Quyết định 468/QD-BYT

DECISION

ON GUIDELINES FOR INFECTION PREVENTION AND CONTROL FOR COVID-19 ACUTE RESPIRATORY DISEASE IN HEALTHCARE ESTABLISHMENTS

THE MINISTER OF HEALTH

Pursuant to the Government’s Decree No.75/2017/ND-CP dated June 20, 2017 on functions, duties, powers and organizational structure of the Ministry of Health;

At the request of the Head of the Medical Service Administration and Ministry of Health,

HEREBY DECIDES:

Article 1. Promulgated together with this Decision is the guidelines for infection prevention and control for COVID-19 acute respiratory disease in healthcare establishments.

Article 2. This Decision takes effect from the date on which it is signed.

Article 3. Head of Office of the Ministry of Health; Chief Inspector of the Ministry of Health; heads of affiliates of the Ministry of Health; Directors of Departments of Health of provinces and central-affiliated cities; directors of hospitals and institutes with hospital beds affiliated to the Ministry of Health; heads of health units of other Ministries and regulatory bodies and heads of relevant units shall implement this Decision./.

GUIDELINES

FOR INFECTION PREVENTION AND CONTROL FOR COVID-19 ACUTE RESPIRATORY DISEASE IN HEALTHCARE ESTABLISHMENTS

 (Enclosed with Decision No. 468/QD-BYT dated February 19, 2020 by Minister of Health)

TABLE OF CONTENTS

Interpretation of terms

Strategies, rules and measures for control of COVID-19

Screening, admission and isolation of confirmed or suspected COVID-19 cases

Guidelines for establishment of isolation areas in healthcare establishments

Use of personal protective equipment

Hand hygiene

Handling of equipment

Handling of textile items

Handling of tableware

 Cleaning and disinfection of environmental surfaces

Cleaning of vehicles transporting confirmed or suspected COVID-19  cases

Waste handling

Collection, preservation, packing and transport of patient samples

Prevention of laboratory-acquired infection of COVID-19

Handling of remains of confirmed or suspected COVID-19 cases

Guidelines for COVID-19 prevention for family members and visitors

Appendixes

References

INTERPRETATION OF TERMS

For the purposes of these guidelines, the terms below shall be construed as follows:

“anteroom” means a small room leading from a corridor into an isolation room where equipment necessary for the isolation room is prepared.

“health care worker” means any staff or worker of a healthcare establishment that is involved in the diagnosis, treatment or care of a patient (including doctors, nurses, medical technicians, physical therapists, social workers, psychiatrists, pharmacists, janitors, etc.).

“contact transmission” refers to the most common route of transmission, which is divided into 2 types:

- Direct contact transmission, where microorganisms are transmitted without intermediaries from one person to another person via direct contact between a tissue or a level of organization of the body  (including skin and mucous membranes) of one person and the skin or a mucous membrane of another person.

- Indirect contact transmission via contact with contaminated objects.

Contact transmission is the major route of transmission of microorganisms from a patient to another patient or from a health care worker to a patient or vice versa.

Health care workers who come into direct or indirect contact with patients or blood or other bodily fluids from patients face the risk of infection or spreading infection in healthcare establishments.

“droplet transmission” means a route of transmission in which a mucous membrane of a susceptible person (nasal mucosa, ocular mucosa or, rarer, oral mucosa) comes into contact with droplets containing pathogens equal to or larger than 5μm. These droplets, which contain pathogenic microorganisms, are produced after coughing, sneezing, talking or certain procedures (suction, endotracheal intubation, chest physical therapy, cardiopulmonary resuscitation, etc.). Droplet transmission takes place upon close contact (less than 2 meters between the patient and the susceptible person). Common droplet-transmitted pathogens are microorganisms causing pneumonia, whooping cough, influenza, SARS, mumps, Ebola, COVID-19, etc.

“occupational exposure” means direct contact between a mucous membrane or broken skin and blood, tissues or another bodily fluid containing pathogens or direct contact with harmful radiation or chemicals made by health care workers while they are working. Occupational exposure may occur via skin damage (punctures caused by needles or sharp objects), contact with mucous membranes (e.g., ocular mucous membrane, nasal mucosa, or oral mucosa) and contact with broken skin.

“standard precautions” means a set of basic precautions applied to all patients in healthcare establishments, regardless of their diagnosis, infection status and care time, by treating all bodily fluids (excluding sweat) and excreta as potentially infectious. Standard precautions must be used in the care of all patients in healthcare establishments regardless of their diagnosis and infection status.

“transmission-based precaution” means precautions against the 3 major routes of transmission during medical examination and treatment which are contact transmission, droplet transmission and airborne transmission.

“personal protective equipment” (“PPE”) means the equipment that health care workers wear to protect themselves from infection when in close proximity with patients. PPE can also protect patients against residential and transient microorganisms from health care workers. Common PPE includes gloves, masks, waterproof aprons, gowns, caps, safety goggles, face shields, boots or shoe covers, etc. PPE is selected based on the potential route(s) of transmission.

“hand hygiene” includes washing hands with soap and clean water or with an alcohol-based sanitizer or with an alcohol-based sanitizer and a disinfectant.

“aerosol generating procedure” means any medical procedure that results in the production of airborne particles (aerosols) capable of remaining in the atmosphere from the respiratory fluid of a patient such as bronchoscopy, endotracheal intubation, tracheotomy, cardiopulmonary resuscitation, non-invasive ventilation, etc.

“air change per hour” (“ACH” or “ACPH”) means the number of times the air volume of an area (usually a room or a limited area) circulates in an hour. If the air is uniform or perfectly mixed, ACH measures the number of times the air within a defined space is changed.

E.g. A room of 30 m³ having 12 ACH means that the amount of air enters and exits that room in an hour is 30 m³ x 12 = 360m³.

“medical mask” or “surgical mask” means the type of facemask daily worn by health care workers in healthcare establishments during medical procedures or contact with patients with droplet-transmitted or airborne diseases. In Vietnam, the group of TCVN 8389-2010 standards provides for medical masks, which includes:

- TCVN 8389-1:2010: Normal medical face mask.

- TCVN 8389-2:2010: Medical face mask preventing bacteria.

- TCVN 8389-3:2010: Medical face mask preventing of toxic chemicals.

In these guidelines, “medical mask” refers to masks of the TCVN 8389-2 standard or equivalent.

“respirators mask” in these guidelines refers to the facemasks meeting the N95 standards of National Institute for Occupational Safety and Health (NIOSH) of the United States or the FFP2 standards of the European Union (EU) or equivalent (hereinafter referred to as “N95 mask”).

STRATEGIES, RULES AND MEASURES FOR CONTROL OF COVID-19

1. Overview of coronaviruses and COVID-19

Coronaviruses (CoV) are a large group of viruses that cause diseases in humans and animals. The family coronaviridae is divided into 4 genera, including alphacoronavirus and betacoronavirus, which are capable of causing illness in humans ranging from the common cold to more serious diseases. Approximately 30% of upper respiratory tract infection is caused by 229E and OC43 viruses from the genus alpha-CoV and NL63 and HKU1 viruses from the genus beta-CoV. Beta-CoV is the cause of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), which cause severe pneumonia and possibly lead to death.

Coronaviruses are spherical with diameters of approximately 125 nm and spike-shaped proteins projecting from the surface. They contain four main structural proteins, which are the spike (S), membrane (M), envelope (E), and nucleocapsid (N) proteins. Inside the envelop is the single-stranded and helically symmetrical nucleocapsid. Coronaviruses have positive-sense, single-stranded and non-segmented RNAs of about 30 kb.

Exhibit 1. Structure of a coronavirus

In April 2012 in Saudi Arabia, a patient was hospitalized for pneumonia and acute kidney injury, which eventually led to death. This was the first casualty caused by a new strain of virus. Shortly afterwards, many other patients who had resided in or traveled through Saudi Arabia exhibited similar symptoms. The pathogen was later identified as a new strain of coronavirus capable of causing acute respiratory syndrome, which was then given the name Middle East Respiratory Syndrome of Coronavirus (MERS-CoV) and classified as a group A infectious disease. The MERS-CoV epidemic recorded 2,494 confirmed cases and 858 deaths (as of 12/2015) in 27 countries, in which, China reported secondary infections due to human-to-human transmission.

The source of MERS-CoV is not fully understood and a number of theories suggest that it originates in bats and is transmitted to camels. Patients usually display symptoms of acute respiratory disease such as fever, cough or severe pneumonia, which quickly leads to acute respiratory failure, and digestive symptoms (e.g., diarrhea) or organ failure, especially renal failure, may also occur. Death rate may be as high as 40%. There is no effective cure or vaccine for this disease.

Late 2019, an outbreak of a Chinese pneumonia caused by a strain of coronavirus, also known as Wuhan pneumonia, took place in China. The epidemic began from the middle of December, 2019 in Wuhan when a number of residents contracted pneumonia of unknown cause, which was mostly related to workers of Huanan seafood wholesale market. Chinese scientists successfully isolated a new strain of coronavirus (initially named 2019-nCoV and later changed to COVID-19 by WHO) whose DNA sequence was at least 70% identical to SARS-CoV.

The first suspected cases were reported on 31/12/2019, with symptoms first appearing on 08/12/2019. The COVID-19 epidemic is progressing unpredictably. As of 18/02/2020, there are 73,335 cases and 1,874 deaths around the world, mostly in the epicenter of Wuhan, Hubei, China. 28 other countries and territories have reported cases of COVID-19, namely Hong Kong, Macau, the Philipines, Cambodia, Thailand, Singapore, Malaysia, Sri Lanka, India, Nepal, UAE, Japan, South Korea, Taiwan, Australia, Germany, France, Spain, Italy, the United Kingdom, Sweden, Finland, Belgium, Russia, the United States, Canada, Egypt and Vietnam; human to human transmission has also been confirmed.

In Vietnam, as of 18/02/2020, there are 16 confirmed cases, including 02 Chinese (father from Wuhan spread the disease to son living and working in Vietnam. Both have been discharged); 06 Vietnamese returning from Wuhan (05 have been discharged, 1 has recovered and is being monitored); 06 Vietnamese having close contact with confirmed cases (02 have been discharged, 1 has recovered and is being monitored); 01 American traveling to Vietnam after transiting in Wuhan, China; and 01 3-month old baby having close contact with a confirmed case.

COVID-19 spreads mainly via droplets upon close contact and via contact, thus, it is of utmost importance to wear facemasks and perform hand hygiene and environmental surface cleaning to prevent transmission. Precautions must also be taken against airborne transmission in areas where aerosol generating procedures are performed, especially in the immediate vicinity of these areas (<2m), and poorly ventilated areas.

2. Definition of COVID-19 cases:

2.1. Suspected cases:

A. The patient has fever and acute respiratory disease AND these diseases cannot be attributed to other causes AND the patient has traveled to/stayed in/returned from a COVID-19 infected area within approximately 14 days prior to the onset of symptoms. OR:

B. The patient displays any respiratory syndrome AND either of the following epidemiological factors takes place within approximately 14 days prior to the onset of symptoms:

a. The patient has had close contact (*) with a suspected or confirmed COVID-19 case.

b. The patient has worked at or visited a healthcare establishment where suspected or confirmed COVID-19 cases are being treated AND has had direct contact with these patients.

* Close contact includes:

- Contact in healthcare establishments, including direct care of a COVID-19 case; working with a health care worker infected with COVID-19; visiting a COVID-19 case or sharing a hospital room with a COVID-19 case.

- Direct contact within less than or equal to 1-2 meter(s) with a suspected or confirmed COVID-19  case.

- Living with a COVID-19 suspected or confirmed case.

- Working in the same room, learning in the same class, participating in the same activity, etc. with a COVID-19 suspected or confirmed case.

- Traveling in a vehicle with a COVID-19 suspected or confirmed case.

2.2. Probable cases:

Probable cases are suspected cases the samples of which cannot be collected or the test results of which are not yet available.

2.3. Confirmed cases:

A confirmed case is a suspected or probable case with positive RT-PCR test result or gene sequencing result for COVID-19.

3. COVID-19 prevention strategies

An infection control strategy to prevent or limit the spread of COVID-19 in healthcare establishments, which consists of:

- Application of standard precautions for all patients.

- Early detection, isolation and containment.

- Application of standard precautions against droplet and contact transmission. Application of precautions against airborne transmission in areas of where aerosol generating procedures are performed.

- Administrative measures.

- Environmental and technical control.

4. Prevention rules

- Combine standard precautions with prevention against contact and droplet transmission in treatment and care of confirmed or suspected COVID-19 cases.

- Add precautions against airborne transmission for aerosol generating procedures to the care of confirmed or suspected COVID-19 cases.

- Perform respiratory hygiene on all patients with respiratory symptoms.

- Good control of ventilation and environment, hand hygiene and use of PPE are the most important precautions against COVID-19 transmission to health care workers.

5. Measures for control of infection in healthcare establishments

5.1. Standard precautions

Standard precautions are a set of basic precautions applied to all patients in a healthcare establishment, regardless of their diagnosis, infection status and care time, by treating all bodily fluids (excluding sweat) and excreta as potentially infectious. Standard precautions include the following measures:

- Perform the 6-step hand washing technique at the 5 moments for hand hygiene.

- Wear PPE suitable to each situation e.g., handling of blood or other bodily fluids or expecting to come into contact with blood or other bodily fluids.

- Practice cough and sneeze etiquette.

- Take precautions against sharp force injuries sustained during patient care.

- Handle reusable patient care equipment properly.

- Collect, transport and handle dirty textile items safely.

- Perform health care environmental hygiene.

- Handle waste according to regulations.

- Ensure safe patient placement as follows:

+ Serious COVID-19 cases shall be placed in emergency rooms of the isolation area or isolation rooms fully supplied with separate emergency equipment.

+ Patients with mild manifestation shall be placed in separate rooms or placed together with patients having similar diseases.

+ Confirmed cases shall not be placed together with suspected cases.

5.2. Transmission-based precautions

a) Contact precautions

Contact precautions shall focus on the following tasks:

- Patients shall be placed in separate rooms. If no separate room is available, the patient shall be placed together with patients contracting the same pathogen.

- Wear clean gloves in isolation rooms. During patient care, change gloves after coming into contact with items possibly containing high viral or bacterial concentration (feces, medical fluids, bodily fluids, etc.).

- Wear clean gowns and shoe covers when visiting a patient’s room and remove them before exiting the anteroom. After gowns and shoe covers are removed, do not let clothing touch any environmental surface or other objects.

- Remove gloves and gowns before exiting a room and immediately perform hand hygiene with a disinfectant. After removing gloves and performing hand hygiene, do not touch any environmental surface or object in the anteroom.

- Minimize moving patients. Prioritize bedside techniques (X-ray, ultrasound, etc.); if the patient must be moved, notify the destination and ask the patient to wear a medical mask during the move; in case of skin damage, the injury site must be covered to avoid the spread of infection; use separate and predetermined routes to minimize exposure for health care workers, other patients and other people.

- Patient care equipment shall be used once for each patient. If not possible, clean, disinfect and sterilize the equipment before using it on another patient.

b) Droplet precautions

Droplet precautions shall focus on the following tasks:

- Patients shall be placed in separate rooms. If no separate room is available, the patient may be placed together with patients contracting the same pathogen or with other patients at a distance of at least 2 meters.

- Wear medical masks, safety goggles or face shields, especially when in close proximity with patients.

- Minimize moving patients; if the patient must be moved, ask the patient to wear a medical mask and move the patient through separate ways to minimize exposure for health care workers, other patients and other people.

c) Airborne precautions

Precautions against airborne transmission must be taken during aerosol generating procedures for confirmed cases.

Air treatment and room ventilation are necessary to prevent transmission.

Airborne precautions include:

- Place each patient in a separate room. If a separate room is not available, group confirmed cases or suspected cases together in one room.

- Ensure safe ventilation: natural ventilation, mechanical ventilation or mixed-mode ventilation may be used provided that the minimum ventilation rate is 12 ACH. Locate the exhaust system in a manner that allows air to be discharged close to the ground (10-15 cm above the ground) to empty areas and prevents contaminated air from recirculating.

- All persons entering an isolation room must wear respirator masks (e.g., N95 masks).

- Limit moving patients and only move them in case of extreme necessity. Wear medical masks for patients when transporting them out of their rooms.

- Perform medical procedures in a single-occupancy room with tightly shut doors and safe ventilation and away from other patients.

- Choose closed sputum suctioning for patients on breathing support.

5.3. Strict compliance with respiratory hygiene rules

Rules of respiratory hygiene include:

- Any patient or health care worker displaying a respiratory symptom must observe the following rules:

+ Cover the mouth and nose with tissue papers before coughing and sneezing, and immediately discard used tissues in waste containers.

+ If no tissue paper is available, cough into the elbow, DO NOT cough into the hands.

+ Request coughing and sneezing patients to wear medical masks during close contact (< 2m) or when health care workers are examining patients with high risk of droplet transmission of COVID-19.

+ Wash hands after coming into contact with bodily fluids.

+ Stand or sit at least 2 meters away from a confirmed or suspected case.

- Put up posters for respiratory hygiene at easy-to-see places such as the examination area and isolation area.

5.4. Environmental control

5.4.1. Floors, walls and corridors

Environmental control is an important precaution against the spread of COVID-19. Focus on the following key areas:

- Environmental surfaces must be cleaned and disinfected with suitable and permitted disinfectants.

- Blood spills or biological waste or fluids (such as vomit or feces) on environmental surfaces must be removed immediately. Wipe the spill using a towel soaked with 0.5% (5.000 ppm) active chlorine, and then rewipe it with a clean towel and another towel soaked with 0.05% chlorine.

See “Cleaning and disinfection of environmental surfaces” for more detail.

4.5.2. Ventilation

Ensure suitable ventilation between the following areas:

- Patient check-in area, corridors and waiting rooms shall be well-ventilated and spacious.

- For patient’s rooms:

+ Negative pressure rooms are the optimal arrangement.

+ In case negative pressure rooms are unavailable, employ mixed air or natural ventilation and ensure that the minimum ventilation rate is 12 ACH.

+ Aerosol generating procedures shall be performed in suitably ventilated rooms (≥12 ACH).

+ If no room meeting the abovementioned standards is available:

P Perform the procedures in a room far away from other patients, which must be well-ventilated, located downwind and equipped with dual airflow windows opening out into empty areas.

P  An exhaust system may be used to discharge air to empty areas, excluding corridors and adjacent rooms.

4.5.3. Equipment, machinery, beds and cabinets

Equipment, machinery, beds and cabinets shall be cleaned and disinfected at least twice a day and when necessary (between patients or when the current user is deceased,  transferred or discharged) using suitable and permitted disinfectants.

See “Cleaning and disinfection of environmental surfaces” for more detail.

4.6. Prevention of community transmission

When taking care of confirmed or suspected cases or cases being monitored, each health care worker shall limit contact with their family and the community until the high-risk period for COVID-19 has lapsed to prevent hospital and community transmission.

Each healthcare establishment shall assign a separate team of health care workers to tend to confirmed or suspected cases. While caring for confirmed or suspected cases, these workers shall not take care of other patients.

Encourage people to limit visits to infected areas. People who have visited these areas or come into close contact with confirmed or suspected cases need to self-quarantine and monitor their temperature for 14 days. If having fever or respiratory symptoms, they must visit the hospital.

Persons without respiratory symptoms should:

- Avoid gathering or visiting crowded areas.

- Keep a distance of at least 2 meters with any person displaying a respiratory symptom (e.g., cough, sneezing).

- Regularly perform hand hygiene with alcohol-based sanitizers if their hands are not dirty. Otherwise, wash their hands with soap and water.

- Cough or sneeze into the elbow or a tissue paper, discard the tissue paper immediately after use and perform hand hygiene.

- Avoid touching the eyes, nose and mouth.

Persons with respiratory symptoms should:

- Wear medical masks and undergo medical examination as soon as possible if having fever, cough, dyspnea, etc.

- Use and manage masks properly.

Mask management:

Medical masks shall be used and discarded properly to ensure efficiency and prevent transmission risks related to improper use and discard of masks.

Masks shall be worn according to their intended use and with the correct technique. Do not misuse masks. Improper use of masks might facilitate the spread of pathogens.

See guidelines for donning and doffing of masks in “Use of personal protective equipment”.

4.7. Other prevention rules

Combine multiple methods for infection control, including organization of screening, isolation, environmental hygiene, waste management and proper donning and doffing of PPE; and control infection during transport, dissection and handling of remains and laboratory-acquired infection.

SCREENING, ADMISSION AND ISOLATION OF CONFIRMED OR SUSPECTED COVID-19 CASES

As COVID-19 is highly contagious, screening, early detection and timely isolation are crucial tasks to be taken. Prompt isolation and precautions against transmission must be applied to confirmed or suspected COVID-19 cases.

1. Objective

Screen patients visiting healthcare establishments to detect and isolate confirmed or suspected COVID-19 cases, thus, preventing the risk of COVID-19 transmission from patients to health care workers, other patients and healthcare establishments.

2. Rules

- Healthcare establishments shall establish systems for detection of and quick response to confirmed or suspected COVID-19 cases.

- Healthcare establishments shall formulate plans for prompt screening, classification and management of confirmed or suspected COVID-19 cases after their arrival at these establishments.

+ Take precautions and control contamination seriously (standard precautions and transmission-based precautions).

+ Classify patients immediately after their arrival at the establishment using questionnaires.

+ Arrange a separate examination area/room for patients with or without manifestation of acute respiratory disease (cough, fever, etc.) but having epidemiological factors (persons traveling from or through Hubei, China within the last 14 days (see Guidelines for quarantine at quarantine zones for prevention and control of COVID-19 acute respiratory disease enclosed with the Decision No. 344/QD-BYT dated February 07, 2020 by the Ministry of Health)).

+ Any confirmed or suspected COVID-19 case detected must be examined and isolated promptly (based on manifestation and determining epidemiological factor(s)).

+ Declare, notify and report confirmed or suspected cases according to regulations.

3. Scope: All healthcare establishments.

4. Organization of COVID-19 prevention and control

Healthcare establishments shall strictly comply with procedures and regulations concerning prevention and control of infectious diseases from the Ministry of Health.

Mobilize all resources to contain COVID-19; treat confirmed cases, prevent transmission to other patients and minimize deaths; proactively cooperate with other forces in timely epidemic hotspot identification, transport, emergency aid, isolation and treatment of patients and environmental remediation.

Healthcare establishments shall proactively prepare for and perform the following tasks:

4.1. Organization and personnel

- Establish steering committees for prevention and control of COVID-19 in hospitals, each of which shall consist of the board of directors, general planning department, outpatient department, intensive care unit, infectious disease department, department of pediatrics, respiratory department, department of administration and management, department of infection control, medical equipment department, pharmacy department, nursing department, personnel organization department and health units of other regulatory bodies. Steering committees of central-level and provincial hospitals may have subcommittees for treatment, subcommittees for infection prevention, logistic subcommittees, etc.

- Based on each hospital’s situation, the hospital’s leaders shall decide the department in charge of admission and treatment of confirmed or suspected COVID-19 cases. This department must be capable of performing standard isolation. Workers of this department must be fully trained in infection control, especially in use of PPE according to guidelines to prevent hospital-acquired infection.

4.2. Hospitalization and isolation

- Classify risk areas and streamline confirmed or suspected COVID-19 cases as follows:

+ High-risk area (red) shall include the departments in charge of admission and treatment of confirmed or suspected COVID-19 cases (e.g., isolation areas; outpatient department; intensive care unit, infectious disease department, laboratories, etc.)

+ Moderate-risk area (yellow) shall include the departments in charge of admission of patients having cough and/or fever (e.g., rooms for examination of patients having cough and/or fever in the outpatient department, emergency department, respiratory department or department of pediatrics);

+ Low-risk area (green) include the departments with low possibility of admission and treatment of confirmed or suspected COVID-19 cases (e.g., surgery department, obstetrics department, etc.).

- Classification of risk areas shall provide the basis for hospitals to assign tasks, launch hospitalization and treatment plans and focus limited resources on prevention operations (equipment, manpower, training and monitoring) in high-risk areas.

- Formulate plans for establishment of isolation areas and allocation of manpower, equipment, etc. in the event of small/large numbers of confirmed or suspected COVID-19 cases.

4.3. Equipment requirements

4.3.1. Hand hygiene

Adequate amount of hand soap, alcohol-based sanitizers and tissues or disposable hand towels at all required locations.

4.3.2. Personal protection

Anti-infection gowns, aprons, paper caps, medical masks, N95 masks, safety goggles (or face shields), boots, shoe covers, medical gloves and cleaning gloves.

4.3.3. Devices

- Breathing support devices and other intensive care unit equipment (portable pulse oximeter, monitors, portable X-ray machine), oxygen and oxygen generators and closed suction machines;

- HEPA filters.

To contain COVID-19 effectively, the abovementioned equipment must be readily available in every patient check-in and treatment area regardless of whether an epidemic has taken place or not. Health care workers must receive training on use of PPE and other regulations on infection control in hospitals and be capable of using PPE properly.

4.3.4. Surface and equipment disinfectants

Calculate budget for adequate amount of chemicals for handling of equipment; disinfection of environmental surfaces; hand hygiene; and handling of waste in case of epidemic; and procure and provide such chemicals.

4.3.5. Isolation rooms

Hospitals must ensure that the isolation rooms/area meet(s) applicable standards and are readily available in case of epidemic.

Other healthcare establishments must provide areas (rooms) for screening of confirmed or suspected COVID-19 cases.

4.3.6. Drugs

List of drugs based on treatment regimens

4.4. Training

Healthcare establishments must develop plans and organize training in infection control for COVID-19 for all of their health care workers. Departments of infection control shall prepare the contents, curriculum, materials and equipment for provision of theoretical and practical guidance to health care workers based on guidelines from the Ministry of Health.

4.5. Drills

The steering committee for prevention and control of COVID-19 of each healthcare establishment shall organize drills to inspect, assess and take note of areas of improvement to amend, complete and align its COVID-19 prevention and control plan with local, regional and national prevention and control plans.

Drills shall focus on:

- Early control: prompt streamlining, screening, detection, diagnosis and isolation of confirmed or suspected COVID-19 cases visiting the healthcare establishment for examination; and compliance with regulations on intra-hospital, inter-department and inter-hospital patient transfer to ensure safety of health care workers, transporting personnel and the community.

- Fulfillment of requirements for admission, treatment, prevention and isolation in healthcare establishments.

- Correct use of PPE by health care workers; preparation of adequate amount of equipment and solutions to PPE shortage.

- Application of standard precautions and transmission-based precautions (droplet transmission, contact transmission and possibly airborne transmission) by health care workers. Compliance with regulations and procedures concerning hand hygiene, disinfection and sterilization of medical equipment, cleaning and disinfection of isolation areas and the hospital environment.

- Infection prevention for health care workers, patient's family members and visitors via control of biomedical waste, management of textile items and tableware of patients in isolation areas, and provision of guidelines for infection prevention upon patient’s death.

- Prevention of other hospital-acquired infections related to caretakers of confirmed or suspected COVID-19 cases (lung infection, sepsis, urinary tract infection, etc.).

4.6. Inspection and monitoring

- Each department of infection control shall perform technical inspection and monitoring of COVID-19 control; formulate and submit procedures for control of COVID-19 in its hospital and procedures for monitoring of such control to the infection control council and steering committee for COVID-19 prevention and control of its hospital, which shall submit these procedures to the hospital’s director for approval and organization of monitoring of compliance with COVID-19 control regulations/procedures.

- General planning department shall cooperate with the department of infection control in promptly monitoring, enumerating and notifying confirmed or suspected cases and health care workers having close contact with these cases; implementing regulations on infection control and inspecting and monitoring such implementation.

- Nursing department shall cooperate with the department of infection control, general planning department, head nurses of clinical departments and head technicians of para-clinical departments in inspecting and monitoring compliance with regulations on infection control.

4.7. Task assignment and performance

Board of directors, heads of departments and relevant individuals shall take responsibility for specific tasks of COVID-19 control in healthcare establishments.

Infection control must be included in the COVID-19 prevention and control plan of each hospital.

Each hospital’s director shall ensure satisfactory facilities, equipment, materials and chemicals for prevention of infection. Isolation areas shall be established at suitable locations. Plans for renovation, upgrade or building of isolation areas shall be formulated according to regulations.

4.8. Funding

Funding shall be allocated as prescribed by the state’s regulations on epidemic prevention and control and shall be used according to regulations. During an epidemic, upon epidemic declaration from the Ministry of Health or the competent authority, funding shall be distributed according to regulations on emergency epidemic prevention and control.

Hospital’s directors shall allocate funding and assign specialized personnel for regular infection control. Hospitals shall prepare budget contingency for epidemic prevention and control.

5. Screening and isolation of confirmed or suspected COVID-19 cases

5.1. Facility and equipment preparation

- Arrange or establish an isolation area and isolation rooms meeting isolation requirements.

- PPE (See “Use of personal protective equipment”).

- Adequate hand hygiene equipment at all locations where patients are checked-in, screened, examined and treated.

- Disinfection equipment and chemicals essential to patient care and treatment.

- Equipment for collection of waste, equipment, textile items, etc.

5.2. Procedures

Each healthcare establishment shall provide a patient screening area in the examination area (at the guard booth or in patient check-in area) and at least one isolated exam room for cases with fever and/or cough of unknown cause. Persons in charge of classifying patients must give instructions on precautions and isolation to patients upon their arrival at the establishment.

* Procedure for diagnosis and early detection of confirmed or suspected cases:

- One of the following epidemiological factors, which occurs within 14 days prior to the onset of symptoms, is detected:

+ Patient has returned from an infected area to Vietnam or had contact with a person coming from an infected area.

+ Patient has come into contact with blood or another bodily fluid of a confirmed or suspected cases in an infected area.

+ Patient has lived in or traveled to an infected area within the last 14 days;

+ Patient has directly handled an animal from an infected area.

- Patient displays one of the following clinical manifestations:

+ Sudden fever equal to or higher than 38°C; may experience headache or myalgia.

+ Cough and dyspnea.

+ Symptoms of pneumonia or acute respiratory failure (See Guidelines for diagnosis of suspected COVID-19 cases by the Ministry of Health, page 8).

- Upon occurrence of any of the abovementioned symptoms and epidemiological factors, the patient shall be admitted to the isolation area and kept away from other patients as soon as possible according to the procedure provided for in the diagram guidelines (Appendix 1).

- During the epidemic, instructional signage shall be affixed at entrances (guard booths) and in examination rooms to instruct patients and their family to visit the screening area immediately if they have fever or cough, preventing them from visiting other areas.

- Waiting rooms, examination rooms and rooms where medical procedures are performed on confirmed or suspected cases must be well-ventilated with an airflow of at least 12 ACH. If a room is naturally ventilated, this airflow rate may be ensured by opening all windows and doors in the same direction. Any hospital using the central air conditioning system must increase ACH and inspect the system’s safety in these areas regularly.

- Any family member accompanying a confirmed or suspected case shall be considered as having been exposed to COVID-19 and must be monitored for the prescribed period to facilitate early diagnosis of COVID-19 and prevent the disease from becoming an epidemic.

- Persons in charge of transporting confirmed or suspected cases must wear PPE and use specialized vehicles. Contaminated items, transport vehicles, discarded items and waste from patients shall be collected and handled according to regulations.

* Notes:

- Every patient caretaker must strictly follow precautions such as wearing PPE or washing hands with soap or another disinfectant after each meeting with the patient (see “Hand hygiene” and “Use of personal protective equipment”).

- All patients must wear medical masks.

- Minimize contact with patients and transporting patients.

- Perform personal hygiene and use nose and throat disinfectants properly.

- Clean and disinfect patient transport vehicles after each use.

- Draw up lists of persons having close contact with confirmed or suspected cases and monitor their health for 14 days starting from the last day of contact with a confirmed or suspected case. Advise these persons on COVID-19 symptoms and precautions for them to proactively prevent the disease and monitor and detect symptoms early. If any symptom appears, they shall notify the nearest healthcare establishment for timely diagnosis and treatment.

5.3. Inspection and monitoring

- Department of infection control, general planning department and nursing department shall inspect, supervise and provide training in isolation procedures for health care workers.

- Supervision shall focus on:

+ Whether patient’s rooms/areas meet the standards for isolation rooms.

+ Adequacy of required PPE (clothing, caps, masks, goggles, gloves, boots, etc.)

+ Compliance with isolation requirements from health care workers during diagnosis and treatment.

- Supervision method: direct observation and filling out supervision sheets.

Duration of isolation of confirmed or suspected cases: They shall be placed in isolation in healthcare establishments in accordance with guidelines from the Ministry of Health.

Reporting COVID-19 cases:

- Within healthcare establishments: examination rooms/emergency department with a confirmed or suspected case shall immediately notify the following entities:

+ The patient and the patient’s family.

+ Other workers of the shift (if reporting during a shift) or all members of the department (if reporting during working hours).

+ Leaders of the hospital and relevant departments (general planning department, department of infection control, nursing department, etc.).

- Outside of healthcare establishments: all confirmed and suspected cases must be reported in writing to leaders of the supervisory healthcare authority and leaders of the preventive medicine authority at the equivalent level according to regulations.

Decisive factors for screening, early detection, timely isolation, treatment and management of confirmed cases posing risk of infection in healthcare establishments:

- Establishment of steering committees for epidemic prevention and control.

- Formulation of detailed procedures for admission, handling, screening, detection and isolation of confirmed or suspected COVID-19 cases from the examination area to the isolation area.

- Training in clinical symptoms, treatment, routes of transmission and procedures for isolation and precautions in hospitals for all health care workers.

- Equipment necessary for strict isolation.

- Inspection and assessment of preparedness regardless of epidemic occurrence.

GUIDELINES FOR ESTABLISHMENT OF ISOLATION AREAS IN HEALTHCARE ESTABLISHMENTS

COVID-19 is a highly contagious disease. Thus, early isolation of confirmed or suspected cases is of utmost importance. To implement isolation efficiently, healthcare establishments shall set up isolation areas and rooms furnished with all necessary equipment and assign health care workers who have received training in the technical procedures to be performed during isolation. To be specific:

- Healthcare establishments shall establish an isolation area in the patient check-in area, including a waiting area for suspected cases, a patient classification area and isolation rooms, and provide all PPE necessary for patient treatment and care to prepare to admit COVID-19 patients.

- Outpatient department, emergency department, department of pediatrics and infectious disease department shall each set up a well-equipped isolation room to isolate patients when necessary.

1. Isolation area model

1.1. Objectives:

- Limit and control the spread of COVID-19 in healthcare establishments and the community, especially to health care workers, patients, patient’s family and visitors.

- Isolate and handle pathogens in the isolation area.

1.2. Rules of isolation area establishment

- The isolation area shall be located at the end of the corridor or in an area where there are few passersby and in the main wind direction.

- Family members are not permitted to care for the patient; and number of visitors shall be minimized.

- The isolation area shall be divided into the 3 following areas based on the risk of transmission:

+ Low-risk area includes the administrative area and workplace of health care workers. Place green notification signage in this area and limit number of visitors. Health care workers shall wear medical masks.

+ Moderate-risk area consists of corridors and anterooms where patient care and treatment equipment is located. Place yellow notification signage in this area. Only health care workers permitted to enter isolation rooms may be present in this area and they must wear adequate and suitable PPE.

+ High-risk area comprises the rooms where emergency aid or treatment are provided to patients, toilets and equipment handling rooms. Place red notification signage in this area. Health care workers shall wear all PPE and perform hand hygiene after coming into contact with patients and environmental surfaces and before leaving the isolation area.

1.3. Requirements for isolation areas

1.3.1. Design of isolation areas in provincial hospitals

- Functional rooms:

1) Administrative rooms.

2) Patient check-in rooms.

3) Treatment rooms.

4) Rooms where severe COVID-19 cases receive intensive care (fully furnished with treatment equipment for each patient).

5) Rooms for suspected cases.

6) Equipment handling rooms with adequate primary disinfection equipment such as wash-basins, drying cabinets and disinfectants.

7) Storage rooms for items essential to patient care and treatment.

8) Patient bathrooms with wash-basins, disposable hand towels and soap for hand washing.

9) Bathrooms with soap for hand washing for health care workers.

Every room in the isolation area must be equipped with a wash-basin, hand towels, alcohol-based hand sanitizers and soap for hand washing. Establish a travel route from the low-risk area to the high-risk area.

10) Ventilation systems: Isolation rooms should be equipped with the negative pressure ventilation system. If not possible, employ forced ventilation to move air from the low-risk area to high-risk area (from green area to red area). Air change rate shall reach at least 12 ACH. Air discharged from the isolation area must be disinfected with UVC or disinfected and filtered through HEPA filters. If disinfection is not possible, air shall be discharged to empty areas.

11) Floors and walls (at least 2 meters high) must be covered with glazed tiles for ease of cleaning and disinfection.

12) Room corners and the floor must form obtuse angles or fillets for easy cleaning and prevention of dirt buildup.

13) Windows must be made of easy-to-clean materials (glasses with few details).

1.3.2. Design of isolation rooms in district-level hospitals

1) Every hospital located in an at-risk area must set up an area for admission of confirmed or suspected cases in the infectious disease department or in a separate area inside the hospital.

2) Isolation rooms must be located away from other patients and crowded areas.

3) The isolation area may lack some function rooms that are available in hospitals at higher levels but must have the following basic rooms:

+ Rooms where patients are examined and admitted.

+ Isolation rooms for treatment of severe cases.

+ Rooms for cleaning and handling of equipment (may be located next to isolation rooms).

4. The isolation area must have a mechanical ventilation system that discharges to areas with few passersby and windows that provide fresh air.

A: Disinfection stations

B: PPE, textile item and clean equipment cabinets

C: Bags for disposal of used PPE, waste and dirty textile items

D: Wash-basins with hand soap and/or alcohol-based hand sanitizers

E: Outward opening windows located away from residential areas and facing empty areas

Exhibit 2. Layout of COVID-19 isolation room

1.4. Bed arrangement in isolation rooms

If possible, each confirmed case shall be placed in a separate isolation room.

If circumstances do not allow or when there are a large number of confirmed or suspected cases, suspected cases, confirmed cases and suspected cases that are waiting for the test result shall each be placed in a separate room. The beds shall be arranged at least 2 meters apart to prevent droplet transmission.

2. List of essential equipment in isolation area/rooms:

- Essential equipment must be readily available in the isolation area, isolation rooms and on trolleys or in cabinets in anterooms.

- Personnel from departments and units involved in the care and treatment of confirmed or suspected cases (cleaning, waste handling, patient transport, etc.) must wear all PPE necessary for their operations (rubber boots, aprons, masks, goggles, etc.)

- List of essential equipment and PPE must be readily available in the isolation area. The equipment and PPE listed must be inspected and restocked with all sizes and adequate amount on a daily basis (see Table 1).

Table 1. Equipment readily available in isolation area/room (Available at least on a daily basis when there is patient being monitored and treated)

3. Ventilation

Increasing ventilation is an essential measure to prevent the spread of COVID-19. There are 3 ways to increase ventilation:

3.1. Mechanical ventilation:

Ensure negative pressure rooms have at least 12 ACH and a negative pressure of at least -3Pa. Air discharged shall go through pre filters and HEPA filters and undergo UVC disinfection.

3.2. Natural ventilation:

Let air enter and exit the isolation room/area via the front door or windows. Each isolation room shall have 2 windows facing each other and kept fully open to ensure at least 12 ACH. Naturally ventilated isolation rooms shall be located downwind and have dual airflow windows that open to empty areas.

3.3. Mix-mode ventilation:

Employ natural ventilation in combination with fan discharge. Do not discharge air into crowded areas, corridors or other rooms. If possible, air discharged via fans shall be disinfected with UVC or disinfected and filtered through HEPA filters. Otherwise, locate the exhaust fans in a manner that allows air to be discharged into empty areas.

Calculate capacity and number of fresh air fans and exhaust fans based on each room’s volume to ensure at least 12 ACH.

USE OF PERSONAL PROTECTIVE EQUIPMENT

Personal protective equipment (PPE) is essential in protecting health care workers against the risk of infection when they come into contact with blood, other bodily fluids and droplets containing pathogens from patients. PPE can also protect patients against residential and transient microorganisms from health care workers and the hospital environment. Use of PPE when caring for confirmed or suspected COVID-19 cases is the most important measure against COVID-19 for health care workers.

1. Objective

Prevent risk of COVID-19 transmission from patients to health care workers, other patients, visitors, patient’s surroundings and the community.

2. Scope

All health care workers, patient’s family members, visitors and persons having contact with confirmed or suspected COVID-19 cases or samples thereof.

3. Rules

3.1. General rules

- PPE shall be used as recommended by standard precautions in combination with transmission-based precautions and suitable to the care of confirmed or suspected COVID-19 cases.

- Ensure a number of PPE are available in isolation areas, anterooms of isolation rooms, laboratories and areas where waste or remains is/are handled.

- PPE is only effective when used in combination with other infection control measures such as implementation of procedures for screening, isolation, surface cleaning and waste management.

- Indications and procedures for putting on and removing PPE must be followed strictly.

3.2. Rules of use of PPE

1. Always wear PPE when coming into contact with, examining, treating and caring for confirmed or suspected COVID-19 cases.

2. Practice donning and doffing PPE properly before caring for confirmed or suspected COVID-19 cases, which must be supervised by trained persons.

3. Prepare all PPE necessary for the forthcoming action.

4. Wear and remove PPE in the anteroom before entering and after leaving an isolation room. Avoid touching or adjusting PPE when inside isolation rooms.

5. Ensure PPE cover the entire body.

6. Change gloves between patients and when a glove is torn; perform hand hygiene before putting on new gloves.

7. Rules for doffing PPE:

- The outside of PPE poses high risk of infection; when removing a piece of PPE, turn it inside out and roll into a bundle; do not hold on to any piece of PPE when removing it.

- The front of PPE has a higher risk of infection than the backside. Avoid touching the front of PPE. 

8. PPE shall be used only once, treated as biomedical waste and immediately discarded in biomedical waste containers (yellow containers) after removal. These containers must be sufficiently large and have automatic lids.

4. Types of personal protective equipment

4.1. Types of personal protective equipment

There are many types of commercially available PPE, which can be classified into the 2 following types:

Type 1: Separate pants, gowns and hoods:

- Waterproof gowns or gowns with waterproof outer layer.

- Waterproof pants.

- Waterproof aprons.

- Medical masks.

- Respirator masks (e.g., N95).

- Safety goggles or face shields.

- Medical gloves.

- Hoods (covering both hair and neck).

- Tall shoe covers.

- Rubber boots.

Type 2: Protective suits with attached hoods:

- Protective suits with attached hoods.

- Tall shoe covers.

- Waterproof aprons.

- Medical masks.

- N95 masks.

- Safety goggles or face shields.

- Medical gloves.

- Rubber gloves.

- Waterproof tall shoe covers.

- Rubber boots.

4.2. Some technical criteria.

- Safety goggles and face shields must hug the wearer’s face and prevent fluids from infiltrating (Exhibit 3 and Exhibit 4).

- Standard waterproof medical masks with a metal wire fitted securely to the nasal bridge to prevent aerosols and droplets from entering.

- Respirator masks (e.g., facemasks meeting the N95 standards or FFP2 standards or equivalent).

- Nitrile or latex gloves of suitable size are recommended.

- Mid-thigh fluid-resistant medical gowns with long sleeves and cuffs and aprons.

- Rubber shoes without holes or tears and of suitable size.

- Waterproof non-slippage knee-high shoe covers.

- Hoods covering head and neck and opening in the front so that they can be removed by pulling backwards.

- Clothing worn under PPE.

5. Procedures for donning and doffing personal protective equipment

5.1. Donning and doffing masks

5.1.1. Medical masks:

* Donning technique:

- Perform hand hygiene.

- Open the wrapping, take the medical mask out and hold a corner with one hand.

- Place the mask onto the face with the waterproof (blue) side facing out and absorbent (white) side facing in. Secure the mask with 1 hand while the other hooks the elastic strings behind the ears.

- Use the tips of the index fingers to mold the metal wire to the nose and face.

- Use 2 fingers to gently pull the lower edge of the mask downwards and tuck it underneath the chin.

* Doffing technique:

- Unhook the elastic strings, avoid touching the mask and discard it in a waste container as regulated.

- Perform hand hygiene.

5.1.2. Respirator masks (e.g., N95)

* Donning technique:

- Perform hand hygiene.

- Open the wrapping, place the mask in one palm with the nosepiece lying on the fingers, and let the straps dangle.

- Place the mask under the chin with the nosepiece up.

- Pull the upper strap over the head and rest it on top of the occipital bone, above the ears. Pull the lower strap over the head and rest it on the nape, below the ears. Do not let the straps cross behind the head.

- Check and adjust the straps if they are twisted.

- Use the tips of the index fingers to mold the nosepiece to the nose.

- Fit check:

+ Negative pressure check: exhale slowly. If the mask fits, negative pressure should cause the mask to collapse on the face. If there is a leak, air will enter through the valves into the mask. Adjust the straps and repeat the check.

+ Positive pressure check: exhale sharply. If the mask fits, positive pressure should build up inside the mask. If not, adjust the straps and repeat the check.

* Doffing technique:

- Remove the lower strap by holding the strap at the back of the head and pull it over the head without touching the mask.

- Perform hand hygiene.

5.1.3. Important notes

- Wear the mask right side up.

- Wear the mask right side out.

- Do not touch the inside of a mask when wearing it.

- Ensure the mask covers both the mouth and nose.

- Adjust the nosepiece and straps until the mask fits the nasal bridge and the face.

- Do not touch the outside of a mask when discarding it.

- After discarding or accidentally touching a used mask, wash hands with alcohol-based hand sanitizers or with soap and water.

- Replace the mask after each clean/sterile procedure, immediately after the mask is soiled or wet or after each shift.

- Do not reuse masks.

5.2. Procedures for donning personal protective equipment

Step 1: Wash hands.

Step 2: Wear boots/shoe covers.

Step 3: Wear pants and gown (wear apron if indicated).

Step 4: Wear medical mask.

Step 5: Wear safety goggles (for goggles with temples).

Step 6: Wear hood and make sure that it completely covers hair, head, ears and face mask strings.

Step 7: Wear face shield or safety goggles (for goggles with strings to be worn outside of cap).

Step 8: Wear clean gloves.

5.3. Procedures for doffing personal protective equipment

5.3.1. Separate pants, gowns and hoods

Step 1: Remove gloves, turn them inside out, roll into bundles and discard in waste container. If wearing apron, remove apron, untie lower string before higher string, turn apron inside out, roll into a bundle and discard it in waste container.

Step 2: Wash hands.

Step 3: Remove gown, turn it inside out, roll into a bundle and discard in waste container.

Step 4: Wash hands.

Step 5: Remove pants and boots or shoe covers at the same time, turn pants inside out and discard in waste container. Place boots in a container with disinfectant.

Step 6: Wash hands.

Step 7: Remove goggles or face shield.

Step 8: Wash hands.

Step 9: Remove hood by sliding hands inside it.

Step 10: Remove mask (using the strings behind head or ears).

Step 11: Wash hands.

5.3.2. Protective suits with attached hoods

Step 1: Remove gloves, turn them inside out and discard in waste container. If wearing apron, remove apron, untie lower string before higher string, turn apron inside out, roll into a bundle and discard it in waste container;

Step 2: Wash hands.

Step 3: Remove goggles or face shield.

Step 4: Wash hands.

Step 5: Remove hood and suit, turn them inside out and discard in waste container.

Step 6: Wash hands.

Step 7: Remove boots or shoe covers, turn them inside out and discard in waste container. Place boots in a container with disinfectant.

Step 8: Wash hands.

Step 19: Remove the mask (using the strings behind head or ears).

Step 10: Wash hands.

Note: Must remove PPE in the anteroom of an isolation area or room.

6. Inspection and supervision of use of personal protective equipment

- Department of infection control and nursing department shall provide training in use of PPE for health care workers and inspect and supervise such use.

- Supervision shall focus on:

+ Availability of PPE in anterooms of isolation areas/rooms.

+ Proper use of necessary PPE by health care workers.

+ Sorting, collection and handling of used PPE.

- Supervision method: direct observation and filling out supervision sheets.

HAND HYGIENE

Hand hygiene is one important measure to prevent and control the spread of COVID-19. Hand hygiene shall be performed at the 5 moments of hand hygiene during the care and treatment of COVID-19 cases.

Requirements for all healthcare establishments:

1. Hand hygiene equipment

Provide adequate hand hygiene equipment in all areas where there are confirmed or suspected COVID-19 cases.

1.1. Hand washing with soap and clean water

- Equip wash-basins in isolation rooms, anterooms, offices, solution or drug preparation areas, laboratories, nutrition rooms, waste or dirty textile item handling areas and morgues for patients and health care workers.

- Wash-basins shall be fully equipped with soap solutions, clean water and containers for disposable tissues (fabric or paper).

Some specific regulations:

- Wash-basins must have sufficient depth to prevent water from splashing out and onto the user, rounded corners, smooth surface and no smudge or water pooling. The height at which a wash-basin is installed must be suitable to users’ height.

- Faucets shall be mounted into the wall; automatic or foot-control faucet switches or faucet switches with handles are preferred.

- Tap water shall be used; water pipes shall be mounted into the wall in a manner that is easy to install, clean and disinfect when necessary

- Liquid soap is preferred, which shall be contained in suitably installed pump bottles that dispense necessary amount of soap; soap bars must be placed in soap cases, which shall be put in a dry place away from splashing water.

- Disposable tissue papers or reusable cotton tissues shall be stored in easy-to-use tissue boxes with lids.

- Dirty tissue containers must be easy to use and require no hand touching.

Exhibit 9: Rinse hands with water

1.2. Hand washing with alcohol/alcohol combined with chlorhexidine

- Equip hand sanitizer bottles containing 60% - 80% alcohol or alcohol combined with chlorhexidine in patient care areas, at the head of beds of seriously ill patients and patients in emergency care, on injection trolleys, dressing trolleys and examination tables, on the wall next to the entrance into patient rooms, anterooms and isolation rooms, in front of elevators, corridors and other locations where there is a high risk of exposure to patient's blood or other bodily fluids.

- Regularly replace and clean hand sanitizer bottles and ensure their availability at the prescribed locations.

- Hand sanitizer bottles shall have pumps that dispense necessary amount of sanitizer and brackets for mounting onto the wall or hanging at the head of patient's beds, in front of patient’s rooms, on injection trolleys, etc.

2. Indications for hand hygiene

2.1. Hand washing with soap and clean water

- Wash hands when visibly dirty with blood and other bodily fluids, during care and treatment of patients (invasive procedures, bathing patients, handling dirty equipment or waste, etc.) regardless of the presence of gloves, when gloves are suspected to have been punctured and when gloves are removed carelessly, leading to contact with contaminants.

- Wash hands with soap and water before and after a shift, after using the toilet, after collecting textile items, equipment, waste, etc.

2.2. Hand washing with alcohol-based hand sanitizers

- Only wash hands with alcohol-based sanitizers when hands are dry, not visibly dirty with blood or other bodily fluids, during care and treatment of patients and after removing PPE.

- Wash hands with alcohol-based sanitizers where wash-basins cannot be installed and when patients care procedures do not produce visible smudges of blood or other bodily fluids.

- Indications for washing hands with alcohol-based sanitizers are similar to those for soap and water if hands are not visibly dirty with blood or other bodily fluids.

- The times at which health care workers must wash their hands are the 5 moments for hand hygiene recommended by World Health Organization.

Exhibit 10. Moments for hand hygiene during patient care

+ Additionally, hand hygiene shall be performed in the following cases:

• When putting on and removing PPE.

• Before wearing gloves.

• When moving from an infected site to an uninfected site on the same patient.

• Before completing work in the isolation area and leaving.

• Before going home.

3. Techniques

3.1. Hand washing with soap and water (Exhibit 11)

- Step 1: Wet both palms with water. Lather with soap by rubbing palm to palm.

- Step 2: Rub one palm over dorsum of the other hand with interlaced fingers hard and vice versa.

- Step 3: Rub palm to palm with fingers interlaced hard.

- Step 4: Rub backs of fingers to opposing palms with fingers interlocked.

- Step 5: Clap one hand around the thumb of the other hand and rub thumb in rotational manner and vice versa.

- Step 6: Rub in rotational manner, backwards and forwards by placing fingertips of one hand in opposing palm and vice versa.  Rinse hands with water.

Exhibit 11. Washing hands with soap and clean water

3.2. Hand washing with alcohol-based sanitizers (Exhibit 12)

- Step 1: Take 3ml - 5ml of solution containing alcohol/alcohol combined with chlorhexidine and rub palm to palm.

- Step 2: Rub one palm over dorsum of the other hand with interlaced fingers hard and vice versa.

- Step 3: Rub palm to palm with fingers interlaced hard.

- Step 4: Rub backs of fingers to opposing palms with fingers interlocked.

- Step 5: Claps one hand around the thumb of the other hand and rub thumb in rotational manner and vice versa.

- Step 6: Rub in rotational manner, backwards and forwards by placing fingertips of one hand in opposing palm and vice versa until hands are dry.

Exhibit 12: Washing hands with alcohol-based sanitizers (20-30 seconds)

Note:

- Trim nails.

- Remove all jewelry on hands (rings, bracelets, watches, etc.).

- The techniques are similar to those for soap and water. Each step shall be done at least 5 times.

See Guidelines for hand hygiene in healthcare establishments enclosed with the Decision No. 3916/QD-BYT dated August 28, 2017 by the Minister of Health for more detail.

HANDLING OF EQUIPMENT

Equipment used for the care and treatment of confirmed or suspected COVID-19 cases all carry the risk of infection. If handled incorrectly, these pieces of equipment can spread the disease to health care workers and the community.

1. Objectives

- Provide procedures for cleaning, disinfection and sterilization of equipment after the care and treatment of patients in accordance with regulations for relevant persons.

- Ensure safety of patients, health care workers and the community.

2. Rules

- Disposable medical equipment is preferred for the care and treatment of patients (e.g., breathing support equipment such as sputum suction tubes, aerosol masks, circuits of medical ventilators, oral care kit, etc.). Reusable equipment must be handled as prescribed by the Ministry of Health.

- Every piece of disposable equipment must be cleaned and disinfected according to guidelines from its manufacturer and regulations of the Ministry of Health before reuse.

- Ensure equipment for patients is handled, cleaned and disinfected according to procedures, functions properly and is adequately and promptly provided.

- Ensure adequate guidelines for disinfection of all types of patient care equipment are available at locations where each type of equipment is used or handled.

- Provide adequate equipment, chemicals, materials and PPE for handlers (especially safety goggles, face shields, waterproof gowns, higher-than-elbow gloves and rubber boots).

- Personnel in charge of disinfection and/or sterilization must receive training and obtain certificates of completion of training in disinfection and/or sterilization.

- Inspect disinfection and sterilization operations, monitor equipment quality (via tests or archived dossiers), ensure safety of health care workers and the environmental when collecting, transporting, disinfecting and sterilizing such equipment.

- Enumerate and report handling and provision of equipment for the care and treatment of confirmed or suspected COVID-19 cases.

3. Regulated entities and scope

3.1. Regulated entities

- Equipment handlers (in isolation areas, clinical and para-clinical units involved in the care of confirmed or suspected COVID-19 cases and central sterilization units).

- Health care workers directly caring for confirmed or suspected COVID-19 cases.

3.2. Scope

- Isolation areas/rooms.

- Central sterilization units/departments of infection control.

- Areas where confirmed or suspected COVID-19 cases are checked-in, classified and examined.

4. Equipment

4.1. Disinfection and sterilization equipment

- PPE, including masks, rubber gloves, waterproof aprons, safety goggles or face shields and boots (if prescribed).

- Adequate clean water.

- Containers with lid and suitable volume to soak equipment.

- Equipment wash-basins (made from materials that are easy to clean and disinfect).

- Equipment washers.

- Steam sterilizers and drying cabinets.

- Low-temp sterilizers (ETO, Plasma, etc.).

4.2. Chemicals

- Cleaning solutions: cleaning agents/enzymes, enzymatic disinfectants.

- Intermediate-level disinfectant solutions:

+ Chlorine compounds: Sodium hypochlorite, including Presept, Javel, Chloramine B, etc.

+ Enzymatic compounds: Cidexzym...

- High-level disinfectant solutions: glutaraldehyde ≥ 2%, orthophthaldehyde 0,55%, Peracetic acid, etc.

4.3. Water: Clean water, sterile water.

5. Procedures

5.1. In isolation areas/rooms

5.1.1. Preparation

- Equipment handlers shall wear adequate PPE (masks, rubber gloves, waterproof aprons, safety goggles/face shields) before handling equipment.

- Prepare the following cleaning and disinfection equipment adequately:

+ Equipment wash-basins - equipment washers.

+ Chemicals.

+ Cleaning equipment (brushes, tube cleaning brushes, etc.).

+ Clean water, sterile water.

5.1.2. Procedures

Mix cleaning chemicals and disinfectants according to guidelines

- Equipment must be handled immediately after use as follows:

Soak the whole equipment in a cleaning solution or an enzymatic solution and then in an intermediate-level disinfectant for the prescribed amount of time and with the correct concentration (see Appendix 4).

+ Rinse the equipment under running water and clean it underwater.

- Let the equipment dry or use a dryer on it, put it in a container with a lid labeled equipment for confirmed or suspected COVID-19 cases and put the container in a yellow bag/box before delivering.

- Notify transport of the clean equipment to the central sterilization unit/department of infection control in advance.

5.2. In sterilization centers and departments of infection control

Arrange an area for timely receipt and handling of equipment from isolation areas, prioritize prompt and separate handling to prevent infection in this area and other departments.

5.2.1. Equipment preparation

- Provide separate equipment and assign certain personnel for handling of equipment of confirmed or suspected cases in isolation areas if possible.

- Equipment handlers shall wear adequate PPE (masks, rubber gloves, waterproof aprons, safety goggles/face shields) before handling equipment.

- Prepare the following cleaning and disinfection equipment adequately:

+ Equipment wash-basins - equipment washers.

+ Chemicals.

+ Cleaning equipment (brushes, tube cleaning brushes, etc.).

+ Clean water, sterile water.

+ Multi-purpose washing, cleaning and disinfecting machines (capable of cleaning different types of metal equipment and plastic breathing support equipment).

+ Steam sterilizers for thermotolerant equipment.

+ Low-temp sterilizers.

5.2.2. Procedures

* For manual cleaning and disinfection (without use of washing and disinfecting machines):

- Dismantle the equipment and place the pieces on trays or shelves according to the manufacturer’s regulations.

- Mix the disinfectant according to guidelines (Appendix 4).

- Soak the equipment in the disinfectant solution with the correct concentration and for the prescribed amount of time.

- Scrub and clean the equipment underwater in the wash-basin. Scrub gently to prevent splash.

-  Rinse the equipment under water.

- Dry the equipment (using a drying cabinet or cloth).

- Soak the equipment in lubricant or spray lubricant on the equipment to protect it.

- Transport the equipment to the packing area (for labeling, testing and writing expiry date) and then take it to the sterilization area.

Cleaning and disinfection with specialized machines

- Dismantle the equipment and place the pieces on trays or shelves according to the manufacturer’s regulations.

- Choose a cleaning program (for thermotolerant or non-thermotolerant equipment).

+ For thermotolerant equipment: soap, water and temperature at 90°C.

+ For non-thermotolerant equipment: soap, water and temperature under 50°C.

+ Chemicals shall be used as recommended by manufacturers of the washer and the equipment.

+ Add lubricant to the washer.

- Run the chosen cleaning program.

- Take the equipment out of the washer and pack it as regulated when the cleaning cycle ends.

- If the washer does not have the dryer function, put the equipment in a dryer or dry it with a clean and dry cloth before packing.

- Begin the sterilization procedure.

- Sterilized equipment shall be stored in cabinets with door in cool storage rooms (air-conditioned rooms with temperature at 20°C-22°C and humidity under 60% are preferred).

- Sterilized equipment shall be distributed daily for the care of confirmed or suspected cases.

Note:

- After finishing their tasks, equipment handlers of each area must remove their PPE and perform hand hygiene before moving to another area.

- Clean equipment handling areas after each shift/at the end of the day.

6. Inspection and supervision of compliance with cleaning, disinfection and sterilization procedures

Heads of departments and head nurses shall regularly inspect and supervise the following matters:

- Adequacy of equipment, materials, chemicals and PPE for handling of equipment.

- Compliance with procedures for cleaning, disinfection and sterilization in areas where equipment is used (examination or isolation rooms, laboratories, etc.).

- Donning and doffing of PPE of health care workers in COVID-19-related areas.

- Retain list of equipment handlers and regularly monitor and detect signs of infection.

See Guidelines for disinfection and sterilization in healthcare establishments enclosed with the Decision No. 3671/QD-BYT dated September 27, 2012 by the Minister of Health for more detail.

HANDLING OF TEXTILE ITEMS

1. Objectives

- Provide appropriate procedures for handling of textile items from confirmed or suspected COVID-19 cases for health care workers.

- Ensure safety of patients, health care workers, patient's family members, visitors and the community.

2. General regulations and rules

- Do not shake, dump or count textile items used in care and treatment of confirmed or suspected COVID-19 cases.

- Used textile items must be tightly packed, promptly delivered to the laundry room using separate equipment and washed immediately and separately. No dirty textile item may be retained.

- Textile items used by confirmed or suspected cases in examination areas, patient’s rooms and isolation rooms must be put into yellow bags and labeled “Đồ vải có nguy cơ chứa COVID-19” ("Potentially COVID-19-contaminated textile items”).

- Bags containing used textile items must have no tear or hole and must be waterproof.

- Persons collecting, transporting and handling dirty textile items must wear and remove PPE according to guidelines and perform hand hygiene.

- Wash textile items with washing machines at high temperatures and with chemicals. If washing machines are unavailable, textile items shall be soaked in disinfectants before being washed with 0.05% active chlorine (see Appendix 4).

- Wash, dry or hang textile items to dry according to the procedures for handling of infectious textile items.

3. Regulated entities and scope

3.1. Regulated entities

- Workers of laundry rooms and persons collecting and transporting textile items.

- Persons working in isolation areas/rooms and patient admission areas.

3.2. Scope

- Patient’s rooms and isolation rooms.

- Laundry rooms.

- Other areas related to textile items of confirmed or suspected cases.

4. Equipment

- Washing machines capable of washing at 60°C-70°C and dryers.

- Yellow bags without holes, with draw string closure and symbols denoting highly infectious textile items (textile items from COVID-19 patients), yellow containers and laundry carts solely for contaminated textile items.

- Personal protective equipment (PPE) for persons in charge of textile item collection, transport and washing.

- Laundry detergents: soap, bleach and disinfectants (Javel and Chloramine B).

5. Procedures

5.1. In patient’s rooms/isolation rooms

- Persons collecting dirty textile items must wear adequate PPE according to regulations before beginning the task and perform hand hygiene after finishing the task.

- Textile items from isolation rooms/areas must be collected and put into waterproof yellow bags, which shall be put into tightly closed containers before being transported to the laundry room.

- Disposable textile items such as gowns, caps, masks and shoe covers shall be put into yellow bags, which shall be tightly closed and put into containers with lids, before being moved to the building where infectious biomedical waste is stored for incineration.

- All bags containing textile items shall be put into another bag, which must be labeled “Potentially COVID-19-contaminated textile items”, before being transported to the laundry room.

- Laundry staff shall collect textile items at the prescribed time(s) or upon request.

5.2. In laundry rooms

- Textile items gathered in the laundry room shall be washed in washing machines with chemicals or soap at 60°C-70°C immediately. Soak used textile items from confirmed or suspected cases in chemical solutions containing 0.01%-0.05% active chlorine, depending on how contaminated they are, for at least 20 minutes before washing. If these items are washed in washing machines, they may be soaked in the machines before being washed.

- Textile items should be dried with heat. If not possible, they may be dried in a separate area that is high above the ground with adequate sunlight.

- After air-drying, textile items shall be ironed and stored in dry and closed cabinets.

Note: if washing machines are not available, textile items shall be promptly soaked in containers containing disinfectants (0.01%-0.05% active chlorine) for at least 20 minutes prior to washing.

Persons washing textile items by hands shall wear PPE during the wash and remove PPE and perform hand hygiene after finishing the wash.

5.3. Preservation and dispensation of textile items

- Textile items used for confirmed or suspected COVID-19 cases must be stored in closed cabinets or on clean racks in the stockroom, and dispensed based on the quantity and type requested.

- Isolation areas and rooms where confirmed or suspected cases are examined must draw up lists of requested textile items and amount thereof and notify the laundry room in advance.

- At least thrice the amount of necessary clean textile items must be stored in isolation areas for daily use.

6. Inspection and supervision

- Department of infection control, nursing department and heads and head nurses of relevant departments shall provide training in procedures for handling of dirty textile items (sorting, collection, transport and handling) and inspect, supervise and expedite strict compliance with such procedures.

- Supervision shall focus on:

+ Equipment for handling of dirty textile items (bags, containers and transport vehicles).

+ Textile item handling guidelines and techniques.

+ Hand washing and equipment cleaning after finishing the task.

+ Textile handling chemicals.

+ PPE for health care workers.

+ Use of PPE.

HANDLING OF TABLEWARE

1. Objectives

- Provide procedures for provision and handling of tableware of confirmed or suspected COVID-19 cases for employees of the nutrition department.

- Ensure safety for patients, health care workers, patient’s family, visitors and the environment.

2. Rules

- All items essential for everyday life, tableware and leftover food of confirmed or suspected COVID-19 cases must be handled as biomedical waste and shall not be used for unintended purposes (watering plants, feeding cattle or poultry, etc.).

- It is best to use disposable items and collect, transport and dispose of them as infectious biomedical waste immediately after use.

- Each patient shall be provided with a separate set of tableware, which shall be collected and handled separately.

- In case disposable items are unavailable, all items reused must be disinfected and sterilized according to the procedures applicable to items used for the care and treatment of confirmed or suspected COVID-19 cases.

3. Regulated entities and scope

Confirmed or suspected COVID-19 cases; and health care workers and employees of the nutrition department that are in charge of confirmed or suspected COVID-19 cases.

4. Equipment

- Personal protective equipment (PPE) for prevention of contact transmission.

- Wash-basins and soap.

- Buckets and containers containing disinfectants with lids to prevent evaporation according to regulations.

- 0.05% (500 ppm) active chlorine.

5. Procedures

5.1. Use of disposable items

- Tableware and leftover food of a confirmed or suspected COVID-19 case must be put into the biomedical waste container in the isolation room after use.

- Janitors shall collect and handle this type of waste as infectious biomedical waste.

5.2. Use of reusable items

- Health care workers shall give instructions on how to put used items into reusable item containers and leftover food into biomedical waste containers to confirmed or suspected COVID-19 cases.

- Health care workers shall collect and put reusable items into closed containers, affix labels denoting tableware of confirmed or suspected COVID-19 cases onto these containers and transport them to the nutrition department (or department of infection control) to have them handled according to handling procedures for contaminated items.

- In-charge personnel shall wear PPE according to guidelines when handling tableware.

- Liquid from food and leftover drinks shall be collected as biomedical waste from the isolation area as regulated before being transported to the handling area.

- Reusable items shall be transported to the centralized equipment handling area in bags or containers with lids and must not be carried with bare hands or on shoulders.

- Soak used tableware in a solution containing 0.05% active chlorine for 10-20 minutes. The tableware must be fully soaked in the disinfectant solution. In case disinfectants are not available, the tableware may be boiled for 10 minutes.

- It is encouraged to clean different types of items of confirmed or suspected COVID-19 cases using automatic equipment washers with lids, chemical cycles, temperature settings and automatic dryer.

6. Inspection and supervision

Department of infection control, nursing department and heads and head nurses of relevant departments shall provide training in the abovementioned procedures and inspect, supervise and expedite strict compliance with such procedures. Supervision shall focus on:

- Use of PPE when handling reusable items.

- Collection, transport, handling and reuse processes.

Refer to Guidelines for disinfection and sterilization in healthcare establishments enclosed with the Decision No. 3671/QD-BYT dated September 27, 2012 by the Minister of Health for more detail.

ENVIRONMENTAL SURFACE CLEANING AND DISINFECTION

1. Objectives

- Provide procedures for cleaning of areas where confirmed or suspected COVID-19 cases are admitted and treated for cleaning staff.

- Eliminate contact transmission of COVID-19.

- Ensure safety of patients, health care workers and the community.

2. Rules

Surfaces of areas where confirmed or suspected 19  cases are screened and isolated must be cleaned and disinfected according to the following rules:

- All surfaces in screening areas and isolation and treatment areas with or without visible blood, other bodily fluids or waste from confirmed or suspected COVID-19 cases must be cleaned and disinfected by wiping at least twice a day and when necessary (after examination, testing, medical procedures, spillage of blood and other bodily fluids, hospital transfer/discharge and death).

- All surfaces (in areas where confirmed or suspected COVID-19 cases are isolated), including surfaces of patient care equipment and transport equipment, must be cleaned and disinfected by wiping with disinfectants permitted by the Ministry of Health.

- When cleaning or disinfecting surfaces related to confirmed or suspected cases, health care workers shall strictly comply with surface hygiene rules and techniques and transmission-based precautions.

- Health care workers in charge of cleaning or disinfecting environmental surfaces in areas where confirmed or suspected cases are treated or isolated must receive training in surface cleaning and disinfection procedures and wear adequate personal protective equipment.

3. Regulated entities and scope

- All health care workers in charge of environmental hygiene in all areas related to the care and treatment of confirmed or suspected cases.

- Surfaces of all patient-related equipment and items, beds, cabinets, tables, chairs, sanitary facilities, etc. in screening and admission areas, isolation rooms, laundry rooms, waste containment areas, reusable equipment handling areas and transport vehicles involved in the care and treatment of confirmed or suspected COVID-19 cases.

4. Equipment

- Personal protective equipment (PPE) (see “Use of personal protective equipment”).

- Procedures and guidelines for mixing chemicals on trolleys on which environmental cleaning and disinfection equipment are loaded.

- Hand soap.

- Cleaning agents and disinfectants containing 0.05% active chlorine mixed according to regulations (handheld sprayers may be used for hard-to-wipe surfaces), and towels soaked with disinfectant solutions or other suitable chemical disinfectants permitted by the Ministry of Health.

- Surface disinfectants containing 0.5% active chlorine or other disinfectants permitted by the Ministry of Health for surfaces dirty with blood, other bodily fluids, vomit or excreta.

- Cleaning towels for screening and isolation areas, mops, chemical buckets and buckets for collection.

5. Technique

- Divide the area into two and place wet floor signage before cleaning the floor, hall and stairs.

- Wipe in a zigzag fashion from the top to the bottom, from inside out and from the cleanest area to the dirtiest area.

- If a chemical spray is used, spray the chemical onto a towel before wiping; when wiping the floor, spray close to the floor and spray only the area that would be wiped immediately. Do not spray in the presence of patients.

6. Procedures

- Step 1: Prepare necessary cleaning and disinfection equipment (containers/buckets containing disinfectant solutions, cleaning towels, mops, etc.), which shall be used for the isolation area only (areas for administrative work, isolation rooms, sanitary facilities, textile item and equipment handling areas, etc.).

- Step 2: Persons in charge of environmental cleaning shall wear PPE properly before entering the isolation area and during the cleaning and disinfection processes (see “Use of personal protective equipment”).

- Step 3: Wipe the surface with water and collect and put waste in biomedical waste containers and bags according to regulations before disinfecting.

- Step 4: Wipe the surface with a disinfectant containing 0.05% active chlorine, let the surface dry for 10 minutes and rewipe it with clean water to take away any chemical residue that might affect patients. Wipe all surfaces in the isolation area at least twice a day and upon request. Use the 2-bucket wash method (one bucket filled with clean water and the other filled with the disinfectant solution), use a clean towel for each wiping turn, do not rinse towels in the buckets and each towel shall be used for an area no larger than 20 m². Take note of the following when wiping:

+ Regularly touched surfaces (injection trolleys, trolleys transporting textile items or equipment, doorknobs, etc.) shall be disinfected immediately after each use or contact.

+ Promptly remove patient’s blood, other bodily fluids, feces or vomit from the surface and wipe it with a disinfectant containing 0.5% chlorine. Let the disinfectant stay on the surface for at least 10 minutes.

- Step 5: Collect, clean and disinfect used cleaning equipment before taking it out of the isolation room, including waste requiring isolation (see “Waste handling”, page 54) and cleaning towels put into isolation bags and delivered to the laundry room (see Guidelines for transport of biomedical waste and textile items out of isolation area).

- Step 6: Remove PPE and perform hand hygiene with a soap solution after finishing the task.

Note: wash hands with soap and water after directly touching a patient’s blood, bodily fluid or waste and after removing PPE.

5.1. Daily surface cleaning and disinfection

This procedure is similar to the abovementioned procedure with the following additional regulations:

- Clean at least twice a day and upon request. Keep a daily surface cleaning record.

- For each cleaning turn, wipe the surfaces with a disinfectant and then with a cleaning agent from the least contaminated areas (areas for administrative work) to more contaminated areas (isolation rooms) and wipe equipment surfaces before disinfecting and cleaning the floor.

- Use disinfectants capable of eliminating SARS-CoV-2 for all surfaces inside a room and ensure sufficient contact time. For example, compounds containing 0.05% (500 ppm) active chlorine require at least 10 minutes of contact time.

Note: do not bring cleaning equipment used in isolation areas to other places, and collect and handle squeegees separately to prevent COVID-19 from spreading to other areas of the hospital.

5.2. Post-discharge/transfer/death cleaning

- Move other patients in the isolation room (if any) to another isolation room before performing the last round of cleaning and disinfection.

- Collect and put dirty equipment and reusable textile items into containers/bags as regulated and deliver them to the sterilization and laundry rooms. Collect and discard waste and other personal items of the patient according to regulations on collection and handling of biomedical waste.

- Wipe the surfaces with a disinfectant and then with a sanitizer from the least contaminated areas (areas for administrative work) to more contaminated areas (isolation rooms) and wipe equipment surfaces before disinfecting and cleaning the floor.

- Use disinfectants capable of eliminating SARS-CoV-2 for all surfaces inside the room and ensure sufficient contact time. For example, compounds containing 0.05%-0.5% active chlorine require at least 10 minutes of contact time.

See Appendix 4 for more detail on concentrations of chemicals used for surface cleaning and disinfection.

5.3. Cleaning and disinfection of surfaces dirty with blood or other bodily fluids.

- This task must be performed immediately upon appearance or detection of a spill of blood or another bodily fluid.

- Wear adequate PPE.

- Remove the blood or bodily fluid spill according to the following procedure: (1) Use a towel or gauze soaked with a solution containing 0.5% (5,000 ppm) active chlorine to remove the spill (if the spill is large, repeat this step until it has been removed from the surface completely); (2) Discard the towel (gauze) in an biomedical waste container; (3) Use another towel or gauze soaked with a solution containing 0.5% chlorine to disinfect the contaminated surface; and (4) Use another towel or gauze soaked with a cleaning solution to wipe the disinfected surface.

- Remove PPE and perform hand hygiene after leaving the isolation room.

5.4. Environmental cleaning for morgues and areas where COVID-19 cases are encoffined

- Wear adequate PPE according to regulations applicable to COVID-19.

- After encoffinment or dissection of remains, all related equipment, surfaces of the operating table, operating room and equipment must be immediately disinfected with a solution containing 0.5% active chlorine and be allowed to air dry for 30 minutes to 1 hour.

- Clean and disinfect PPE according to prescribed procedures.

- Remove PPE and perform hand hygiene after finishing this task.

5.5. Cleaning of cleaning equipment

- Cleaning equipment must be cleaned after each shift and at the end of each day.

- Cleaning equipment, including mopsticks and buckets/basins containing towel soaking water/chemicals, must be scrubbed clean with water and soap and stored in its designated place.

- Decontaminate buckets/basins containing cleaning/disinfectant solutions with 0.05% active chlorine, wash them with clean water and place them upside down on racks for drying.

- Collect and return cleaning equipment to designated places. Do not use dirty cleaning equipment for daily cleaning tasks.

6. Inspection and supervision

- Department of infection control, nursing department and heads and head nurses of relevant departments shall provide training in procedures for daily or ad hoc environmental surface cleaning and disinfection and inspect, supervise and expedite strict compliance with such procedures.

- Daily supervise compliance from health care workers with procedures for surface disinfection, disinfection in the event of spillage of blood or other biological fluids, use of PPE and cleaning in areas where confirmed or suspected cases are isolated.

- Supervision results shall be reported to persons under supervision and heads of departments and hospital’s leaders immediately.

See Guidelines for cleaning of environmental surfaces in healthcare establishments enclosed with the Decision No. 3916/QD-BYT dated August 28, 2017 by the Minister of Health for more detail.

CLEANING OF VEHICLES TRANSPORTING CONFIRMED OR SUSPECTED COVID-19 CASES

Hospitals must strictly follow the procedures and rules for environmental control and control of safe use of personal protective equipment (PPE) during intra- and inter-hospital patient transport.

1. Objectives

- Provide regulations on cleaning and disinfection of vehicles transporting confirmed or suspected COVID-19 cases for health care workers.

- Prevent the spread of COVID-19 through contact with surfaces of vehicles transporting confirmed or suspected COVID-19  cases.

- Ensure safety of health care workers in charge of transport and the community.

2. Rules

- Surfaces of a patient transport vehicle to be cleaned and disinfected include the inside (stretchers, medical equipment consoles, floor, walls, ceiling and surfaces of the action area, door handles, radios, keyboards and phones) and the outside of the vehicle (door handles, doors and the entire outer surface of the vehicle).

- Handlers of transport vehicles (persons directly transporting patients or assigned the cleaning task) must be trained individuals capable of applying the rules and techniques concerning cleaning of surfaces of machines, equipment and transport vehicles, standard precautions and precautions against contact transmission.

- Hospitals shall stipulate locations for handling of transport vehicles and provide adequate equipment to ensure safe handling of the vehicles.

- Locations for handling and disinfection of patient transport vehicles must have adequate PPE, chemicals and equipment for cleaning, disinfection, sterilization and biomedical waste collection.

- All equipment for transport, handling and care of patients shall be immediately handled after use according to prescribed procedures before they are used for other patients.

3. Regulated entities and scope

- All equipment used to transport patients to the hospital and within the hospital.

- All health care workers assigned the task of patient transport from all departments involved in transport of confirmed or suspected cases.

4. Equipment

- PPE: full PPE suits, N95 masks, medical masks, safety goggles or face shields, rubber boots, clean gloves and sterile gloves for invasive procedures.

- Cleaning chemicals and disinfectants:

+ Soap.

+ Alcohol-based hand sanitizers.

+ Surface disinfectants containing 0.05% or 0.5% active chlorine, ethanol 70^o or other disinfectants permitted by the Ministry of Health.

- Handling equipment: spray bottles, cleaning towels and waste bags.

- Separate areas in the hospital for handling of transport vehicles.

5. Procedures

Health care workers shall obtain adequate PPE and perform the following steps:

- Step 1: Mix the chemicals according to regulations and pour them into chemical containers available at the handling site.

- Step 2: Wear adequate PPE.

- Step 3: Collect and put equipment and waste into yellow bags, close the bags tightly and label them transport generated waste, which are to be transported to waste handling areas.

- Step 4: Wipe all surfaces of the transport vehicle with the disinfectant, allow a dwell time of at least 10 minutes, then rewipe them with the cleaning agent (bleach or soap and water), and dry them with towels or air duster guns. If there is a large amount of blood or another bodily fluid or spill of blood or another bodily fluid (e.g., vomit, biological fluids, etc.), first, use disposable blotting papers soaked with 0.5% active chlorine to localize and remove it; then use towels soaked with 0.5% active chlorine solution to cover the spillage area for at least 10 minutes; and then wipe the area clean with 0.05% active chlorine solution.

- Step 5: After finishing the abovementioned steps, remove and put PPE in bags or containers with lids, transfer them to disinfection or disposal areas, wash hands with soap and perform personal hygiene.

Note: Vehicles traveling to infected areas must have their bodies, tires and undersides sprayed with 0.05% active chlorine solution before leaving infected areas.

6. Inspection and supervision and responsibilities therefor

- Department of infection control, nursing department and heads and head nurses of relevant departments shall provide training in procedures for cleaning of vehicles transporting confirmed or suspected cases and inspect, supervise and expedite strict compliance with such procedures.

- General planning department and intensive care unit shall inspect emergency aid equipment, ambulances and regulations on emergency aid in case of epidemics and natural disasters.

- Medical equipment department and pharmacy department (or other units in charge of provision) shall provide adequate PPE and disinfectants and sterilants permitted by the Ministry of Health.

- Department of infection control shall supervise compliance with procedures for cleaning and disinfection of equipment, handling of biomedical waste and environmental hygiene in vehicle handling areas.

WASTE HANDLING

1. Objectives

- Provide procedures for classification, isolation, collection, transport and handling of waste from isolation areas.

- Prevent the spread of COVID-19 from waste to the environment and community.

- Ensure safety of patients, health care workers and the community.

2. Rules

- All waste from screening areas and isolation areas for confirmed or suspected COVID-19 cases shall be treated as biomedical waste, promptly collected on site and put in yellow nylon bags and containers with lids affixed with biohazard signage.

- Prevent spread of pathogens during collection, transport and handling of biomedical waste from screening areas and isolation areas; ensure safety for health care workers and biomedical waste managers.

- Biomedical waste must be contained in yellow waste bags labeled “Chất thải có nguy cơ chứa COVID-19” (“Potentially COVID-19-contaminated waste”) before taken to the waste containment building of the hospital.

- Health care workers and biomedical waste and environmental hygiene managers must be fully equipped with suitable PPE while working.

3. Scope

3.1.  Regulated entities

- Persons in charge of collection, transport and handling of waste from confirmed or suspected cases.

- All health care workers participating in the care and treatment of confirmed or suspected cases.

- Confirmed or suspected cases and family and visitors thereof.

3.2. Regulated areas

- All locations where waste from confirmed or suspected cases is generated such as areas where these cases are checked-in, screened, isolated, tested, etc.

- Waste handling areas.

4. Equipment

- Yellow containers and nylon bags bearing the biomedical symbol used to collect biomedical waste according to regulations and placed in screening areas, isolation rooms, patient’s rooms and anterooms.

- Equip sharps containers (yellow, puncture-proof and disposable) for injection trolleys or isolation rooms.

- On vehicles transporting confirmed or suspected cases.

- PPE (hoods, masks, safety goggles, suits, rubber boots/shoe covers) for persons in charge of collection, handling and management of biomedical waste.

5. Procedure

- Samples from confirmed or suspected cases must be safely handled according to guidelines for handling of highly infectious waste before being transported to the centralized handling system.

- All solid waste from the screening area, isolation area and areas related to confirmed or suspected cases must be put in biomedical waste containers or bags immediately.

- Close the lids of biomedical waste containers in the temporary storage area tightly, and prevent waste from falling out or leaking while it is collected and delivered to the centralized waste containment area of the healthcare establishment.

- Persons collecting and/or transporting waste must wear PPE according to regulations.

- Waste must be collected and delivered to the centralized waste containment area when waste containers are 3/4 full or at least twice a day and upon request.

- Liquid waste such as feces or urine from isolation rooms or the isolation area must be collected via the combined wastewater collection and treatment system of the hospital. In case the hospital does not have a wastewater treatment system meeting environmental standards, liquid waste from the isolation area must be collected and disinfected with a solution containing 1.0% active chlorine before it is discharged outside.

- Respiratory fluids (sputum, saliva, postnasal drip or bronchial fluid) of patients must be thoroughly handled with a solution containing 1.0% active chlorine in a ratio of one to one for at least 10 minutes before they are collected according to each treatment unit’s regulations.

- If high-temp steamers are available, solid waste and patient samples from laboratories shall be steamed at 121°C for 20 minutes before it is collected and handled as regulated.

- For centralized waste handling and transport: biomedical waste containers must fulfill the requirements prescribed in the Joint Circular No. 58/2015/TTLT-BYT-BTNMT dated December 31, 2015 by the Ministry of Health and Ministry of Natural Resources and Environment on management of biomedical waste, bear the “Chất thải có nguy cơ chứa COVID-19” ("Potentially COVID-19-contaminated waste”) label and have hard sides, tightly closed lids and wheels. Biomedical waste must be collected and handled within the day and transported at a non-busy time and along a route with few passersby.

- Textile items and clothing of confirmed or suspected cases and PPE of health care workers, biomedical waste managers and persons in charge of environmental hygiene in areas where confirmed or suspected cases are screened, monitored, isolated, cared for or treated shall also be collected and handled according to this procedure.

6. Inspection and supervision

- Department of infection control, nursing department and heads and head nurses of relevant departments shall provide training in procedures for handling of waste from confirmed or suspected COVID-19 cases and inspect, supervise and expedite strict compliance with such procedure. Supervision shall focus on:

+ Collection and transport equipment.

+ Waste classification, collection, transport and disposal.

+ Waste weight.

- Immediately report to heads of departments, head nurses, steering committees for COVID-19 prevention and control and hospital’s leaders upon any incident or matter concerning the spread of COVID-19 via waste.

COLLECTION, PRESERVATION, PACKING AND TRANSPORT OF PATIENT SAMPLES

All biological samples from confirmed or suspected COVID-19 cases are latent sources of infection that pose a threat to persons collecting, transporting and/or handling them. It is imperative that regulations on biosafety level 2 be strictly observed upon contact with or handling of such samples.

1. Objectives

- Prevent COVID-19 transmission via contact with patient samples and persons having contact with confirmed or suspected COVID-19 cases during collection, preservation, packing, transport, handling and testing of samples from these cases.

- All sample collectors must properly and strictly comply with procedures and regulations concerning collection, preservation and transport of samples from confirmed or suspected COVID-19 cases.

- Prevent COVID-19 transmission and ensure safety of health care workers and the environment.

2. Rules

Precautions against contact transmission shall take priority during collection, preservation, packing and transport, handling and testing of samples from confirmed or suspected COVID-19 cases.

2.1. Requirements for persons collecting, preserving, packing and transporting samples from confirmed or suspected COVID-19 cases

Only trained heath care workers capable of following guidelines for precautions against transmission may collect, preserve, pack, transport, handle and test samples from confirmed or suspected COVID-19 cases.

- Comply with regulations on biosafety in collection, preservation, packing, transport, handling and testing of samples containing pathogens transmitted via blood, air or contact.

- Use personal protective equipment (PPE) properly.

- Understand the risk of transmission and be capable of detecting and assessing potential risk to themselves, managing their health after work and following procedures if exposed to the disease.

- It is preferable that the health care workers in charge of monitoring and caring for a patient collect samples from such patient to minimize the number of persons having contact with the patient.

2.2. Equipment requirements

All equipment used to collect, preserve, pack and transport patient samples, testing equipment and excess samples from confirmed or suspected cases pose high risk of infection and must be disinfected in laboratories before being handled as biomedical waste.

- Prioritize disposable equipment, which shall be disposed of as biomedical waste immediately after use.

- Reusable equipment must be disinfected and sterilized according to regulations in separate wash-basins to avoid contaminating another patient’s equipment.

- Equipment for different patients shall be collected and handled separately.

2.3. Requirements for sample collecting sites and testing areas

- Sample collecting sites and testing areas must be treated as isolation areas.

3. Regulated entities and method

- Health care workers shall strictly comply with regulations on biosafety and be capable of using PPE properly.

- Confirmed or suspected cases must stay in isolation areas.

- Sampling equipment, testing equipment and excess samples from confirmed or suspected cases must be handled as highly contagious biomedical waste after testing.

4. Equipment

4.1. Personal protective equipment

- Disposable protective suits

- Waterproof gowns.

- Waterproof caps or hoods.

- Respirators masks (e.g., N95) or masks with filters and breathing support (supplying oxygen).

- Safety goggles or face shields.

- Two layers of gloves, with the inner being medical gloves that shall always be kept clean and away from dirty equipment.

- Rubber boots/waterproof ankle boots.

- Alcohol-based sanitizers/hand soap.

4.2. Sampling equipment

- Sterile swabs with soft/hard handles.

- Tongue depressors.

- Vials containing 3ml of viral transport medium (VTM, UTM) to contain samples.

4.2.1. Respiratory samples:

- Nasopharyngeal swab: sterile swabs with soft handle (according to each laboratory's regulations).

- Throat swab: sterile swabs with hard handle (according to each laboratory's regulations).

- Nasopharyngeal wash: nonbacteriostatic saline and sterile plastic cups (sample shall be collected in a cup or petri dish and diluted with a transport medium according to each laboratory’s regulations).

- Tracheal aspirate, broncheoalveolar lavage fluid or pleural fluid: specialized equipment.

4.2.2. Blood samples:

- Sterile 10ml syringes.

- Blood collection tubes with or without coagulants (according to each laboratory’s request)

- Tourniquet, cotton, alcohol, etc.

4.2.3. Sample packing:

- Plastic containers with tightly shut lids, plastic shelves or nylon bags to pack samples.

- Cold sample preserving containers and sample transport boxes.

- Gauzes soaked with antiseptics (to handle sample leaks or sprays)

4.3. Information written on sample vials

- Patient’s name (or identification number of sample).

- Age.

- Date and time of collection.

- Type of sample.

4.4. Laboratory test request form and epidemiological investigation form

Fill in all information (using the forms enclosed with the Decision No. 343/QD-BYT dated February 07, 2020 on interim guidelines on surveillance, prevention and control of COVID-19 acute respiratory disease).

5. Procedures

5.1. Personal protective equipment

Wear personal protective equipment according to regulations (see “Use of personal protective equipment”). Wear N95 masks and 2 layers of gloves when collecting samples.

5.2. Regulations on collection of samples

5.2.1. Patient samples

At least 01 of the following respiratory tract samples must be collected and blood sample is optional:

- Upper respiratory samples:

+ Nasopharyngeal swab and throat swab.

+ Nasopharyngeal wash.

- Lower respiratory samples:

+ Sputum

+ Tracheal aspirate, broncheoalveolar lavage fluid, pleural fluid, etc.

+ Lungs, bronchus, trachea (upon prescription).

- Blood samples: 3-5 ml of venous blood with or without EDTA. Serum or plasma samples shall be taken if requested by the laboratory (testing upon request)

5.2.2. Time of sample collection

Respiratory tract samples must be collected as soon as possible after the onset of the disease.

Table 2. Times of collection of samples for COVID-19 confirmatory testing

5.2.3. Sampling techniques

5.2.3.1 Nasopharyngeal swab and throat swab (use 02 cotton swabs for 02 types of sample), collect nasopharyngeal swab together with throat swab

a. Throat swab

- Ask the patient to open their mouth wide.

- Use a tongue depressor to depress the tongue.

- Insert the cotton swab into the throat, rub and rotate the cotton swab 3-4 times against both tonsils and the posterior pharyngeal wall to obtain secretion and cells from the throat.

- Place the cotton swab in a vial containing 3ml of transport medium (VTM or UTM) for preservation. Note that the tip of the cotton swab must be completely immersed in the transport medium. If the swab is longer than the vial, cut or break its handle to fit it inside the vial.

b. Nasopharyngeal swab

- Ask the patient to sit still and tilt their head slightly backwards; children must be held by adults.

- Tilt the patient’s head back 70° and support the back of the patient’s neck with one hand.

- Use the other hand to gently insert the swab into the patient’s nose and rotate the swab at the same time to ease the slide until reaching half the distance from the corner of the nose to the front of the ear.

Note: if resistance is met before reaching such depth, remove the swab and try the other nostril. When reaching the posterior nasopharynx, stop, rotate and the swab and slowly remove it.

- Keep the swab in place for 5 seconds to ensure maximum absorbency.

- Slowly rotate and remove the swab.

- Put the tip of the swab in a vial containing transport medium and break the shaft of the swab at the score mark to fit it in the vial. The nasopharyngeal swab and the throat swab shall be put together in one vial.

- Recap the vial tightly and wrap it in paraffin paper (if any).

Store the samples at 2-8°C before transporting to the laboratory. If the samples are not transported to the laboratory within 48 hours starting from the time of collection, they must be stored at -70°C.

Note: Children shall sit in their parent’s lap with their backs to their parent’s chest. The parent shall hold the child’s body and hands tightly and tilt the child’s head back.

5.2.3.2 Throat wash

The patient shall gargle with 10ml of saline solution. The fluid shall be collected into a cup or petri dish and diluted 1:2 in transport medium.

5.2.3.3 Broncheoalveolar lavage fluid

This type of sample is collected from patients mechanically ventilated via an endotracheal tube. Place a suction catheter along the endotracheal tube and use the pump to collect the broncheoalveolar lavage fluid into a vial containing transport medium.

5.2.3.4 Blood sample

Collect 3ml-5ml of venous blood into a vial (with or without EDTA) and store it at 4°C for up to 24 hours.

Note:

- Include name, age and address of patient, type of sample and date of collection on sample vials.

- Lower respiratory samples (tracheal aspirate, broncheoalveolar lavage fluid, pleural fluid) must be collected with the participation of the doctor(s) in charge of the patient.

5.2.4. Disinfection of sampling equipment and sample collecting sites

- Handle sampling equipment and PPE as biomedical waste.

- Disinfect surfaces of sample collecting sites following the disinfection procedures for isolation rooms.

5.3. Regulations on preservation of samples

Samples must be delivered to laboratories as soon as possible and:

- Samples shall be stored at 2°C-8°C and delivered to laboratories as soon as possible within 48 hours from the time of collection.

- Samples must be stored at -70°C if they cannot be delivered to laboratories within 48 hours from the time of collection.

- Do not store samples in freezers or at under -20°C.

5.4. Regulations on packing of samples

Samples must be wrapped in 3 layers before delivery to ensure biosafety.

- Samples shall be packed according to regulations in Circular No. 40/2018/TT-BYT on sample management.

5.4.1. Packing of samples for regular tests

- Innermost layer: sample containers in compliance with the laboratory’s regulations and capable of preventing leakage.

Exhibit 13. 3 layers sample packing for intrahospital delivery for regular tests

- Middle layer: a plastic or foam vial rack or plastic case to keep the sample containers upright.

- Outermost layer: a hard plastic container with lid, handle and biohazard label.

5.4.1. Packing of samples for long-distance transport for COVID-19 confirmatory testing

The samples must be carefully packed in 3 layers according to WHO guidelines before transport.

- The samples shall be contained in plastic capped vials containing transport medium. The cap must be closed tightly and properly.

- The sample vials shall be contained in a plastic case or rack.

The respiratory sample and blood sample of a patient shall be placed together in one plastic case with tightly closed lid or one vial rack.

- The case (or rack) shall be placed inside a sample transport box that meets the following requirements:

+ The box must be sturdy with tightly closed lid to prevent breakage.

+ The box must be an insulated ice box.

- Sample packing procedure:

Note:

- A sample testing request must be sent together with the transport box

- WHO-required labels (biohazard label, this side up label and fragile label) must be affixed on the transport box.

Exhibit 14. Specimens of biohazard label, this side up label and fragile label

 (Enclosed with the Government's Decree No. 92/2010/ND-CP dated August 30, 2010)

5.5. Sample shipping regulations

- Inform the laboratory of the date of shipping and estimated time of arrival.

- Deliver the samples by land or air to the laboratory as soon as possible.

- Deliver the samples in person within the hospital premises. Do not use the compressed air sample delivery system.

- Do not let sample vials leak or break during transport.

- Ensure all transport personnel are trained in biosafety and decontamination of leakage of blood or other bodily fluids.

- Samples should be consistently kept at 4°C during transport to the laboratory to maintain their quality.

- The samples shall be delivered together with a sample testing request filled out with all required information.

6. Inspection and supervision

- Department of infection control, nursing department and heads and head nurses of relevant departments shall provide training in the procedures and regulations concerning biosafety and use of PPE during collection, preservation, packing, transport, handling and testing of COVID-19 samples and inspect, supervise and expedite strict compliance with such procedures and regulations. Supervision shall focus on:

- Handling of sampling equipment, testing equipment and excess samples as highly contagious biomedical waste after testing.

- Handling of areas where COVID-19 samples are collected, handled and tested.

See Guidelines for diagnosis and treatment of COVID-19 acute respiratory disease enclosed with the Decision No. 125/QD-BYT dated January 16, 2020 and Interim guidelines for surveillance, prevention and control of COVID-19 acute respiratory disease enclosed with the Decision No. 343/QD-BYT dated February 07, 2020 by the Ministry of Health.

PREVENTION OF LABORATORY-ACQUIRED INFECTION OF COVID-19

1. Objectives

- Prevent COVID-19 transmission via droplets from and contact with patient samples and persons having contact with confirmed or suspected COVID-19 cases during testing of samples from these cases.

- All laboratory personnel must properly and strictly comply with procedures and regulations concerning collection, preservation and transport of samples.

- Prevent transmission and ensure safety of health care workers and the environment.

2. Regulated entities

- Laboratory personnel who must strictly comply with regulations on biosafety and be capable of using personal protective equipment (PPE).

- All samples from confirmed or suspected COVID-19 cases, which may come from the outpatient department, emergency department, infectious disease department, etc. or other healthcare establishments.

3. Methods

3.1. Patient samples

- Upper respiratory samples.

- Lower respiratory samples.

- Serum samples

3.2. Testing for suspected cases

- Blood tests.

- Biochemical tests.

- Tests for microorganisms.

+ Differential diagnosis:

• Influenza causing severe illness.

• Atypical pneumonia.

• Sepsis leading to acute respiratory failure and renal failure.

• Acute hand, foot and mouth disease leading to respiratory failure and renal failure.

+ Other regular tests.

3.3. COVID-19 confirmatory tests

COVID-19 may be detected via Real time RT-PCR or next-generation sequencing.

4. Biosafety requirements

Prevention of COVID-19 transmission via droplets, contact and aerosols during aerosol generating procedures shall take the priority in testing of confirmed or suspected COVID-19 cases.

4.1. Facilities

- For regular tests: biosafety level II

- For COVID-19 confirmatory tests: biosafety level II

4.2. Equipment

- Equipment for biosafety level II laboratories

- Calibrated and certified biosafety level II cabinets.

- Personal protective equipment:

+ For regular tests: regular PPE.

+ For COVID-19 confirmatory tests: adequate PPE, including protective suits, powder free gloves, N95 masks and safety goggles or face shields.

4.3. Laboratory personnel

- Only trained laboratory personnel may test confirmed or suspected COVID-19 cases. This task should be solely assigned to a number of personnel.

- Strictly comply with regulations on biosafety and be capable of using PPE.

- Wear regular PPE such as gloves, waterproof gowns, face shields or safety goggles and masks when performing regular tests.

- Wear adequate PPE when performing COVID-19 confirmatory tests, including gloves, protective suits, N95 masks and face shields or safety goggles.

- Do not touch equipment consoles, doorknobs, phones, switches, etc. with gloves worn to test samples from confirmed or suspected COVID-19 cases.

- Persons testing confirmed or suspected COVID-19 cases shall not leave the laboratory where they are performing COVID-19 tests  while wearing their PPE.

- Understand risk of transmission and be capable of detecting and assessing potential risk to themselves, managing their health after work and following procedures if exposed to the disease.

- Do not touch samples from confirmed or suspected COVID-19 cases or COVID-19 testing equipment with bare hands.

- Do not use hand to touch the face, nose or mouth when testing confirmed or suspected COVID-19 cases.

5. Inspection and supervision

Department of infection control, nursing department and heads and head nurses of relevant departments shall provide training in procedures and regulations concerning biosafety during testing of confirmed or suspected COVID-19 cases and inspect, supervise and expedite strict compliance with such procedures and regulations. Supervision shall focus on:

- Strict compliance with procedures for disinfection of sample collecting sites and equipment from health care workers.

- Compliance with biosafety regulations and proper use of PPE when performing tests from health care workers.

- Handling of reusable equipment after testing.

- Handling of highly infectious waste after testing.

- Handling of laboratories as isolation areas.

Note:

- Sample collecting areas must be treated as isolation areas.

- Laboratories shall be well ventilated. Air in laboratories shall not be discharged into crowded areas, corridors or other rooms.

- Any test operation that may generate aerosols or droplets must be conducted in biosafety level II cabinets such as opening sample vials; dividing or diluting samples; mixing using vortex mixers; or isolating or extracting DNA/RNA.

- Do not touch equipment consoles, doorknobs, phones, switches, etc. with gloves worn to test samples from COVID-19 cases.

- All PPE (gloves, gowns, masks, etc.) must be turned inside out and rolled into bundles to minimize risk of transmission of pathogens to sampling or transport equipment.

- Sampling equipment and samples from confirmed or suspected COVID-19 cases must be handled as highly infectious waste after testing.

HANDLING OF REMAINS OF CONFIRMED OR SUSPECTED COVID-19 CASES

1. Objectives

- Provide procedures and regulations concerning handling of remains of confirmed or suspected COVID-19 cases for health care workers.

- Prevent transmission of COVID-19 to health care workers, patient’s family members, funeral attendees and the community.

2. Scope

- Departments of anatomic pathology, morgues and clinical departments having deceased COVID-19 cases (both confirmed and suspected).

- Health care workers and patient’s family members having contact with remains of confirmed or suspected COVID-19 cases.

3. General rules

- Use standard precautions and precautions against contact and droplet transmission during transport and handling of remains.

- Only in-charge health care workers and patient’s family members provided with precautions and adequate PPE may handle remains of confirmed or suspected COVID-19 cases.

- Prevent spread of pathogens during handling, transport, cremation and burial of remains of confirmed or suspected COVID-19 cases.

- Move other patients in the isolation room (if any) to another isolation room before handling remains.

- Remains of confirmed or suspected COVID-19 cases may be buried when cremation is not possible.

- Remains must be encoffined as soon as possible and cremated or buried within 24 hours from the time of death.

- All waste produced during handling, transport, cremation or burial of remains of confirmed or suspected COVID-19 cases must be handled as biomedical waste.

4. Equipment

4.1. Equipment for transport, preservation and handling of remains

- Automobiles and stretchers used to transport remains must be cleaned and disinfected immediately after each use.

- Body bags; if body bags are unavailable, remains must be placed in waterproof and durable nylon zipper bags of suitable size and on disposable bed linen.

- Mortuary cold chambers equipped with hand washing equipment, surface and floor disinfectants and surface disinfection equipment.

4.2. Equipment for personal protection, hand hygiene and waste collection

Equipment for precautions against transmission shall be fully equipped for clinical departments with confirmed or suspected COVID-19 cases and morgues, including:

- Hand washing equipment: soap and alcohol-based sanitizers.

- PPE: disposable and waterproof equipment (gloves, paper caps, medical masks, gowns, safety goggles, aprons).

- Waste collecting equipment: sufficiently large yellow containers and bags for collection of used PPE.

- Disinfectants for remains: 0.5% chlorine solution.

- Environmental disinfecting equipment: Cleaning cloth, squeegees, spray bottles or manual spray machines.

5. Procedures

5.1. At units where there are deceased COVID-19 cases

Upon death of a confirmed or suspected COVID-19 case, the health care workers in charge of the patient shall perform the following tasks:

- Do not move another patient (including other confirmed or suspected COVID-19 cases)  to the room of the deceased patient. Other patients in this room must be relocated to another room immediately.

- Inform the morgue via telephone and draw up a request for transport of the remains to the morgue.

- Prohibit unauthorized personnel and the patient’s family from entering the patient’s room.

- Explain the risk of infection to the patient’s family and provide them with regulations on precautions against transmission upon contact with the remains and during encoffinment and visitation.

- Do not bring any item out of the patient’s room before the room is disinfected for the last time.

- While awaiting the morgue to collect the remains, health care workers shall cover the remains with bed linen and wipe the entire surface where the patient had been lying with 0.5% chlorine solution.

- Morgue staff shall wear adequate PPE when handling the remains. See Appendix 3 for more detail on PPE for handlers of remains.

- Isolate the remains according to the following procedure:

+ Place all remains in a body bag; cover the inside of the bag with anti-leak material if necessary.

+ Spray the outside of the first and second body bags with 0.5% (5,000 ppm) chlorine solution. Body bags must be made of anti-leak, non-transparent and durable material with a thickness equal to or more than 150μm and secure zippers.

+ If body bags are unavailable, wrap all of the remains with 02 layers of thick cotton cloth and then 02 layers of nylon. Spray the outside of the first and second nylon layers with 0.5% (5,000 ppm) chlorine solution.

+ After the body bag is zipped up, affix a biohazard card or sticker (using the specimen prescribed in the regulation on biomedical waste management enclosed with the Decision No. 43/2007/QD-BYT) on the outside of the bag.

+ Place the remains on top of a piece of clean bed linen in the transport vehicle, walk to the door of the patient’s room and remove PPE (and leave such PPE inside the room), disinfect hands and exit the room.

+ Morgue staff, who must wear adequate PPE, shall receive the remains outside of the patient’s room and transport it to the morgue.

- Disinfect the patient’s room and corridor after the remains have been handled.

- From the time of the patient’s death to the time the remains are removed from the room, health care workers of the department in charge of the patient shall supervise and remind all persons entering the room to adhere to isolation regulations.

5.2. Transport of dead bodies to morgues

- Health care workers must wear adequate PPE while transporting the remains (medical masks, gloves, paper gowns, caps, boots). See Appendix 3 for more detail on PPE for handlers of remains.

- Transport the remains on an isolated route and spray disinfectant immediately afterwards. Unauthorized persons shall not ride an elevator currently transporting remains. If the patient's family members would like to join, they must wear adequate PPE. Avoid transporting remains through crowded areas.

- After the remains are delivered to the cold chamber, the morgue staff transporting the remains must spray the transport vehicle with 0.05% (500 ppm) chlorine solution, wait 30 minutes, then remove their PPE properly, dispose of all equipment in yellow nylon bags, wash their hands and perform personal hygiene before taking on other tasks.

5.3. Encoffinment

Remains shall be encoffined in compliance with special procedures for dangerous infectious diseases:

- Encoffin remains as soon as possible.

- Remains must be encoffined in hospital morgues. Minimize number of participants in encoffinment.

- Persons directly encoffining remains must wear adequate PPE (medical masks, gloves, paper gowns, caps and boots) and wash hands with alcohol-based sanitizers and soap.

- Do not allow the patient’s family to visit before the remains are encoffined.

- Encoffinment procedure:

+ Place a nylon cloth large enough to cover the remains at the bottom of the coffin.

+ Wrap the nylon cloth placed in the coffin around all of the remains.

+ Close the coffin tightly. Inspect and seal all gaps in the coffin (if any) with waterproof tape.

- Morgue staff shall disinfect all surfaces of the encoffinment room and the coffin’s surface with 0.05% chlorine solution.

+ Remove and discard PPE (medical masks, gloves, paper gowns, caps and boots) into yellow nylon bags.

+ Wash hands with alcohol-based sanitizers and soap.

+ Shower before taking on other tasks.

5.4. Funeral visitation and handling of remains of confirmed or suspected COVID-19 cases

- Limit number of visitors. Visitors must wear masks, refrain from touching the coffin and wash their hands with alcohol-based sanitizers after the visitation.

- Do not transport the remains to another province. Transport the remains with a specialized automobile that the patient’s family is not permitted to enter directly to the cremation site. The driver must wear adequate PPE.

- Remains of confirmed or suspected COVID-19 cases must be cremated as soon as possible within 24 hours from the time of death.

- After transporting the coffin to the cremation or burial site, all surfaces of the transport vehicle must be disinfected with a disinfectant granted the certificate of free sale by the Ministry of Health.

- Corpses and ashes may be transported across the border according to regulations in the Government’s Decree No. 89/2018/ND-CP dated June 25, 2018 on guidelines for implementation of a number of Articles of the Law on Prevention and Control of Infectious Diseases regarding border health quarantine.

6. Inspection and supervision and responsibilities therefor

- Department of infection control, nursing department and heads and head nurses of relevant departments shall provide training in procedures and regulations concerning handling of remains of confirmed or suspected COVID-19 cases and inspect, supervise and expedite strict compliance with such procedures and regulations.

- Units having deceased patients shall abide by all regulations on infection control for the areas under their management.

- Morgues shall receive remains, transport remains to morgues, encoffin remains and organize funeral visitation and handling of remains according to regulations.

- Funeral services shall prepare vehicles to transport remains, comply with regulations during transport of remains to cemeteries and prepare a number of PPE for the patient's family in case of necessity.

- General planning department shall supervise implementation of these regulations, receive requests and report to its hospitals’ steering committee for resolution to difficulties arising during such implementation.

- Department of infection control shall inspect and supervise compliance with these regulations.

- Lists of health care workers, family members and other persons participating in handling and encoffinment of remains shall be drawn up in order to report and monitor these persons for 14 days, and provide them with guidelines on symptoms to be noted and on reporting to and visiting healthcare establishments for examination.

GUIDELINES ON COVID-19 PREVENTION FOR FAMILY MEMBERS AND VISITORS

Patient’s family members and visitors are at high risk of contracting COVID-19 and transmitting the disease to the community. All healthcare establishments must encourage these individuals to minimize their visits and provide them with personal protective equipment.

1. Objectives

- Prevent transmission to patient’s family and visitors when they have contact with confirmed or suspected COVID-19 cases.

- Ensure community safety and prevent widespread transmission of COVID-19.

2. Rules

- Do not allow close contact with or visit to confirmed or suspected COVID-19 cases that are being isolated, treated and/or monitored in healthcare establishments.

- Do not let visitors into the isolation area during procedures that may generate aerosols or droplets to prevent infection.

- Minimize visits to the isolation area to prevent community transmission.

- If visit to or contact with a patient is imperative, all visitors must follow the precautions applicable to the isolation area and receive instructions on how to wear and remove personal protective equipment prior to their visit.  

- Visitors shall not have close contact with patients (within 2-meter radius).

- Nursing infants whose mothers are confirmed or suspected to have contracted COVID-19 must be isolated and must not breastfeed unless prescribed by the in-charge doctor.

Visitors shall remove their PPE following proper procedures and wash hands as regulated before leaving the isolation area; provide adequate contact information and keep in touch with health authorities as instructed to monitor post-contact exposure.

- Health care workers shall accompany visitors, give them instructions on compliance with regulations and obtain each visitor’s name for monitoring purpose.

3. Regulated entities and scope: All visitors, patient’s family members and health care workers having close contact with patients in isolation.

4. Methods

4.1. Before entering isolation rooms

- Patient’s family members and visitors shall receive instructions on how to wear PPE properly, especially PPE that protects against respiratory transmission, and must wear PPE before entering the isolation area.

- Health care workers shall assist visitors with donning and doffing PPE and monitor visitor’s actions.

- Health care workers shall check visitor’s compliance with guidelines and understanding of precautions before allowing them into the isolation area.

4.2. In isolation rooms

- All visitors must comply with health care worker’s instructions and supervision in the isolation area and shall not touch any item in the isolation area or have close contact with patients (hugging, kissing or shaking hands).

- Keep a distance of at least 2 meters with patients.

4.3. Exiting isolation rooms

- Remove PPE in accordance with the instructions from health care workers in the anteroom.

- Do not bring any used item or piece of PPE from the isolation area to other places.

- Draw up lists of persons having close contact with confirmed or suspected COVID-19 cases and notify local preventive healthcare authorities to monitor the health of these persons and handle as regulated.

- Encourage patient's family members and visitors to declare relevant personal information proactively for monitoring purpose and to self-monitor for symptoms for 14 days after leaving the isolation area. Any abnormal sign must be reported to the nearest health authority for advice.

- Inspection and supervision:

+ Department of infection control, nursing department and heads and head nurses of relevant departments shall provide training in procedures and regulations concerning participation in care of or visiting confirmed or suspected COVID-19 cases and inspect, supervise and expedite strict compliance with such procedures and regulations.

+ Supervision shall focus on whether health care workers provide training and instructions for the patient’s family members and visitors and supervise the patient’s family members and visitors.

APPENDIXES

APPENDIX 1

DIAGRAM OF HANDLING OF SUSPECTED COVID-19 CASES

APPENDIX 2

DIAGRAM OF INFECTION PREVENTION AND CONTROL DURING DIAGNOSTIC PROCESS

APPENDIX 3

USE OF PERSONAL PROTECTIVE EQUIPMENT BY HEALTH CARE WORKERS IN COVID-19 PREVENTION AND CONTROL

Note: (+) Must use.

(+/-) Use shall be considered based on situation.

APPENDIX 4

CHEMICALS FOR EPIDEMIC PREVENTION AND CONTROL

The progress of infectious diseases is becoming harder and harder to predict while new and dangerous infectious diseases are emerging in many countries around the world. During an outbreak, it is crucial that chemicals be used to disinfect contaminated items and areas to reduce the spread of the disease and the number of victims.

Adequate information on disinfectants used in healthcare establishments must be provided for their users. These chemicals must be highly effective in handling the environment, room air, medical equipment and waste. Here are some chemicals commonly used for prevention and control of infectious diseases in healthcare establishments:

1. Chemicals for hand hygiene and disinfection

1.1. Alcohol

1.1.1. General characteristics

Ethyl 70° or Isopropyl 50° alcohol is used for disinfection, which is usually regarded as highly effective. Hand hygiene preparations contain 60%-80% alcohol by volume. High concentrations of alcohol lead to faster evaporation, which reduces its antibacterial efficacy.

1.1.2. Mechanism of action

Alcohol denatures bacterial and viral proteins and is effective against somatic cells (including mycobacterium tuberculosis, enveloped viruses and fungi) but not against spores.

Alcohol destroys viral lipids and eliminates viruses tens of seconds after contact.

1.1.3. Use

Alcohol and its preparations may be used for hand hygiene during use and  removal of PPE. In addition, alcohol can be used to disinfect equipment such as thermometers, retinal endoscopes, rubber caps of multiple-dose drug bottles or vaccine vials, bag valve masks, ultrasound equipment or drug preparation equipment.

As alcohol is flammable, it needs to be kept in a cool and well-ventilated place. Due to its fast evaporation rate, alcohol must be stored in containers with lids and equipment to be disinfected must be completely soaked in alcohol.

1.2. Chlorhexidine gluconate solutions

1.2.1. General characteristics

Chlorhexidine solutions are strong, fast-acting and broad-spectrum disinfectants with skin moisturizers. Their effects are more long-lasting than alcohol or iodophor solutions and they do not sensitize the skin.

1.2.2. Mechanism of action

Chlorhexidine is widely effective against Gram-positive and Gram-negative bacteria, yeast, skin fungi and lipid-attached viruses and ineffective against spores.

1.2.3. Use

Chlorhexidine 2% solution for skin disinfection such as showering, hand hygiene or mucous membrane disinfection (oral aerosols).

Chlorhexidine 4% solution for pre-surgery or pre-delivery hand hygiene.

1.3. Iodophor compounds

1.3.1. General characteristics

Iodophor disinfectants used in healthcare establishments such as Povidone-Iodine (Polyvinylpyroiodine combined with iodine) can eliminate bacteria and viruses but not spores, rarely sensitize the skin and do not leave any tint after use.

1.3.2. Mechanism of action

Iodophor compounds can quickly infiltrate cell walls of microorganisms and destroy their proteins and nucleic acids.

1.3.3. Use

Chemicals containing Iodophor can be used for skin disinfection, changing surgical bandage and disinfection of non-invasive medical equipment such as thermometers, stethoscopes, sphygmomanometers, etc.

2. Chemicals for environmental remediation

2.1. Chlorine and chlorine compounds

2.1.1. General characteristics

Chlorine and its compounds are the most common chemicals for prevention and control of epidemics in healthcare establishments, which exist in liquid form (Javel) or solid form (Calcium Hypochloride). Chlorine-based disinfectants have a board spectrum and are fast acting and inexpensive. However, one disadvantage of these chemicals is their corrosion effects on medical equipment and lower effectiveness in the presence of organic substances.

Chlorine-releasing compounds used in hospitals include Chloramine B (chlorine dioxide) and Chloramine T.

2.1.2. Mechanism of action

Chlorine compounds can inhibit activity of the enzymes necessary for viral replication, denature proteins and inactivate viral nucleic acids.

2.2.3. Use

Chlorine-based disinfectant solutions shall have a concentration of at least 0.05% (500 ppm) after dilution. 0.05% solution may be used to decontaminate surfaces such as floors, walls, ceilings, etc. Transport vehicles such as ambulances, stretchers and other items must be sprayed with disinfectants after use.

Solutions containing 0.05%, 0.5%, 1% and 1.25% active chlorine concentrations commercially available are used for different purposes and methods of disinfection. A solution’s concentration must be calculated based on active chlorine. As different chlorine-releasing compounds have different active chlorine contents, it is necessary to calculate the amount of compound necessary to obtain a solution with the desired active chlorine concentration.

Amount of chlorine necessary to obtain a solution with desired active chlorine concentration is calculated using the following formula:

* Active chlorine content of the chlorine-releasing compound is written on the product’s label, wrapping or instructions for use.

Example:

- To obtain 10 liters of a solution containing 0.5% active chlorine from Chloramine B powder containing 25% active chlorine, the amount of Chloramine B powder needed is (0.5 x 10/25) x 1,000 = 200 gram.

- To obtain 10 liters of a solution containing 0.5% active chlorine from Calcium hypochlorite powder containing 70% active chlorine, the amount of Calcium hypochlorite powder needed is (0.5 x 10/70 ) x 1,000 = 72 gram.

- To obtain 10 liters of a solution containing 0.5% active chlorine from Sodium dichloroisocyanurate powder containing 60% active chlorine, the amount of Sodium dichloroisocyanurate powder needed is : (0.5 x 10/60) x 1,000 = 84 gram.

Table 1. Amount of chlorine-releasing compound necessary to obtain 10 liters of solution containing active chlorine for hospital surface cleaning

Chlorine is commonly used for water disinfection. High chlorine concentration can eliminate bacteria in contaminated water significantly.

As chlorine solutions lose strength over time, these solutions should be prepared in suitable quantity and used as soon as possible. It is best to prepare and use chlorine solutions within the day instead of in advance. Prepared solutions shall be stored in closed containers in a dry and cool place out of direct sunlight.

2.2. Quaternary ammonium compounds

Quaternary ammonium compounds are hospital disinfectants capable of eliminating fungi, bacteria and lipophilic viruses but not spores. They shall only be used as disinfectants and not as antiseptics on skin or tissues.

While quaternary ammonium compounds are good cleaning agents, they are not recommended for COVID-19 due to poor effectiveness against SARS-CoV-2.

3. Equipment disinfectants and sterilants

3.1. Glutaraldehyde

3.1.1. General characteristics

Glutaraldehyde, a saturated dialdehyde, is a high-level sterilant and disinfectant. Glutaraldehyde is acidic and ineffective against spores. Only when a Glutaraldehyde solution is activated by use of alkalinizing agents with pH from 7.5 to 8.5 does it become sporicidal.

Glutaraldehyde is widely used in healthcare establishments for the following reasons:

- High effectiveness against bacteria;

- Consistent activity even in the presence of organic matters (sputum, blood, pus, etc.).

- Noncorrosive to all equipment.

3.1.2. Mechanism of action

Activity of Glutaraldehyde is a consequence of alkylation of the sulfhydryl, hydroxyl, carboxyl and amino groups of microorganisms, which alters DNA, RNA and protein synthesis.

3.1.3. Use

The alkaline ≥ 2% Glutaraldehyde solutions are usually used for high-level disinfection of equipment with low heat resistance such as endoscopes, anesthetic equipment, spirometers and other equipment used in diagnosis and treatment of respiratory diseases.

After a piece of equipment is soaked in Glutaraldehyde, it must be rinsed with sterile distilled water thoroughly and dried before use.

Health care workers may experience dermatitis, nasal or ocular mucosa irritation, etc. due to Glutaraldehyde exposure if a basin containing Glutaraldehyde solution is not fully covered or the ventilation system in the equipment handling area fails to meet required standards.

In such events, Glutaraldehyde concentration may reach 0.05 ppm. Glutaraldehyde solutions need to be contained in basins with tightly shut lids to mitigate exposure during use. The ventilation system in the equipment handling area must reach 7-15 ACH. 

As the level of Glutaraldehyde concentration decreases over time, antibacterial efficacy of Glutaraldehyde solutions must be checked regularly.

3.2. Hydrogen peroxide

3.2.1. General characteristics

Hydrogen peroxide is highly effective against bacteria, viruses, fungi and spores.

3.2.2. Mechanism of action

Hydrogen peroxide destroys hydroxyl radical, leading to changes to lipid membranes, DNA and other vital components of microorganisms. This chemical can inhibit the production of catalase, an enzyme that protects microorganisms from hydrogen peroxide by breaking hydrogen peroxide down into water and oxygen.

3.2.3. Use

6%-25% hydrogen peroxide solutions are used for sterilization. Solutions containing 7.5% hydrogen peroxide and 0.85% phosphoric acid (for maintenance of low pH) are commercially available. 5% hydrogen peroxide solution can inactivate 10⁵ multidrug-resistant Mycobacterium tuberculosis after 10 minutes and poliovirus and hepatitis A virus after 30 minutes. Antibacterial efficacy of 10% hydrogen peroxide solution is equivalent to that of 2% Glutaraldehyde in 20 minutes.

As the level of hydrogen peroxide concentration decreases over time, antibacterial efficacy of activated hydrogen peroxide solutions must be checked regularly.

3.3. Orthophthaldehyde

3.3.1. General characteristics

Orthophthaldehyde (OPA) is a compound containing 0.55% 1,2-benzenedicarboxaldehyde. OPA is highly effective against bacteria and more effective against Mycobacterium tuberculosis than Glutaraldehyde.

3.3.2. Mechanism of action

The mechanism of action of OPA is not fully understood.

3.3.3. Use

OPA solutions are usually used to disinfect endoscopy equipment, are stable at a pH range from 3 to 9, do not require activation and are fast-acting (fully soak equipment in the solution for 5 minutes, then remove the equipment, rinse it with sterile water and dry it before use).

3.4. Peracetic acid

3.4.1. General characteristics

Peracetic acid, also known as peroxyacetic acid, is a fast-acting and broad-spectrum antibacterial compound. Its degradation products such as acetic acid, water, oxygen or hydrogen peroxide are harmless to users and the environment.

Peracetic acid is corrosive and can cause metal equipment to lose its shine. Diluted peracetic acid solution (1%) is unstable due to hydrolysis. 40% peracetic acid loses 1%–2% of its active ingredients per month.

3.4.2. Mechanism of action

Peracetic acid oxidizes sulphur bonds in proteins of microorganisms, leading to changes in the protein structure.

3.4.3. Use

Peracetic acid with 0.2-0.35% concentrations is a highly effective sterilant against bacteria and spores and usually used to sterilize surgical and endoscopy equipment. It has very poor stability and only a 24-hour use life.

Table 2. Virus inactivation effectiveness of disinfectants

Table 3. Chlorine-based disinfectants for COVID-19 prevention and control in healthcare establishments

Note: Depending on the extent in which a chemical is used, the user must wear adequate PPE to avoid the adverse effects of the chemical.

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