmationsdonebytelephoneifpossible,toavoidpatientscrowdinginthewaitingarea.

• HospitalcareteamsshouldtryasmuchaspossibletoofferpatientstelephoneorvideoconsultationsduringtheCOVID-19outbreak.

• Healthfacilitiesshouldofferemergencycareforsicklecrisisandothercomplicationson24-hourbasis

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5.8 SickleCellTraitPatientswithsicklecelltraitmayfollowtheguidancegiventothegeneralpublic.SickleCellTraitPatientsarenotmorevulnerabletocoronavirusinfectionthanthegeneralpopulation5.9SpecificpointsrelatingtoSickleCellDisordersandCOVID-19infection

• Patientswith sickle cell diseaseareprone toacute chest syndromewhose symptomsmirror those of COVID-19 infection. These two conditionsmay also superimposeovereachotherworseningeither condition.Ahigh indexof suspicion is requiredwith theclinicianbeingrequiredtotestforbothandmanagetheconditionsappropriately

• Differentials to fever include other viral infections, bacteremia and urinary tractinfections

• SickleCellDiseasepatientstendtobeveryyoungandthisshouldnotbeoverlookedininvestigationforCOVID-19

5.10RoutineSickleCellDisorderintheContextofCOVID-19Outpatientcare• Optimizationofcurrenttherapyifappropriateandensuringthatthepatientshaveadequatesupply

ofessentialdrugs(3months’supply)• Cautionondiscontinuationofestablishedtherapywithoutconsultingthehealthcareprovider• Where possible, utilization of Telemedicine and Community HealthWorkers strategy tomaintain

shielding• CounselingonhealthydietsandphysicalactivitybeprovidedtoallPLWSCD• Toensuremaximumsocialdistancing

o Establishseparateconsultationareasforpeoplelivingwithdiabetesandcancer.(?)o ProvidePPEstohealthcareworkersandpatientso Thequeuingsystemshouldensurethatpatientsareatleast2metersfromeachother

InpatientcareItisimportanttoidentifywhichcomplicationhasprecipitatedthepatient’sadmissionandmanagethesickle cell disease while the management for COVID-19 is ongoing. PLWSCD / COVID-19 should bemanagedintheICUwherepossiblebymultispecialtyteamsinthecaseofabnormalchestradiographsinpatientssuspectedtohaveacutechestsyndrome.SickleCellDiseaseemergenciesintheinpatientsettingAcutePainCrisisIfapatientpresentwithpainitisimperativetotreatthepainfirstandmakethepatientcomfortableas

32

themanagementforCOVID-19continues.ThiscanbedonewithanalgesicssuchasNSAIDsand if thepainissevereopioidssuchascodeinecanbeusedbutrespiratoryfunctionmustbemonitored.BecausepatientswithSCDhaveahistoryofmanyadmissionsovertheirlifetime,andbecausedehydrationisacommonproblem, venous accessmaybe limitedwarrantinguseof subcutaneous injections and / orinfusionswhereneededasashort-termalternative.Encouragepatientstoregisterwithpalliativecareunitsforpainmedicationandpsychosocialsupport.

ChronicPainCrisisThistendstobeneuropathicinnatureandcanbemanagedbyacombinationofpharmacologicaswellasothertherapiessuchasmassageandmusclerelaxationdependingonthelocalizationandcharacterofthepain.

AcuteChestSyndromeThis is characterized by fever and/or respiratory symptoms and a new pulmonary infiltrate on chestradiographwhichmaymimicCOVID-19symptomsInchildrenthiscanhaveamultifactorialcausationrangingfromvaso-occlusivecrisestoinfections,fatembolism and infarction. Management includes intravenous fluids, analgesics, inventive spirometry,supplemental oxygen with arterial blood gases monitoring, respiratory support, antibiotics andtransfusion therapy. In adults hydroxycarbamide (hydroxyurea) may be useful in severe cases inaddition to the above measures, in order to decrease the risk of recurrence after the patient hasrecovered.Hydroxyureadoesnotprovidebenefitintheacutesetting.

SplenicSequestrationCrisisInthiscrisisthereisarapiddropinhemoglobinduetovaso-occlusioncombinedwithincreaseinspleensize due to pooling of red blood cells in the spleen. It is common in children where it can causehypovolemic shock with a palpable spleen and left upper quadrant pain among other signs andsymptoms. Aggressive fluid hydration and transfusion are the mainstays of treatment. Ultimately,splenectomymayberequiredHyperhemolyticCrisisDuetoabnormalshapeofsicklecells there isongoinghemolysisthatresults in lowhemoglobinonachronicbasis.A combinationof factors suchas stress, infectionorevenmedications can lead to thepatient complaining of weakness, fatigue, or even exertional dyspnea. Management includestransfusion as the first line. Hyperhemolysis may occur as a manifestation of a delayed hemolytictransfusion reaction, inwhich case there is a history of preceding transfusion in the recent past. Inthese cases, theremay be a role for intravenous immunoglobulins (IVIG) and steroids in addition tosupportivecare.

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5.11 RecommendedserviceprovisionduringCOVID-19periodCategoryofservice DescriptionofservicesEssential Services to bemaintained

OutpatientCare• Laboratoryinvestigations • Provisionofmedication• GeneticCounseling • Rehabilitationservicesincludingphysiotherapy

InpatientSickleCellDisease

• Tomaintainpatientsafetyandpatientflowasabove• Includingsupportforemergencies

Virtualsupport(useofCHWs,Peereducatorsortelephonehelplines)- Foradmissionpreventionbyprovidingsafetyadvice- Proactivesupportforhighriskpatients

o Recurrenthospitaladmissionso Recurrentsevereanemiaandothercomplications

- Provisionofsupportfollowingdischarge-

Services to be put onhold or provide spacedconsultations

- Allfacetofacestructurededucation- Allnon-urgentsicklecellreviews

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5.12References

1. SickleCellEmergencies:RyanPeterfy,KevinTomecsek2. Guideline on the management of acute chest syndrome in sickle cell disease: JO

Howard,NicholasHart,etal3. COVID-19ResourceCentre:Guidelinesaimtoensurepropercareofpatientswithsickle

celldiseaseamidCOVID-19pandemic-Hematology–Oncologytoday4. Coronavirus(COVID-19)&SickleCellDisorder:SickleCellSociety5. Interim Guidance on Continuity of Essential Health Services during the COVID 19

Pandemic

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ListofContributors

No Organization Organization1 Dr.WaqoEjersa MOH-DNCD2 Dr.EphantusMaree MOH-DNCD3 Dr.MaryNyangasi MOH-DNCD4 Dr.GladwellGathecha MOH-DNCD5 Ms.DorcasKiptui MOH-DNCD6 Mr.ZachariaNdegwa MOH-DNCD7 Dr.JoanPaulMalenya MOH-DNCD8 Dr.NasirumbiMagero MOH-DNCD9 Dr.ValerianMwenda MOH-DNCD10 Dr.StephenMutiso MOH-DNCD11 Dr.ZipporahAli KEPHCA12 SamuelMbunya IndianaUniversity13 Prof.AnneGreist IndianaUniversity14 Prof.JessieGithanga UON15 Dr.OrenOmbiro PATH16 Dr.EricNjenga KDSG and Agha Khan

University17 Dr.BenardGitura KenyaCardiacSociety18 Dr.BenardSamia KenyaCardiacSociety19 Dr.LilianMbau KenyaCardiacSociety