Policy responses for Turkey - HSRM

Turkey


Policy responses for Turkey

1.3 Isolation and quarantine

Probable and confirmed cases are required to undergo isolation of 14 days and treatment as follows:

• Home isolation and monitoring:  cases who are under 50 years of age, have mild clinical factors and do not have risk factors (hypertension, diabetes, chronic lung disease, chronic heart disease, chronic renal failure or immunodeficiency etc.) and bad prognostic factors (blood lymphocyte count<800/ μl, serum CRP>40 mg/l, ferritin >500ng/ml, D-Dimer >1000 ng/ml) that can cause a severe COVID-19, asymptomatic individuals who have come into contact with probable or confirmed COVID-19 cases.

• Hospital isolation and treatment: severe and critical cases

Infection control and isolation in hospitals/health care institutions

Hospitalization:
•        Probable case is followed up at secondary and tertiary hospitals. 
•        Confirmed cases are followed up at secondary and tertiary hospitals or at hospitals separated and designed as ‘Pandemic hospitals’
•        Confirmed cases who need intensive care are followed up at isolation chambers in 2nd or 3rd degree intensive care units at ‘pandemic hospitals’
 
Healthcare institutions should implement standard infection prevention and control methods. In addition, contact and droplet protection methods should be implemented until the patient becomes asymptomatic. 

The following infection prevention and control measures should be taken to prevent spread/transmission of disease:
 
• Health care workers are to keep a distance of 1 meter from COVID-19 patients whenever possible and wear/use the following personal protective equipment (PPE): 
1.        Gloves
2.        Gown (non-sterile, preferably fluid resistant and long-sleeved)
3.        Medical mask (surgical mask)
4.        N95/FFP2 or N99/FFP3 mask (only during the process that causes droplet/aerosolization)
5.        Face shield
6.        Goggles
7.        Liquid soap
8.        Alcohol based antiseptics,

• Medical coveralls and foot protectors may also be used in case of intense contact with body fluids and secretions. Recommendations on the use of PPE can be found at: https://hsgm.saglik.gov.tr/depo/covid19/rehberler/COVID_TABLE_HSGM.pdf?type=file 
 
Patient rooms
1.        Standard contact and droplet measures should be taken for hospitalization of probable or confirmed COVID-19 cases. 
2.        Patients should stay in single rooms with a private bathroom
3.        If single rooms are not available, confirmed COVID-19 cases may be put in the same room as other confirmed cases but probable COVID-19 cases should preferably not stay in the same room. In cases where this is unavoidable, probable COVID-19 cases should be kept at least at 1-meter distance apart from other patients. Probable cases should wear medical masks. 
4.        Medical materials used should be specific to a patient and should not be taken outside the room. Patients must not share any common materials. If any equipment is to be used for multiple patients (e.g. stethoscopes, thermometers), they should be cleaned and disinfected after each use (e.g. ethyl alcohol, 70%). 
5.        Unless medically required, the transfer of patients from one room to another should be avoided. Portable X-ray device and/or other important diagnostic devices designated to probable COVID-19 should be used. However, if no mobile diagnostic device is available, a COVID-19 patient should be the last to be treated, if possible, to minimize contact with other patients. 
6.        Healthcare workers should wear medical masks, gowns and gloves during the transfer of patients and should be mindful of hand hygiene.
7.        The patient’s environment should be cleaned and disinfected according to the infection control rules of the hospital. 
8.        Two separate medical waste units should be kept available at the entrance of and within the patient’s room for disposal of used personal protective equipment. 
  
Entering patient rooms and bedside behavior
1.        Entries into the patient room should be restricted to the healthcare workers who are responsible for caring for the patient. Patient visitors should be prohibited and attendants, if necessary, should be restricted to a single person. 
2.        Personal protective equipment (gloves, gown (non-sterile, preferable fluid resistant and long-sleeved), medical mask (N95/FFP2 mask), face shield, goggles, alcohol-based hand antiseptics) should be available at the entrance of the patient room. 
3.        Healthcare workers, who are responsible for examining, treating and personal care of patients, should wear gloves, gowns and medical masks. Healthcare workers should make sure to wear N95/FFP2 mask and face shield in case of intervention that may cause aerosolization of patient secretions or excreta.
4.        Healthcare workers should make sure to wear personal protective equipment (gown, mask, goggles, face shield and gloves) and take off (gloves, goggles, face shield, gown, mask) in the right order. In particular, the mask should be taken off last after leaving the patient room and then hand hygiene must be performed. 
5.        In the case of potentially contaminated or disintegrated gloves, these should be taken off, hand hygiene performed, and new gloves should be worn. 
6.        During aerosol-generating procedures, no individuals except for the necessary healthcare workers should be allowed into the patient room. Door should be kept closed during the procedure and should always be kept closed for a while afterwards, including entries and exits. Related procedures should be performed in adequately ventilated rooms, preferably in negative pressure rooms. 
7.        Hand hygiene should be performed before and after contact with the patient. Soap and water or alcohol-based hand antiseptics may be used for such purposes. If hands are visibly dirty, water and soap must be used instead of hand antiseptics. 
8.        Patient should not be allowed outside the room unless medically required. If it is necessary, patient should be transferred wearing a medical mask. 
9.        If the patient is undergoing noninvasive or invasive respiratory support, respiratory isolation measures should be taken and N95 mask is recommended instead of a surgical mask. 
10.        The rules specified by the infection control committees should be applied in the environment and ambient cleaning where the patient is present. 
11.        Surfaces contaminated with patient excreta and secretions should be cleaned in accordance with the “Guidelines for Protection against Infections in Emergency Health Services Before Hospital”.
12.        The room and floors should be disinfected after patient leaves the rooms. New patients should be allowed into the room only after the room is adequately ventilated. 

Patient isolation and monitoring at home
Patients fitting the criteria for home isolation can be monitored at home and given appropriate treatment until they recover. However, if the patient has specific social indications (inadequate housing conditions, other household members are at high risk of developing severe COVID-19 and/or are over 65) s/he can be monitored in hospital in accordance with the attending physician’s decision.

In addition, hospitalized patients who meet the discharge criteria can complete their recovery period at home. The patient is discharged with the necessary medicine and adequate number of masks and should self-quarantine for 14 days.

Rules for home isolation
1.        Patients monitored at home should be followed up by their family physician. The patient’s medical information should be shared with the family physician, and their health condition is evaluated by asking about symptoms via phone every other day.
2.        After explaining what to do at home during the monitoring period, and criminal liability for non-compliance with isolation requirements, the patient signs a consent form containing all the information.
3.        The patient should stay at home during the monitoring period.
4.        House guests are not allowed.
5.        Medical masks should be used whenever the patient must be in the same environment with other housemates/ people.
6.        The monitored patient(s) should be in a separate room; if this is not possible, the room should be well ventilated, the patient should wear a medical mask and maintain a 1 meter distance from any other household members to minimize the risk of transmission. The mask should be renewed if it becomes damp. If possible, the individuals who are at risk of contracting severe COVID-19 and/or who are over 65 should not be in the same house as a confirmed case or contact risk should be minimized.
7.        The patient should have limited movements within the house.
8.        The patient should use a separate bathroom, if possible.
9.        The bathroom should be well ventilated if it is common. The bathroom should be cleaned with diluted bleach (1:100 with normal dilution) (sodium hypochlorite CAS no: 7681-52-9) at least once a day.
10.        The patient and the close contact should be informed about respiratory hygiene (covering the mouth while sneezing/coughing preferably with a paper tissue, the used tissues should be disposed of in closed and non-perforated nylon bags and should be put in a second nylon bag and the nylon bag should be closed, hands should be washed frequently).
11.        The patient should not share personal belongings, should not use the same towels, glasses, and plates with the household. If these items must be shared, they should be washed with soap and water. The textile products such as clothes, towels, and linens of the case should be washed with detergent at 60-90 degrees.
12.        Gloves and medical masks should be used while cleaning the room of the patient. All the surfaces that are contaminated with respiratory secretions or body fluids should be cleaned with bleach in normal dilution (sodium chlorite Cas No: 7681-52-9), in the case of significant contamination 1:10 bleach with normal dilution should be used. (Bleach preparation rates (10%): preparing 1/10 bleach: 1-part bleach + 9 parts water (releases 5000-6000 ppm chlorine), preparing 1/100 bleach: 1-part bleach + 99 parts water (releases 500-600 ppm chlorine). 1 small tea glass of bleach is added to 10 liters of water to have 1/100 bleach.
13.        All the household should monitor themselves and contact health authorities immediately if they develop symptoms.
14.        The dedicated telephone number 112 should be called if the patient’s general conditions deteriorate, and health authorities should be informed about the case.
15.        Medical masks should be used if the patient needs to be transferred to a hospital.

Safety protocols during patient transfer with an ambulance 
When a patient calls the COVID-19 hotline 112, a series of questions are asked, and the individual is regarded as a probable case if s/he answers yes to at least two of the questions. If the answer to the first two questions is yes, the 112 emergency dispatch personnel should use N95/FFP2 mask and goggles/face protection; medical masks and goggles/face protection are enough in other cases. Adult patients are not accompanied by a family member/other person in the ambulance but children are accompanied by an adult wearing a medical mask, as per legal requirements. A bacteria/virus filter should be placed, if possible, between the mask and the balloon when the probable/confirmed COVID-19 case needs an intervention. In cases requiring a ventilator, a filter should be placed in the exhalation line if possible, if not, at least a bacteria/virus filter should be placed between the endotracheal tube and the circuit.

Rules for ambulance transfer
1.        Personal protective equipment should be kept readily available in ambulances. 
2.        The first-responding team should use personal protective equipment until the patient is delivered to the first responding hospital and until the ambulance is cleaned.
3.        Patient must wear a medical mask, and ambulance personnel must wear a medical mask and goggles/face protection while transferring outpatients whose general condition is good.
4.        N95/FFP2 mask, coveralls, and goggles/face shield should be used in cases where patients who are coughing uncontrollably or who can need aspiration.
5.        Ambulances should be cleaned and disinfected after transfer of probable/confirmed COVID-19 cases. Cleaning should be performed with personal protective equipment. 
6.        The vehicle should be cleaned and disinfected when it has reached its destination.
7.        Ambulances should be cleaned in accordance with the “Guidelines for Protection Against Infections in Emergency Health Services Before Hospital”. 
8.        Ambulances should not be dispatched to any other case before being cleaned.
9.        An assessment with the following question should be carried out before the ambulance is dispatched.
Triage questions of 112 command control center:
a).        Do you have a cough?
b).        Are you experiencing difficulties in breathing?
c).        Do you have a fever or have a history of fever?
d).       Has any of your close contacts been hospitalized due to a respiratory disease in the last 14 days?
e).       Has any of your close contacts been diagnosed with COVID-19?

26.09.2020

For those who are infected with COVID-19 or suspected to be and have either already violated isolation guidelines or are living in temporary residences where they cannot safely and responsibly isolate, places such as dormitories and hostels will be made available by the provincial governors to undergo and complete the isolation process. In this context, as of September 26, 2020, a total of 2,157 people have been subjected to isolation in dormitories and pensions with a capacity of 92,790 people. Of those, 689 were people who were subjected to compulsory isolation on the grounds that they violated the isolation conditions, while 1,359 were people who were subjected to isolation due to only having a temporary residence (seasonal agricultural workers, construction site workers, etc.). Within the scope of the circular, 3,524 people have been hosted in compulsory or temporary dormitories or hostels so far.

07.12.2020

The Ministry of Health’s “Covid19 Contact tracking, epidemic management, home patient monitoring and filiation guide” was renewed. According to new document, people who had close contact with a person with COVID-19 are to stay in quarantine for ten days. Mandatory quarantine for those who do not develop any symptoms during the quarantine period will conclude at the end of the tenth day without conducting a PCR test, but these people will continue taking the necessary precautions in public spaces.

22.12.2020

A new section titled "What to do in case of COVID-19 positive cases in schools?" was added to the guide for COVID-19 Epidemic Management and Study that was previously issued by the Ministry of Health.

Featured in the new addition to the guide:

• With the detection of a single positive case in the classroom, all classrooms and teachers are considered to be in close contact.
• Care should be taken to limit the classes to a maximum of 15 students.
• Staff in the school will constantly check whether the mask is used correctly.
• Students will wear masks in schools.
• If a student in the classroom is positive:
   o Teachers and other students of the class who have positive cases are questioned by the school twice a day at least 2 lesson hours for 14 days, and fever measurements are made, and these are recorded.
   o It should be ensured that the recess time of children in this class is differentiated from other classes.
   o Persons with symptoms or high fever are directed to the appropriate health institution.
   o According to the evaluation of the health institution, the student / teacher who does not show any symptoms continues to attend school; otherwise, it is considered a case.
   o If there are positive cases in kindergartens, preschools, or the 1st, 2nd and 3rd grades, entire classes are considered as having close contact. All students in these classes are to be sent home and monitored for 14 days.

Source:
https://covid19.saglik.gov.tr/Eklenti/39560/0/covid-19rehberitemaslitakibievdehastaizlemivefilyasyonpdf.pdf
https://covid19.saglik.gov.tr/Eklenti/39265/0/covid-19salginyonetimivecalismarehberipdf.pdf