Guidelines for Management COVID-19, 3rdwave based on MOHFW Guidelines 5.1.22, 9.1.

22 and
AIIMS ICMR, Regional and State COEs Webinar on 5.1.22

Omicron variant has over 50 new mutations, multiplies faster in Upper respiratory tract and
is associated with milder symptoms. It is more commonly involving the bronchus as compared to the
lung parenchyma

Symptoms Omicron Delta Cold Flu

Cough   Mild 
Variant Average
Sore throat  Rare  Rare
Incubation
Fever   Rare 
period in Days
Tiredness  Rare Mild 
Omicron 3
Headache  Rare Rare 
Delta 4
Aches & Pain  Rare  
Alpha 5
Sneezing    
Doubling time
Diarrhoea Rare Rare  Rare
Omicron 1.5
Runny nose Rare Rare  Rare
Delta 1.9
Chills    
Night sweats    
Burning eyes    
Appetite loss    
Loss of smell    
Loss of taste    
Nausea    

Clicical criteria Epidemiological criteria

Acute onset fever and In prior 14 days, exposure to
cough or ≥ 3 COVID19 positive case/ work in
symptoms (refer list) High risk area/ Travel history/
Suspected cases working in Healthcare settings

SARI
H/O fever ≥38⁰C and Cough within last 10
days needing hospitalization
Probable case:
[Link] criteria met
2. Contact with suspected/positive case
3. Death- Preceding Respiratory distress, not otherwise explained, contact of probable/confirmed case
Confirmed Case
Test for SARS CoV2- Negative- Observe (re-test if symptoms persist or SOB worsens)
Tested positive, classify into mild, moderate and severe

Confirmed

Mild Moderate Severe

Uncomplicated URTI RR≥ 24/min RR≥30/min
No SOB, No Hypoxia SOB SOB
Home isolation Sp02: 90-93% on Room Air Sp02<90% on Room Air

Home based care pre-requisites

 Patient is stable- Mild disease

 Caregiver available 24/7
 Regular communication with hospital
 Room for isolation available
 Separate bathroom
 Access to food, clean water
 Other household members can adhere to COVID appropriate precautions

Patient selection

Patients without co-morbidities with Mild disease who meet above criteria can be isolated at Home

Those with the following co-morbidities with mild disease can be isolated at home after proper
evaluation (Age>60, DM, HTN, Chronic illness-CLD/CKD/CHF/CVS/Lung disease,
Immunocompromised status-HIV/Transplant recipient/Cancer patients)

Measures to prevent transmission

Large droplet transmission Airborne transmission

Reduce direct contact – Distance >3ft Adequate ventilation
Regular cleaning of High touch areas Reduce crowding, decrease time spent indoors
Follow respiratory etiquette Use of mask
Use of well fitted masks Ensure proper fit of mask, discard when soiled
Taking care at Home- Frequent handwashing, proper use of mask, good ventilation

Isolate the sick person Reduce contact with the virus Care of the sick individual
Prepare a separate room Identify a caregiver who Monitor Vitals (PR,Sp02, RR),
doesn’t have comorbidities
and is vaccinated
Well ventilated, open windows Always wear a well fitted mask Pay special attention to high
risk individuals
Symptomatic RX Patient to use separate dishes, Ensure hydration, regular
Congestion-Saline gargles bedding etc. meals and sufficient rest
Fever -T. Paracetamol SOS Regular cleaning of High touch Contact Medical Practitioner if
Cough- Anti-tussives (syrup) areas patient has SOB, Sp02<93%,
Cold- Levocetrizine Chest pain, confusion,
worsening symptoms >4 days

No Blood/Radiological investigations are needed for those under home isolation

Testing of asymptomatic contacts is not recommended
Testing of asymptomatic healthcare workers is not recommended even after exposure
HCWs caring for COVID patients need not be quarantined unless they become symptomatic

Disinfection- Needed for high touch surfaces

Soap solution at all hand wash areas

Alcohol with emollient for hand rub
Alcohol without emollient for surface disinfection of metallic surfaces (Spraying not recommended,
wiping is enough)
Hypochlorite not to be used on metallic surfaces (Can be used for other high touch surfaces)

Testing

If Rapid antigen test is positive- RT-PCR not needed

If Rapid antigen test is negative and symptoms persist, RTPCR is recommended

Discharge criteria for COVID positive patients -Mild cases- Home isolation to end after 7 days from
testing date provided patient remains afebrile for>3 days. No re-testing required after completing
home isolation

Moderate cases Patients whose signs and symptoms resolve and maintain saturation above 93% for
3 successive days (without oxygen support), and stable comorbidities, if any, will be discharged as
per the advice of the treating medical officer. There is no need for testing prior to discharge.

Patients on oxygen whose signs and symptoms do not resolve, and demand of oxygen therapy
continues, will be discharged as per the advice of the treating medical officer only after
• Resolution of clinical symptoms
• Ability to maintain prescribed oxygen saturation for 3 successive days without oxygen support
• Stable comorbidities
Severe Cases including immunocompromised (HIV patients, transplant recipients, malignancy etc.)
Discharge criteria for severe cases will be based on clinical recovery at the discretion of the treating
medical officer.

The patients post discharge are advised to self-monitor their health for further 7 days and shall
continue wearing masks. Post discharge, if the patient develops any symptoms of fever, cough or
breathing difficulty or she/she continues to experience residual/sustained symptoms, he/she shall
contact the treating doctor for further clinical guidance

Waste disposal – General soiled waste to be put in a black bag and handed over to BBMP
Used swabs, masks, gloves, tissues should be treated as BMW and collected separately in Yellow bag

Medications

Vitamins C and Zinc – No role

Antibiotics (Doxycycline, Azithromycin)- No role

Oral steroids –No benefit in non-critically ill. They prolong viral shedding and increase duration of
hospitalization. They also increase mortality, ICU admission and ECMO requirement

Inhalational Budesonide- maybe considered in select cases if fever/cough persist >5 days. Not to be
used routinely

Ivermectin – Not recommended

Remdesivir- Not recommended in home isolation, to be used only in Hospital setting (No benefit in
Mild cases)

Monoclonal Antibody-Caserivimab, Imdevimab, Bamlanivimab, Etesevimab and Sotrovimab act

against Delta variant. Only sotrovimab acts against Omicron
Use with caution (risk of adverse effects, anaphylaxis)
Can be given in mild disease with >10 % risk of progression -Unvaccinated, elderly and
immunocompromised
To be given <10 days of onset and to individuals >12 years and weight >40 kg

Molnupiravir- Can be used for unvaccinated, non-pregnant, non-hospitalized mild-moderate

COVID19 symptoms within <5days of symptoms onset who have risk factors for progression
Adverse effects- ?carcinogenicity, Embryo-fetal toxicity, Toxic to bone-cartilage in young and gonadal
tissue toxicity (Women of reproductive age group to use contraception for 3 months)

Investigations

Mild /asymptomatic: - No routine blood investigation required

Moderate/severe: - Will required blood investigation based upon presence of co-morbidities and
clinical presentations

Common investigation:- CBC,LFT,RFT,PT/APTT/TT/FIBRINOGEN,D-DIMMER,CRP,LDH,IL-6,BLOOD

SUGAR,BLOOD CULTURE,PCT
Specialized investigation: - TROPONIN, FERRITIN, ABG (Risk stratify COVID-19), THYRIOD PROFILE
HBA1C, VIRAL MARKERS (General Assessment)

CBC- Greater severity and worse prognosis

Reduced Absolute lymphocyte count
Thrombocytopenia
Eosinopenia
Neutrophil : Lymphocyte ratio ≥3.13

LFT – AST elevation associated with mortality risk, ALT elevation occurs in hepatitis induced liver
injury

RFT- Dysfunction indicates severe disease; watch for rising creatinine and K+ levels in critically ill

Ferritin- Associated with higher mortality and worse outcomes

LDH- Its elevation could indicate impending deterioration

CRP- Higher CRP associated with greater disease severity, VTE, AKI and higher mortality

In severe disease with rapid worsening, rising CRP may help decide patients needed higher dose of
anti-inflammatory/Tocilizumab

LDH/CRP/PCT/D-Dimer/IL6 help in risk stratification and prognostication

Procalcitonin- maybe elevated in COVID19 so interpret with caution

D-Dimer >2 times upper limit of normal needs aggressive clinical monitoring for severe disease

D-Dimer elevation is usual. Until DVT/PTE suspected/Confirmed, therapeutic anticoagulation should

be avoided

Fibrinogen- not useful, Troponin and CPK-MB maybe useful in follow up of tachyarrhythmias

IL6- higher levels were associated with cytokine storm, but not useful for identifying patients eligible
to benefit from tocilizumab

Therapeutic decisions to be made based on clinical severity and may only be aided by biomarkers
Mild disease – do not treat just because biomarkers are elevated, just keep a close watch

Imaging of COVID-19 pneumonia: - CXR and CT-SCAN

Use of CXR: - Fever, Shortness of Breath, Respiratory Rate ≥ 20/min, Hypoxia, Room air SpO2 ≤ 94%
Patient with moderate to severe symptoms CXR can be taken at baseline.
In mild cases if they have risk factors for developing severe diseases such as age > 60 yrs, Cardio
vascular disease, DM, immunocompromised status, chronic liver, kidney ,lung diseases.

CT SCAN: -Do in case Suspected COVID19 (patients RT-PCR is negative with severe SARI symptoms)
Equivocal pattern on CXR
CT score does not always match the clinical severity, patients to be managed based on clinical
severity. Not to be done routinely to check the status of lungs/to asses improvement