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. 2021 Jan 6;104(3_Suppl):3-11.
doi: 10.4269/ajtmh.20-1064.

Pragmatic Recommendations for Identification and Triage of Patients with COVID-19 in Low- and Middle-Income Countries

Lia M Barros  1 , Jennifer L Pigoga  2 , Sopheakmoniroth Chea  3 , Bhakti Hansoti  4 , Sarah Hirner  5 , Alfred Papali  6 , Kristina E Rudd  7 , Marcus J Schultz  8   9   10 , Emilie J Calvello Hynes  11 ; COVID-LMIC Task Force and the Mahidol-Oxford Research Unit (MORU)
Affiliations

Pragmatic Recommendations for Identification and Triage of Patients with COVID-19 in Low- and Middle-Income Countries

Lia M Barros et al. Am J Trop Med Hyg. .

Abstract

Effective identification and prognostication of severe COVID-19 patients presenting to healthcare facilities are essential to reducing morbidity and mortality. Low- and middle-income country (LMIC) facilities often suffer from restrictions in availability of human resources, laboratory testing, medications, and imaging during routine functioning, and such shortages may worsen during times of surge. Low- and middle-income country healthcare providers will need contextually appropriate tools to identify and triage potential COVID-19 patients. We report on a series of LMIC-appropriate recommendations and suggestions for screening and triage of COVID-19 patients in LMICs, based on a pragmatic, experience-based appraisal of existing literature. We recommend that all patients be screened upon first contact with the healthcare system using a locally approved questionnaire to identify individuals who have suspected or confirmed COVID-19. We suggest that primary screening tools used to identify individuals who have suspected or confirmed COVID-19 include a broad range of signs and symptoms based on standard case definitions of COVID-19 disease. We recommend that screening include endemic febrile illness per routine protocols upon presentation to a healthcare facility. We recommend that, following screening and implementation of appropriate universal source control measures, suspected COVID-19 patients be triaged with a triage tool appropriate for the setting. We recommend a standardized severity score based on the WHO COVID-19 disease definitions be assigned to all suspected and confirmed COVID-19 patients before their disposition from the emergency unit. We suggest against using diagnostic imaging to improve triage of reverse transcriptase (RT)-PCR-confirmed COVID-19 patients, unless a patient has worsening respiratory status. We suggest against the use of point-of-care lung ultrasound to improve triage of RT-PCR-confirmed COVID-19 patients. We suggest the use of diagnostic imaging to improve sensitivity of appropriate triage in suspected COVID-19 patients who are RT-PCR negative but have moderate to severe symptoms and are suspected of a false-negative RT-PCR with high risk of disease progression. We suggest the use of diagnostic imaging to improve sensitivity of appropriate triage in suspected COVID-19 patients with moderate or severe clinical features who are without access to RT-PCR testing for SARS-CoV-2.

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Conflict of interest statement

GROUP MEMBERS OF THE “COVID-LMIC TASK FORCE”

Heads: Alfred Papali (Atrium Health, Charlotte, NC) and Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, location “AMC,” Amsterdam, The Netherlands).

Advisors: Neill K. J. Adhikari (Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada); Emilie J. Calvello Hynes (University of Colorado School of Medicine, Department of Emergency Medicine, Denver, CO); Martin Dünser (Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria) and Mervyn Mer (University of the Witwatersrand, Johannesburg, South Africa).

Subgroup members, in alphabetical order: Andrew Achilleos (Sunnybrook Health Sciences Centre, Toronto, Canada); Hanan Y. Ahmed (Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia). Kevan Akrami (Universidade Federal da Bahia, Salvador, Brazil and University of California San Diego, CA); Lia M. Barros (University of Washington, Seattle, WA); B. Jason Brotherton (AIC Kijabe Hospital, Kijabe, Kenya); Sopheakmoniroth Chea (Calmette Hospital, Phnom Penh, Cambodia); William Checkley (The Johns Hopkins University School of Medicine and The Johns Hopkins University Center for Global Health, Baltimore, MD); Elif Cizmeci (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); Natalie Cobb (University of Washington, Seattle, WA); Finot Debebe (Department of Emergency Medicine and Critical Care, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia); Juliana Ferreira (University of São Paulo, São Paulo, Brasil); Gabriela Galli (University of Pittsburgh School of Medicine, Pittsburgh, PA); Tewodros Haile (Department of Internal Medicine, College of Health Sciences, Addis Ababa University); Bhakti Hansoti (Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD); Madiha Hashmi (Ziauddin University, Karachi, Pakistan); Rebecca Inglis (Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit [LOMWRU], Mahosot Hospital, Vientiane, Lao People’s Democratic Republic and Department of Intensive Care, Oxford University Hospital Trust, Oxford, United Kingdom); Burton W. Lee (NIH, Bethesda, MD; University of Pittsburgh School of Medicine, Pittsburgh, PA); Faith Lelei (AIC Kijabe Hospital, Kijabe, Kenya); Ganbold Lundeg (Mongolian National University of Medical Sciences, Ulan Bator, Mongolia); David Misango (The Aga Khan University, Nairobi, Kenya); Ary Serpa Neto (Department of Critical Care Medicine and Institute of Education and Research, Hospital Israelita Albert Einstein, São Paulo, Brazil; Department of Intensive Care, Amsterdam University Medical Centers, location “AMC’”, University of Amsterdam, Amsterdam, The Netherlands); Alfred Papali (Atrium Health, Charlotte, NC); Casey Park (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); Rajyabardhan Pattnaik (Ispat General Hospital, Rourkela, India); Jennifer L. Pigoga (Division of Emergency Medicine, University of South Africa, Cape Town, South Africa); Luigi Pisani (Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy; Doctors with Africa – CUAMM, Padova, Italy; Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand); Elisabeth D. Riviello (Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA); Kristina E. Rudd (University of Pittsburgh School of Medicine, Pittsburgh, PA); Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, location “AMC,” Amsterdam, The Netherlands); Varun U. Shetty (University of Pittsburgh Medical Center, Pittsburgh, PA); Gentle S. Shrestha (Tribhuvan University Teaching Hospital, Kathmandu, Nepal); Chaisith Sivakorn (Mahidol University, Salaya, Thailand); Shaurya Taran (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); T. Eoin West (University of Washington, Seattle, WA).

Group members of the subgroup “Triage”: Lia M. Barros (Division of Cardiology, University of Washington Medical Center, Seattle, WA), Jennifer L. Pigoga (Division of Emergency Medicine, University of South Africa, Cape Town, South Africa), Sopheakmoniroth Chea (Department of Cardiology, Calmette Hospital, Cambodia), Bhakti Hansoti (Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD), Sarah Hirner (School of Medicine, University of Colorado, Denver, Colorado), Alfred Papali (Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, NC), Kristina Rudd (Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA), Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, location “AMC,” Amsterdam, The Netherlands), and Emilie J. Calvello Hynes (Department of Emergency Medicine, University of Colorado, Denver, Colorado).

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