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Management Protocol for COVID-19 Patients Version 1.4/30th May 2020 Ministry of health and population (MOHP), Egypt.

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Abstract

Ministry of Health and Population Coronavirus Disease 2019 (COVID-19), SARS COV2 Management Guide
Version 1.4 / 30th May 2020 1
Management Protocol
in Hospitals
C VID-19
Ministry of Health and Population, Egypt
Management protocol for COVID-19
Patients
Version 1.4 / 30th May 2020
Management Protocol for
Patients
Version 1.4 / 30th May 2020
2
Version 1.4 / 30th May 2020 3
Table of contents
Item Page
Number
Management in Triage Hospitals 4
Management of Mild Cases 6
Management of Moderate Cases 7
Management of Severe and
Critically Ill Cases 8
Version 1.4 / 30th May 2020
4
A
Any one of the epidemiological
history with any of the clinical
features.
epidemiological history:
1. History of travel to or
residence in communities
where cases reported within
the last 14 days.
2. In contact with viral RNA
positive people
within the last 14 days.
3. In contact with a patient who
has fever or respiratory
symptoms or from a
community
with conrmed cases reported
within the last 14 days.
B
Asessing the presence of at
least two of the following
clinical features:
1.Fever and/or respiratory
symptoms.
2.Imaging characteristics.
CT scan is preferred, if not
appicable do CXR
3.Dierential CBC ndings:
white blood cells is normal
or decreased, with decreased
lymphocytic count.
C
Severe Acute Respiratory
Infection
(SARI) with no other
obvious cause.
Patient enters Triage Hospital
(referred from another hospital, referred by 105, walkin)
Assess to identify suspected cases
OR OR
N.B.
- Asymptomatic contact to +ve case should undergo home isolation and should seek medical
advice whenever symptoms develop.
- Healthcare providers exposed to suspected or conrmed COVID-19 cases should follow the
algorithim shown in MoHP guide booklet.
Management in Triage Hospitals
Version 1.4 / 30th May 2020 5
Suspected COVID-19
Assess patient
Yes No
Non Covid-19 Cases
Management in Triage Hospitals
Impossible home isolation
or
sever symptoms (dyspnea,
tachypnea, tachycardia,
uncontrolled comorbidities,
Immunosuppressant, above
60 years)
Mild symptoms
(CT or CXR not
showing pneumonia)
Home Isolation if
possible until
PCR result
- start managment:
* Rest
* Infection control
(IPC measures)
* Antibiotic if needed
* Anti-pyretic
(Paracetamol)
Obtain PCR
sample
Continue treatment
until the 7th day
Home isolation for
14 days and close
follow up
Symptoms
resolved
Yes
-ve
Manage accordingly
-ve
PCR results
Repeat PCR
after 48
No
Manage
accordingly
Transfer to
COVID-19 hospitals
Repeat PCR
after 48
-ve
-ve
+ve
PCR result
Admied to COVID-19 area
in triage hospital
and manage according
to protocol
Obtain PCR sample
If deteriorated to
severe symptoms
Is it an
emergency
case?
Refer to
general
hospital
Stabilize
patient
Admit to non
COVID area
Yes No
Unstable
Stable
Stable
Version 1.4 / 30th May 2020
6
PCR Positive Cases
Mild Case
Symptomatic case
with lymphopenia or leucopenia
with no radiological signs for pneumonia
1. Age
2. Temperature > 38
3. SaO2 ≤ 92%
4. Heart Rate ≥ 110
5. Respiratory Rate ≥ 25 /min.
6. Neutrophil / lymphocyte ratio
on CBC ≥ 3.1
7. Uncontrolled Comorbidities
8. Immunosuppressive Drug
9. Pregnancy
10. Active Malignancy
11. On Chemotherapy
12. Obesity (BMI>40)
Check for
Any YES
All No
Age ≥ 60
OR
Age < 60
AND
• Strict Home Isolation (Symptomatic
Treatment)
• Follow and use personal protective guide
equipment
• If any deterioration occurs, back to
hospital
NB: Paracetamol is the preferred antipyretic
Isolation in
a healthcare facility
Treatment
- Hydroxychloroquine (400 mg twice in
rst day then 200 mg twice for 6 days)
- Vitamin C (1gm daily)
- Zinc 50mg daily
- Acelylcysteine 200 mg t.d.s.
- lactoferrin one sachet twice daily
Version 1.4 / 30th May 2020 7
Moderate Case
Patient has pneumonia manifestations on radiology associated with
symptoms &/Or leucopenia or lymphopenia
Hospitalization
• Lopinavir/Ritonavir (2 tab
200/50) every 12 hrs
• Ribavirin 400 mg every 12 hrs
for 14 days
(Not recommended if symptoms
started for more than 7 days)
+
• Anticoagulation: prophylactic
or Therapeutic if D-dimer > 1000
• Hydroxychloroquine (if NO
contraindication) 400mg /12 hrs
for 1 day then 200 mg every 12
hours for 9 days
+
• Anticoagulation: prophylactic
or Therapeutic if D-dimer > 1000
OR
Steroids if patients is dyspneic or CT SCAN showed signicant deterioration
PCR Positive Cases
Version 1.4 / 30th May 2020
8
Severe and Critically Ill Case
PCR Positive Cases
If any of the following criteria is present
1. RR > 30
2. Sa02 < 92 at room air
3. PaO2/FiO2 ratio < 300
4. Chest radiology showing
more than 50% lesion or
progressive lesion within 24 to 48 hrs
5. Critically ill if SaO2 <92, or RR>30,
or PaO2/FiO2 ratio < 200 despite Oxygen Therapy.
Admit to Intermediate Care Or Intensive care
Tocilizumab
4-8mg/kg/dose
Max 2 doses
Early Block
the storm
if steroids
failed
Antiviral
Drugs As is In
Severe case
Steroids
Methylpred-
nisolone
1-2 mg/kg/d
Anti-
Coagulation
Enoxaparine
1 mg/kg BID
Prone
Awake or
ventilated
Avoid
Hypoxia
O2/ NIV/
HFNC/IMV
Add
Antibiotics
As per
protocol
1 mg for non
ventilated
and 2 mg for
ventilated
Consider
D-dimer level
as a guide
Improves
V/Q matching
and survival
Don’t wait
too much for
any type of
support Keep
plateau<30
Version 1.4 / 30th May 2020 9
Antiviral drugs
• Lopinavir/Ritonavir (2 tab
200/50) every 12 hrs.
+ Ribavirin 400 mg /12 hrs
+ Interferon beta 1b +
Azithromycin (500mg daily) or
doxycycline (200 mg rst day
then 100mg daily OR
NB: Remdesivir if available: 200
mg day 1 then 100 mg daily for 9
days
Hydroxychloroquine (if NO con-
traindication) 400mg /12 hrs for 1
day then 200 mg every 12 hours
for 9 days +
• Lopinavir/Ritonavir (2tab
200/50) every 12 hrs.+
• Doxycycline 200 mg rst day
and 100 mg daily or Azithromy-
cin 500 mg
OR
COVID 19 Critical Care Chain of Survival
PCR Positive Cases
Non Invasive Ventilation or High Flow Nasal Cannula (HFNC):
• Conscious patients with minimal secretions.
• Hypoxia SpO2 < 90% on oxygen. Or PaCO2 >40 mmHg provided pH 7.3
and above.
• NIV trial shall be short with ABG 30 minutes apart.
• Any deterioration in blood gases from baseline or oxygen saturation or
consciousness level shift to IMV.
• CPAP gradually increased from 5-10 cmH2O.
• Pressure support from 10-15 cm H2O.
• HFNC can be alternative to NIV.
Invasive Mechanical Ventilation:
• Use PPE specially goggles during intubation and avoid bagging.
Version 1.4 / 30th May 2020
10
Plateau
P<30 cmH2O
Incremental
PEEP
PCR Positive Cases
Indications:
• Failed NIV or not available or not practical.
• PaO2 < 60 mmhg despite oxygen supplementation.
• Progressive Hypercapnia.
• Respiratory acidosis (PH < 7.30).
• Progressive or refractory septic shock.
• Disturbed consciousness level (GCS ≤ 8) or deterioration in consciousness
level from baseline.
Initiation of Invasive Mechanical Ventilation
Step 1:
VCV
TV 8 ml/kg
PEEP 5 cmH2O
Plateau
Pressure
Less than 30
cmH2O
Sat >93
Keep and Watch
Less than 30
Sat<93
Increase PEEP
to 10
More than 30
ARDSnet
protocol
Inspiratory Pause for 1 second
Shift to ARDSNet protocol if needed
Step 2:
IF PLATEAU ABOVE 30 CMH2O
- ARDSNet protocol:
LOW TV
6-4 ml/kg Driving
P<15 cmH2O
Version 1.4 / 30th May 2020 11
PCR Positive Cases
Start with tidal volume of 6 ml/Kg to keep plateau pressure on volume
controlled ventilation (VCV) below 30 cmH2O, decrease to 4 ml/kg if the
plateau remain higher than 30 allow permissive hypercapnia so long the
pH is above 7.3 compensate by increasing respiratory rate up to 30 breath/
minute. Consider heavy sedation and paralysis. If pressures are high or
any evidence of barotrauma shift to pressure controlled ventilation and be
cautious about low tidal volume alarms for fear of unnoticed endotracheal
tube obstruction. Consider ECMO early if eligible. Increase PEEP
gradually if the patient remains hypoxic according to FIO2 level to keep
driving pressure < 15cmH2O. NEVER FORGET PRONE POSITION.
Assessment of respiratory support outcome
Step 3:
ImprovedImproved
Weaning of
respiratory
support
AssessAssess
ABGs, Clinical
Radiological
StationaryStationary
Continue
respiratory
support as
needed
DeterioratingDeteriorating
Criteria for
ECMO*
*Criteria for VV ECMO: Age below 55, mechanical ventilation duration
less than 7 days, no comorbidities, preserved conscious level, PaO2/FiO2
<100 despite prone RESPscore >0.
Expert opinion is needed and depends on availability.
Version 1.4 / 30th May 2020
12
Treatment Protocol
Revised By:
NAME AFFILIATION
Hossam Hosny Masoud
Professor of Chest Diseases. Head of
Pulmonary Hypertension Unit, Faculty of
Medicine, Cairo University
Gehan Elassal Professor of Pulmonary Medicine
Ain Shams University
Samy Zaky Professor of Hepatogastroenterology and
Infectious Diseases, Al Azhar University
Amin Abdel Baki
Consultant of Hepatoogy, Gastroenterology and
Infectious Diseases. National Hepatology and
Tropical Medicine Research Institute
(NHTMRI),Cairo, Egypt
Hamdy Ibrahim
Consultant of infectious diseases and director
of ICU, Imbaba Fever and infectious diseases
hospitals, MoHP
Wagdy Amin Director General for Chest Diseases, MoHP
Akram Abdelbary
Professor of critical care medicine, Cairo
University Chairman elect of ELSO SWAAC
chapter
Ahmad Said Abdel Mohsen Lecturer of critical care medicine,
Faculty of Medicine, Cairo University
Mohamed Hassany
Fellow of Infectious Diseases and
Endemic Hepatogastroentrology,
National Hepatology and
Tropical Medicine Research Institute
Alaa Eid Head of Preventive Medical Sector, MoHP
Noha Asem Mohamed
Minister’s Advisor for Research and
Health Development. Chairman of Research
Ethics Commiee, MoHP. Lecturer of Public
Health, Cairo University
Ehab Kamal
Researcher of Tropical Medicine.
Medical Division National Research
Center. General Director of Directorate of Fever
Hospitals, MoHP
Version 1.4 / 30th May 2020 13
Ministry of Health and Population
Management protocol for COVID-19
Patients
Egypt / May 2020
Version 1.4 / 30th May 2020
14
Ministry of Health and Population
Egypt / May 2020
... (accessed on 20 September 2021). and Egyptian Ministry of Health [21] diagnosis criteria were considered in this study. The patients were randomly treated with cefepime or ceftazidime with the addition of steroids to the treatment protocol. ...
... 19-nCoV-clinical-2021-1), (accessed on 20 September 2021). and the Egyptian COVID-19 management protocol [21], neither of which includes cefepime or ceftazidime (110 patients). The protocol of treatment used for Group 3 included the following therapeutics: (i) supportive multivitamins; (ii) favipiravir, remdesivir, hydroxyl chloroquine, and ivermectin as antiviral agents; (iii) anticoagulants according to the D-dimer level; (iv) colchicine and dexamethasone as anti-inflammatory and immunomodulatory agents. ...
Article
Full-text available
The purpose of this study was to explore the value of using cefepime and ceftazidime in treating patients with COVID-19. A total of 370 (162 males) patients, with RT-PCR-confirmed cases of COVID-19, were included in the study. Out of them, 260 patients were treated with cefepime or ceftazidime, with the addition of steroids to the treatment. Patients were divided into three groups: Group 1: patients treated with cefepime (124 patients); Group 2: patients treated with ceftazidime (136 patients); Group 3 (control group): patients treated according to the WHO guidelines and the Egyptian COVID-19 management protocol (110 patients)/ Each group was classified into three age groups: 18–30, 31–60, and >60 years. The dose of either cefepime or ceftazidime was 1000 mg twice daily for five days. Eight milligrams of dexamethasone were used as the steroidal drug. Careful follow-ups for the patients were carried out. In vitro and in silico Mpro enzyme assays were performed to investigate the antiviral potential of both antibiotics. The mean recovery time for Group 1 was 12 days, for Group 2 was 13 days, and for Group 3 (control) was 19 days. No deaths were recorded, and all patients were recovered without any complications. For Group 1, the recovery time was 10, 12, and 16 days for the age groups 18–30, 30–60, and >60 years, respectively. For Group 2, the recovery time was 11, 13, and 15 days for the age groups 18–30, 30–60, and >60 years, respectively. For Group 3 (control), the recovery time was 15, 16, and 17 days for the age groups 18–30, 30–60, and >60 years, respectively. Both ceftazidime and cefepime showed very good inhibitory activity towards SARS CoV-2′s Mpro, with IC50 values of 1.81 µM and 8.53 µM, respectively. In conclusion, ceftazidime and cefepime are efficient for the management of moderate and severe cases of COVID-19 due to their potential anti-SARS CoV-2 activity and low side effects, and, hence, the currently used complex multidrug treatment protocol can be replaced by the simpler one proposed in this study.
... Moderate COVID-19 cases in this study were defined according to the Ministry of Health and Population in Egypt [6] as patients with radiological evidence of pneumonia in addition to symptoms suggestive of COVID-19 infection. However, severe cases were defined as moderate cases who meet any of the following: oxygen saturation less than 93%, respiratory rate greater than or equal to 30 breaths/ min at rest, and patients with greater than 50% pulmonary-lesion progression within 24-48 h. ...
... Moderate COVID-19 cases in this study were defined according to the Ministry of Health and Population in Egypt [6] as patients with radiological evidence of pneumonia in addition to symptoms suggestive of COVID-19 infection. However, severe cases were defined as moderate cases who meet any of the following: oxygen saturation less than 93%, respiratory rate greater than or equal to 30 breaths/ min at rest, and patients with greater than 50% pulmonary-lesion progression within 24-48 h. ...
... According to the Egyptian Ministry of Health and Population's (MOHP) guidelines, patients were divided into two groups based on the severity of their disease. 15 The first group (n = 49) consisted of patients with mild-to-moderate COVID-19, who were diagnosed, treated, and sent back to their homes for home isolation with none of them complaining of further severe complications. The second group (n = 48) consisted of patients with severe SARS-CoV-2 infection admitted to the SARS-CoV-2 ICU isolation unit. ...
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Background: Dysregulated immunity is a hallmark of SARS-CoV-2 infection. Immune suppression is indicated by low monocyte expression of human leukocyte antigen D-related (mHLA-DR). T cells are important antiviral cells. We aimed to assess the role of mHLA-DR and T lymphocyte frequency in predicting COVID-19 severity. Patients and methods: This cross-sectional study enrolled 97 SARS-CoV-2 positive patients, including mild to moderate (n = 49) and severe cases admitted to intensive care unit (ICU) (n = 48). These ICU cases were further subdivided into survivors (n = 35) and non-survivors (n = 13). Results: Severe cases had a significant decrease in the mHLA-DR mean fluorescence intensity (MFI) and T lymphocyte percentage compared to mild to moderate cases (P<0.001). Non-survivors had a lower T lymphocyte percentage (P=0.004) than survivors. The mHLA-DR MFI and T lymphocyte percentage correlated with oxygen saturation (r=0.632, P<0.001) and (r=0.669, P<0.001), respectively. According to the ROC curves, mHLA-DR MFI, at a cutoff of 143 and an AUC of 0.9, is a reliable biomarker for distinguishing severe COVID-19 cases, with 89.6% sensitivity and 81.6% specificity, while T lymphocyte frequency had 81.3% sensitivity and 81.6% specificity at a cutoff of 54.4% and an AUC of 0.9. The T lymphocyte percentage as a predictor of ICU survival at a cutoff of 38.995% exhibited 100% sensitivity and 57.1% specificity. According to multivariate regression analysis, reduced mHLA-DR MFI and T lymphocyte percentage are independent predictors of COVID-19 severity (OR = 0.976, 95% CI: 0.955-0.997, P = 0.025) and (OR = 0.849, 95% CI: 0.741-0.972, P = 0.018), respectively. Conclusion: Reduced mHLA-DR expression and T-lymphocyte percentage are independent predictors of COVID-19 severity. Oxygen saturation percentage is correlated with mHLA-DR MFI and T lymphocyte frequency. The T lymphocyte frequency is a proposed predictor of COVID-19 survival in ICU admitted patients.
... Egypt [6] as patients with radiological evidence of pneumonia in addition to symptoms suggestive of COVID-19 infection. However, severe cases were defined as moderate cases who meet any of the following: oxygen saturation less than 93%, respiratory rate greater than or equal to 30 breaths/ min at rest, and patients with greater than 50% pulmonary-lesion progression within 24-48 h. ...
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Introduction The impact of coronavirus disease-2019 (COVID-19) on the heart is variable, but cardiac damage is associated with a bad prognosis. The mechanism behind the association between COVID-19 and cardiovascular diseases is not clear, but most of these patients reported with diseased immune system. Patients and methods This retrospective study included 70 hospitalized (moderate and severe) RT-PCR-positive COVID-19 patients. Data were retrieved from Mansoura University quarantine records from October 2020 to December 2020. The 12-lead channel conventional ECG collected at the first time after the patients were admitted to the hospital was used. Results About 94.3% of studied patients were in sinus rhythm, premature ventricular contractions were found in 2.9%. Atrial fibrillation was present in 4.3% and multifocal atrial tachycardia in 1.4%. Ischemic changes were found in 25.7% of the studied patients. About 14.3% had conduction defects. In this study, ECG ischemic changes only were significantly correlated with progress of respiratory support needed during hospitalization (44.4% of mechanically ventilated patients had ECG ischemic changes), mortality (P=0.04), and higher D-dimer level. Conclusion Baseline ECG ischemic changes associated with worse outcome of moderate and severe COVID-19 patients. Continuous monitoring of ECG changes in COVID-19 patients is recommended as it can provide an important assessment of COVID-19 severity.
... They were recruited from Al-Zahraa Hospital, Faculty of Medicine (Girls), Al-Azhar University, Cairo, Egypt named for SARS-CoV-2 positive patients' isolation. Patients were classified according to disease severity based on the guidance of the Egyptian ministry of health and population (MOHP) [18] into 80 mild to moderate COVID-19 patients and 80 severe COVID-19 patients. Mild to moderate cases met the following criteria: fever and respiratory symptoms, CORAD 1-5 and oxygen saturation (SpO 2 ≥92%) while severe cases met the following criteria: fever and respiratory symptoms, CORAD 4-5 and oxygen saturation (SpO 2 <92%). ...
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Aim: To investigate the change in a serum level of copeptin, a neuroendocrine biomarker, in differentiating grades of COVID-19 severity on admission time and to find its diagnostic potential. Materials & Methods: 160 COVID-19 patients were classified according to disease severity into 80 mild to moderate and 80 severe patients. Serum copeptin level was assessed by ELISA on their admission time. Besides, serum CRP, ferritin and D-dimer were estimated. Results: Severe COVID-19 patients showed higher serum copeptin level in comparison to mild to moderate cases, with diagnostic potential to distinguish disease severity with 93.33% sensitivity and 100% specificity at cut-off value >18.5 Pmol/l. Conclusion: Serum copeptin was remarkably increased with COVID-19 severity with reasonable differentiation potential for recently admitted patients.
... All cases had a positive history of recent COVID-19 infection at the time of diagnosis with ROCM. According to Egyptian national guidelines, moderate to severe COVID-19 patients were treated with steroids; oral (prednisolone) in 9 and parenteral (methylprednisolone/ dexamethasone) in four cases [28]. All patients are treated with oxygen mask; no one needs an invasive respiratory device. ...
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COVID-19 is a pandemic disease which predominantly affects the respiratory system with high critical care mortality and morbidity; however, it also causes multi-organ dysfunction in a subset of patients. Although causality between COVID-19 and mucormycosis remains unclear, many factors including glucocorticoids, worsening of blood glucose control, and viral-induced lymphopenia have been attributed to cause mucormycosis in patients with COVID-19. In COVID-19 patients, especially those who need oxygen support, inflammatory and cytokine storm or usage of steroids make the immune system weak. This may pave the way for opportunistic infections including mucormycosis. We report fourteen cases of COVID-19 infection, who developed rhino-orbito-cerebral mucormycosis, during treatment. Early recognition of this life-threatening infection is the key to allow for optimal treatment and improved outcomes.
... • patients with mild symptoms (fever, cough, and other complaints of respiratory tract system), and without changes, or with mild findings on CT (multiple small patchy shadows and interstitial shifts, especially in the outer zone of the lung and under the pleura) were categorized as non-severe types; • the existence of one or more of the following criteria was identified as severe SARS-CoV-2 infection: i) respiratory rate (RR) ≥ 30 times/minute, ii) oxygen saturation at room air and resting condition ≤ 92%, iii) arterial blood gas measurement: partial pressure of oxygen/fraction of inspired oxygen (PaO 2 /FiO 2 ) ≤ 300 mmHg, CT of the chest revealing more than 50% lesion or progressive lesion within 24 to 48 h. Critically ill patients were diagnosed if SaO 2 < 92, or RR > 30, or PaO 2 /FiO 2 ratio < 200 despite oxygen therapy [10]. ...
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COVID-19 is an infectious disease caused by SARS-CoV-2 and has spread globally, resulting in the ongoing coronavirus pandemic. The current study aimed to analyze the clinical and epidemiological features of COVID-19 in Egypt. Oropharyngeal swabs were collected from 197 suspected patients who were admitted to the Army Hospital and confirmation of the positivity was performed by rRT-PCR assay. Whole genomic sequencing was conducted using Illumina iSeq 100® System. The average age of the participants was 48 years, of which 132 (67%) were male. The main clinical symptoms were pneumonia (98%), fever (92%), and dry cough (66%). The results of the laboratory showed that lymphocytopenia (79.2%), decreased levels of haemoglobin (77.7%), increased levels of interleukin 6, C-reactive protein, serum ferritin, and D-dimer (77.2%, 55.3%, 55.3%, and 25.9%, respectively), and leukocytopenia (25.9%) were more common. The CT findings showed that scattered opacities (55.8%) and ground-glass appearance (27.9%) were frequently reported. The recovered validated sequences (n=144) were submitted to NCBI Virus GenBank. All sequenced viruses have at least 99% identity to Wuhan-Hu-1. All variants were GH clade, B.1 PANGO lineage, and L.GP.YP.HT haplotype. The most predominant subclade was D614G/Q57H/V5F/G823S. Our findings have aided in a deep understanding of COVID-19 evolution and identifying strains with unique mutational patterns in Egypt.
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Background Caring for our patients while taking care of our own safety as well as theirs is a major concern during the current pandemic. Therefore, many societies developed guidance documents to educate clinicians about the required precautions. This study aims to assess personal protective equipment (PPE) usage, hand hygiene practice and infection control training among phoniatricians and otolaryngologists during the pandemic. An online survey was administered during the first wave of the COVID-19 pandemic in June 2020. Data collected included PPE availability, infection control training, adopted infection control precautions, hand hygiene practice, and use of different PPE elements as well as adherence to its use during potential aerosol generating procedures. Results Based on their country of residences, eligible 154 participants were grouped into 4 groups and their responses were compared. Conclusion Following the suggested recommendations, while adequate for some precautions, was still not satisfactory. Certain defects that are specific to particular groups had also been identified.
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