Screen Shot 2020-03-19 at 11.32.17.pngCommunity Health Workers & Disability support groups or centres:

Local community: Use local councillors/chiefs/tribal authority/traditional healers/hospital & clinic committees :
  • As key informants on what is happening at local hospital and clinic and as recorders & reporters of CV cases to a key person in that area
  • To pass on DoH infographics above and to limit mass gatherings such as funerals/weddings/church gathering/tomb unveiling/sports etc
  • To recommend that people do not travel between urban areas and rural areas e.g do to come home at month end
  • Have information workshops for local shops & restaurants on queuing, hygiene, staff with coughs

Our main targets are pressure sore & urinary tract infection treatment and those with mental illness:

General:
  • Allocate key person per patient to keep in contact/continue rehab rather than teams
  • Identify those patients that have good adherence and do telephonic contacts rather then home/clinic visits
  • Identify those patients with poor adherence or high risk for suicide/aggression for continued direct intervention
  • Assess mental health/life satisfaction to identify risk of depression or suicide in patients with high risk e.g people with SCI
  • Advise families to report any changes in behaviour that may indicate patient is regressing
  • Provide all patients with the information in #Rural Rehab Coronavirus 1: Educate the community
  • Suggest alternative ways to maintain a healthy lifestyle while avoiding group gatherings
  • Establish a key contact number other than the hospital number  for patients or families to call
Pressure Sores provide:
  • 3 month supply of nappies/linen savers/hebitane ointment/catheters/masks

Mental Illness, intellectual impairment or anxiety about CV-19

  • Advocate for 3 month supply of medication
  • Spend time with patients explaining the need to stay at home if they have a cough & temperature and that they should tell the family if they talked to someone with a cough in the community
  • If the family cannot contain the person within the home environment advise on hygiene to prevent spread of virus from community into the family and from patient to community
  • For those with anxiety or depression, families should limit time spent listening to TV/Radio programmes about the virus and time talking about the virus. Teach some quick & simple relaxation methods such as deep breathing, whole body muscle relaxation, and relaxing visualisations; and remind them to concentrate on the “facts” not “fears” and make sure they have the DoH Whats App help
  • For those with intellectual impairment teach coughing hygiene & hand washing by demonstration. Ask families to set up a routine buddy system for hand washing and wearing masks eg when the carer washes their own hands they should also wash the patients hands
  • SADAG Mental Health Line 011 234 4837
  • Suicide Crisis Line 0800 567 567
  • Suicide support  line manned by trained counsellors 0800 21 22 23  (8am to 8pm) 

    0800 12 13 14  (8pm to 8am) Or SMS 31393.


We still need to see patients on wards and in our Rehab departments so some tips are:

General:
  • Know your hospital Coronavirus testing point
  • Hand sprays and hygiene posters at the entrance to the department . Posters are available in English, Afrikaans, Xhosa & Zulu
  • Wipe down surfaces between patients, especially patient response buttons
  • Encourage patients to wash or sanitise their hands at the end of their appointment and  instruct on how to do so properly
  • Practice social distancing during the appointment, as far as possible.
  • Wear a mask and get patient to wear a mask if you are doing close contact work for assessment or intervention and they have a cough & temperature

Outpatients:

    • Schedule appointments instead of everyone arriving at 8.00 so that the queue is less
    • Draw files for booked patients
    • Encourage patients to wait outside rather than indoors
    • Space waiting room chairs for  social distancing (if possible)
    • Have infographics from  #Rural Rehab Coronavirus 1: Educate the community on the waiting area walls and have someone talk through these with the people in the queue
    • Screen the queue for people with cough & temperature and separate them from the rest (by 2m if no separate room). Provide them  with masks. Send for testing if they have acute respiratory illness with sudden onset of at least one of the following: cough, sore throat, shortness of breath or fever [≥ 38°C (measured) or history of fever (subjective)] AND In the 14 days prior to onset of symptoms, met at least one of the following epidemiological criteria: Were in close contact with a confirmed or probable case of SARS-CoV-2 infection; OR Had a history of travel to areas with local transmission of SARS-CoV-2 OR Worked in, or attended a health care facility where patients with SARS-CoV-2 infections were being treated 
    • Have 1 area/plinth/mat for use with those with a cough & temperature
    • Advise those with cough & temperature to self isolate at home (own room, don’t share cups etc, don’t have visitors, wash clothes in hot water or iron to kill virus) and give  rehab home programme with telephonic or key person follow up, and advise to contact if condition gets worse
    • Identify disability at risk cases that need to continue regular outpatients e.g. hand injuries
    • Identify slow recovery cases that can use home programmes & train MLW in community to check the programme to reduce the number of hospital visits
    • All patients entering audiology assessment area to wear mask and sanitise hands before entering as closed space
Regular Groups:
  • Teach about COVID-19 and the risks to that group and how they can spread health messages in their community
  • Share ideas on how to sanitise themselves & family when shopping, at church/social gathering and travelling in a taxi, & how to self isolate at home. This is particularly important in rural areas where poverty effects the buying of soap, travelling by taxi, several people sharing beds and bedrooms.
  • Identify when they must return to rehab/go to the clinic/hospital for non-COVID related problems eg pressure sores
  • Start Whats App groups so that you can keep in contact with the group, especially the people who decide not to return for therapy
  • Transfer the patients in groups to MLW in the community eg OTT to reduce travel
Ward patients:
  • Sanitise your own and the patient’s hands before and after the session.
  • Both to wear masks.
  • Educate patients and caregivers about COVID-19 if ward staff are not doing this.
  • If Ward visiting is stopped then organise key contact to provide telephonic updates for families and times when they can call for updates
  • Ensure that frail & disabled  patients have a support system for sanitising routines and self-isolation when discharged.
  • If hospital has high influx of COVID-19 cases then beds will be freed up by early discharge so make sure all patients have follow up appointment procedures explained on Day 1 of rehab and appointment dates for outpatients or clinic outreach date
Your own mental health and that of your co-workers during crisis time at the hospital
  • Quick activities to reduce stress are: deep breathing for 10 breaths, whole body muscle tense & relax 3 – 5 times, positive visualisations eg picture a place you feel calm and relaxed for 1 minute, a minute to appreciate nature around you, prayer
  • Practice mindfulness: take a quick check of how you are coping several times a day: how tense your muscles are, how controlled your thoughts are, how in control you feel and use one of the techniques to bring you down to “normal” if you are feeling stressed
  • You can only continue to work in crisis mode if you look after yourself so do take tea and lunch breaks
  • Make the opportunity to practice these at different points in the day eg at the beginning and end of a meeting, tea & lunch times etc
  • At home have at least 1 positive/enjoyable activity a day for you and your family
COVID-19 in a Rural Setting
4 lessons from the #coronavirus #COVID19:
Lesson 1: public health is political
Lesson 2: science matters
Lesson 3: education of the public matters

Lesson 4: we should always be talking about public health

Problems
Distances from home to health facility, especially when a person in self-quarantine becomes unwell and needs to visit hospital
Less-regulated employment practices than in urban settings (more potential abuse of employees viz. job security)
Baseline economic status of most rural communities is poor, and poor municipal services (water, sanitation)
Import of infections from urban to rural environments:
  • university residences being vacated – mass return to home (many students from rural areas)
  • international tourism to many rural areas with contact with local staff
  • Month end & Easter return home by migrant workers
Poor penetration of public health messages to the most rural communities
Potential solutions
Local Co-ordination & Innovation
Identify the key stakeholders in your area that need to be involved in the local discussions & plans  e.g. Imbizos and DSD SASSA pay points are “mass meetings”, and set up a local co-ordination group
Community leadership to designate areas for mass quarantine
Promote COPC model with healthcare workers being available to for community to consult about rural community’s own solutions to public health goals
Encourage innovation at community and facility level – leadership to give principles/goals, communities come up with their own solutions to be concordant with public health principles e.g. tech savvy youth could run a Whats App Health campaign
Come up with local policies around unavoidable events e.g. funerals, taxi travel
Public Health Messages
  • District/traditional/health facility leadership to lead by example in embracing disruptive nature of recommendations (selfless approach, cancelling non-urgent travel, hygiene)
  • Counter poor penetration of public health message, but unclear mechanism:
    • District/traditional/health facility leadership to use DoH COVID-19 infographics. DoH KZN has ones in Zulu and DoH has 1 in Xhosa. 
    • Home visits by CHWs are an opportunity for education, screening and community-based care (which could limit wider movement of people between households) vs. home visits by CHWs are a potential mechanism of spread
    • Target high risk transmission groups e.g. taxis & food industries and adjust health messages for these groups. The Taxi & Tourism industries are developing guidelines.
    • Have clear messages on self isolation within the home e.g. where possible separate room/crockery/cutlery/facecloth etc
Reducing face-to-face Contact
  • Consider a local WhatsApp health message group for the community
  • Have District DoH meetings via Skype/Hangouts/Zoom
  • Multi-month prescriptions to be issued to patients with controlled chronic disease
Economics
Work with the Department of Labour about this.
  • Give clear messages about the time span of the illness to local employers. Most people will have short illness like cold or flu and will return to work quickly.
  • Job security while ill: Everyone to take measures seriously, so that those who do self-quarantine for good reason are not singled out/punished by employer (safety in numbers).  
  • As there is poor employment opportunities the labour pool should be enough for employment of temporary staff while permanent staff are on sick leave.
  • Have a list of retired health staff in the area that would be willing to return to work if health facilities have a lot of staff on sick leave.
COVID-19 Clinical Management
National Institute for Communicable Diseases  0800 029 999
Hospitals are making their own SOPs while waiting for National & Provincial Guidelines:
  • A number of guides have been posted on the RuDASA Forum & Facebook page. These are listed in the reference section.
  • Share SoPs between facilities
  • Have a dedicated COVID-19 Whats App group to get information out to all hospital staff & clinic staff quickly
  • Establish a screening area/ward
  • Sanitising spray in every department and waiting area
  • Get good stock supplies
  • Liaise with EMRS regarding confirmed cases in transit
  • Train gate security on queuing suspected COVID-19 cases
Mental Health
  • SADAG Mental Health Line 011 234 4837
  • Suicide Crisis Line 0800 567 567
  • Suicide support  line manned by trained counsellors 0800 21 22 23  (8am to 8pm) 0800 12 13 14  (8pm to 8am) Or SMS 31393

References

Clinical Management (SA & International)
NICD
Note for Clinicians In our efforts to expand and streamline testing for COVID-19, we have decided that doctors do not need to contact the NICD for approval as long as they apply the case definition before testing. The NICD will test the submitted samples as long as the required supporting documents accompany the sample (specimen submission form and PUI form) which is available on the NICD website: http://www.nicd.ac.za/diseases-a-z-index/covid-19/
There is more information on the NICD web so keep checking their updates!
South African HIV Clinicians Society
DoH Western Cape
Disaster Management
Health Education:
DoH Health Messages Whatsapp 0600 123 456 
International COVID-19 Mapping
Local Mapping & Statistics
WHO
Guidance on 14 topics: from clinical management to refugee camps
WHO Twitter feed
WONCA Africa 
Will host a webinar every Friday starting 20th March 2020 Kindly register Register for this webinar: https://who.zoom.us/webinar/register/WN_5K4o4CiARvKARgriYI37vw
After registering, you will receive a confirmation email containing information about joining the webinar. 

 

Regards
Stephanie