Background:

Despite widespread recognition that adherence to clinical preventive guidelines improves patient outcomes, clinicians struggle to implement guideline changes in a timely manner. Multiple factors influence guideline adoption and effective implementation. However, few studies evaluate their collective and inter-related effects. This qualitative study provides a comprehensive picture of the interplay between multiple factors on uptake of new or changed preventive guidelines.

Objective

We aimed to assess adherence to the Australian national guideline (COPD-X) against audited practice, and to document the outcomes of patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (COPD) at discharge and 28 days after.

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Recommendations to eat less meat for environmental reasons won’t be included in the final 2015 dietary guidelines.

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Industrial units in rural areas will be allowed to function from April 20 provided they follow social distancing norms while all kinds of public transport will be barred and public places closed till May 3, according to guidelines issued on Wednesday to enforce the second phase of the lockdown.

Wearing masks/face covers in public places is now compulsory across the country. Besides, spitting in public has been made a punishable offence and a strict ban enforced on the sale of "liquor, 'gutka' tobacco etc" under the new Ministry of Home Affairs guidelines that come a day after Prime Minister Narendra Modi announced the extension of the nationwide lockdown till May 3.

Prime Minister Narendra Modi in his address to the nation on Tuesday, extended the nationwide lockdown till May 3. Pic/Twitter Narendra Modi

The prime minister also said necessary activities will be allowed from April 20 in identified areas of the country. A three-week lockdown to contain the spread of COVID-19 came into effect after his announcement on March 24.

Laying out the dos and don’ts for phase two of the pan India lockdown, the guidelines state that all work places should make adequate arrangements for temperature screening and must provide sanitisers at convenient places.

Services provided by self-employed electricians, IT repair personnel, plumbers, motor mechanics and carpenters will be allowed from April 20. While inter-state, inter-district movement of people, metro, bus services will be prohibited till May 3, the government has allowed industrial units located in rural areas to function from April 20 by observing strict social distancing norms.

Mumbai police officials snapped during a candid moment at the Gateway of India amid lockdown

Manufacturing, industrial units with access control in SEZs, export oriented units, industrial estates, industrial townships will also be allowed to function from that date. Educational institutions, coaching centres, domestic, international air travel, train services will remain suspended, the ministry said.

Public places such as cinema halls, malls, shopping complexes, gymnasiums, sports complexes, swimming pools and bars will be shut too till May 3. All social, political, sports, religious functions, religious places, places of worship will also be closed till then, according to the guidelines.

However, highway ''dhaba'' (eateries), truck repairing shops, call centres for government activities will remain open from April 20. Shops selling agriculture machinery and those dealing with spare parts, supply chains and repairs as well as ''custom hiring centres’ related to farm machinery will also be open from that day.

Activities permitted five days from now include those related to agricultural and the horticultural sectors, farmers and farm workers in the field as well as procurement of agri products. Units manufacturing drugs, pharmaceuticals, medical devices, medical infrastructure, including manufacture of ambulances, will be open from April 20.

A woman carries ration on her shoulders as a police officer looks on amid lockdown in the city

The guidelines state that grocery stores, fruits, vegetables shops/ carts, milk booths, poultry, meat and fish shop will remain open during the lockdown. However, exemptions given from April 20 will not be applicable in COVID-19 hotspots/containment zones. The document specifies that state/UT governments shall not dilute guidelines in any manner but may impose stricter measures in accordance with local requirements.

The Home Ministry said permitted industries must make arrangements for the stay of workers within their premises or in adjacent buildings by observing social distancing norms. It said Defence, paramilitary, Health and Family Welfare, disaster management, NIC, FCI, NCC, Nehru Yuva Kendra and Customs offices will function without any restrictions.

Other ministries and departments will function with "100 per cent attendance" with deputy secretary and above rank officers. "Remaining officers and staff to attend up to 33 per cent as per requirement," it said. According to the guidelines, in order to mitigate the public’s hardship, select additional activities will be allowed from April 20.

"However, these additional activities will be operationalised by states and UTs and district administrators based on strict compliance to existing guidelines on lockdown measures," it said.

Activities permitted from April 20 are aimed at ensuring that agricultural and related activities remain fully functional, rural economy functions with maximum efficiency, employment opportunities are created for daily wage earners and other members of labour force, select industrial activities are allowed to resume their operations, with safeguards and mandatory standard operating protocols and digital economy, states the document.

Police authorities seal off Worli-Koliwada after coronavirus positive cases were confirmed from Worli

The revised guidelines will not apply in containment zones, as demarcated by states/ UTs/ district administrations. If any new area is included in the category of a containment zone, the activities allowed in that area till the time of its categorization as a containment zone will be suspended except those specifically permitted under the Health Ministry’s guidelines.

Containment zones will be demarcated by states/UTs/ district administrations in accordance with the ministry’ guidelines. In these zones, no unchecked inward/outward movement of population would be allowed, except for essential services.

The government described digital economy as critical to the services sector. Accordingly, e-commerce operations, operations of IT and IT enabled services, data and call centres for government activities, and online teaching and distance learning are all permitted.

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Amid the rising number of coronavirus cases in India, the health ministry on Tuesday, issued home quarantine guidelines for people who have very mild symptoms of COVID-19. According to the guidelines, those with mild syptoms can opt for home isolation but will have to be in constant communication with the District Surveillance Officer, and a hospital and will have to sign an undertaking.

The present guidelines were issued in addition to guidelines on appropriate management of suspect/confirmed cases of Covid-19 issued by the Health Ministry on April 7

.@MoHFW_INDIA has issued guidelines for Home Isolation of very mild/pre-symptomatic COVID-19 cases: Media briefing on #COVID19

Details: https://t.co/koNEShuVZ7 pic.twitter.com/6wUPLNg9Ne

— PIB India #StayHome #StaySafe (@PIB_India) April 28, 2020

As per the revised guidelines, patients who have mild symptoms or are pre-symptomatic can now opt for self-isolation at their homes but they need to follow the norms laid down by the Health Ministry. 

Who is eligibile for self isolation at home?

COVID-19 patients who have been clinically assigned as a very mild case or pre-symptomatic case by the treating medical officer are eligible for self-isolation at home.

What are the pre-requisites in order to self-isolate at home?

• Patients who are eligible for self-isloation at home must have a requisite facility at their place of residence for self-isolation. More so, the patients must also ensure that there is enough space for other members of the family to quarantine at home.
• The patient must have a caregiver who can look after the patient and provide care 24x7. 
• Another prerequisite is that there should be a communication link between the caregiver of the patient and the hospital during the entire duration of home isolation.
• The caregiver and all the close contacts of the COVID-19 patient should take Hydroxychloroquine prophylaxis as per the protocol and as prescribed by the treating medical officer.
• The patient has monitor his or her health and regularly inform their health status to the District Surveillance Officer for further follow up by the surveillance teams.
• Finally, the patient needs to fill an undertaking on self-isolation stating that they shall follow all home quarantine guidelines laid down by the Health Ministry.

When should a COVID-19 patient seek medical attention?

According to the revised guidelines issued by the Health Ministry, mild or pre-symptomatic patients shall seek immediate medical attention on the following grounds.

• When they face difficulty in breathing
• If they experience persistent pain/pressure in the chest
• Feel mentally confused or inability to arouse
• If they develop bluish discolorations of lips or face
• And if advised by treating medical officers

When will home isolation end?

Home isolation for COVID-19 patients can only be discontinued when the symptoms are clinically resolved and the surveillance medical officer certifies the mild or pre-symptomatic patient to be free of infection after the necassary laboratory testing.

Do's and don'ts for self-isolation patients and caregivers

• Caregivers must wear triple layered medical mask when in the same room with the COVID-19 patient.
• Caregivers should avoid direct contact with body fluids of the patient, especially oral or respiratory secretions.
• Caregivers must use disposable gloves while handling the patient. Hand hygiene should be undertaken done before and after removing gloves.
• Caregivers should pay strict attention to hand hygiene before and after preparing food, before eating, after using the toilet, and whenever the hands look dirty.
• Caregivers should avoid sharing cigarettes, eating from the same utensils, or exposing themselves to used towels or bed linen.
• COVID-19 patient should wear triple layer medical mask at all times. The patient must discard the mask after eight hours of use or earlier if they have become wet or visibly soiled.
• The patient must isolate themselves in a room and stay way from people.
• Patient must stay away from the elderly who maybe suffering from co-morbid conditions like hypertension, cardiovascular disease, renal disease.
• During self-isolation, mild or pre-symptomatic patients must drink lots of fluids to stay hydrated and follow respiratory etiquette all the time.

With inputs from Agencies

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Cycle rickshaws, autos, taxi, cabs, barber shops and intra-district plying of vehicles and buses are restricted in Red Zones mentioned in the fresh lockdown 3.0 guidelines to break the chain of COVID-19 transmission. However, the guidelines allowed the movement of individuals and vehicles, only for permitted activities with restrictions. Four-wheeler vehicles will have maximum two passengers besides the vehicle driver; for two wheelers, pillion rider is not allowed, according to the guidelines issued with the announcement of extension of nationwide lockdown for another 14 days beginning on May 4.

The lockdown 3.0 will end on May 17. Industrial establishments in urban areas such as Special Economic Zones (SEZ), Export Oriented Units (EOUs), industrial estates and industrial townships with access control; manufacturing units of essential goods, including drugs, pharmaceuticals, medical devices, their raw material and intermediates; production units, which require continuous process, and supply chain; manufacturing of IT hardware have been allowed in the Red Zone.

Jute industry with staggered shifts and social distancing and manufacturing units of packaging material are permitted. All industrial and construction activities are permitted in rural areas. Construction activities in urban areas; only in situ construction (where workers are available on site and no workers are required to be brought in from outside) and construction of renewable energy projects are permitted.

All malls, market complexes and markets shall remain closed in urban areas such as areas within the limits of municipal corporations and municipalities. However, shops selling essential goods in markets and market complexes are permitted, all standalone (single) shops, neighbouring (colony) shops and shops in residential complexes are permitted to remain open in urban areas without any distinction of essential and non-essential. All shops in rural areas, except in malls, are permitted to remain open without any distinction of essential and non-essential.

"Social distancing ('do gaj ki doori') will be maintained in all cases." E-commerce activities will be permitted only in respect of essential goods. Private offices can operate with upto 33 per cent strength as per requirement with the remaining persons working from home. All government offices shall function with officers of the level of Deputy Secretary and above to the extent of 100 per cent strength.

The remaining staff will attend up to 33 per cent as per requirement. However, defence and security services, health and family welfare, police, prisons, Home Guards, civil defence, fire and emergency service, disaster management and related services, National Informatics Centre (NIC), customs, Food Corporation of India (FCI), National Cadet Corps (NCC), Nehru Yuva Kendra (NYK) and municipal services shall function without any restrictions. Delivery of public services shall be ensured and necessary staff will be deployed for such purpose, the guidelines said.

The fresh guidelines were issued after the Ministry announced extension of the lockdown for more 14 days till May 17, splitting the country in Red, Green and Orange Zones. The criteria for identification of districts as Red, Green and Orange Zones have been spelt out in detail in the letter dated April 30, issued by the Ministry of Health and Family Welfare (MoHFW). The Ministry made the announcement as the lockdown 2.0 was to end on May 3.

The government took the decision after a comprehensive review, and in view of the lockdown measures having led to significant gains in the COVID-19 situation in the country.

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The Excise Department of Punjab on Tuesday released new guidelines for home delivery of liquor in a bid to ensure that social distancing norms are not violated amid curfew and COVID-19 lockdown. Now, only two people in a group with an official pass are allowed to make home delivery of liquor.

One household will not receive more than two litres of booze. The delivery person is restricted to visit in the vehicle authorised by the department. Moreover, social distancing norms should be followed at liquor shops and not more than five people are allowed to gather outside the shops.

Proper sanitisation will be done at liquor stores, which are allowed to open only if relaxation is given by the district administration in their area.

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The International Tennis Federation (ITF) has issued a set of guidelines for local and national-level competitions when tennis returns to action once the restrictions put in place due to coronavirus pandemic are lifted. The guidelines include arriving at a venue already dressed and leaving immediately after the conclusion of a match, no handshake, no sharing of equipments (rackets, towels, water bottles, etc), no doubles matches. Besides the guidelines also say that competitions should be held without spectators.

The ITF has also said that players use separate sets of balls (and mark them clearly prior to play) and should go around opposite sides of the net at changeovers. "The guidelines -- at this stage for local and national-level competitions only -- seek to provide a framework in which tennis can be played again in a manner that protects against the risk from transmission or infection by the COVID-19 virus, and provide a number of practical suggestions as to how this might be achieved," said ITF in a statement on Friday.

"While following measures such as these will ensure that the risk from COVID-19 is minimised, the guidelines are clear that the risk cannot be eliminated altogether," it added.

Currently, all tennis activities remain suspended until July 13 due to coronavirus pandemic which has so far claimed more than 2.3 lakh lives across the world.

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