The Ministry of Health and Family Welfare (MoHFW) on Saturday released a revised policy on the discharge of patients hospitalised for COVID-19 infections. The revised guidelines state that only severe cases of COVID-19 will be tested before discharge, while mild and moderate cases do not need to be tested before they are discharged. Earlier, all patients were being tested and used to be discharged only when their chest radiograph exam was cleared and two consecutive RT-PCR tests returned negative.
Now, for mild/very mild/pre-symptomatic cases, the patient can be discharged after 10 days of getting the symptoms and if the patient does not report a fever for three days. A test is not needed and the patient will be advised to follow home isolation for seven days after they are discharged.
For moderate cases, the patient can be discharged if one, they are asymptomatic for 3 days or after 10 days of the patient reporting symptoms. Similar to mild cases, the patient will be advised to follow home isolation for seven days after discharge.
For severe cases, the patient will be discharged only after clinical recovery and if the patient tests negative once by RT-PCR after the symptoms subside.
Health Ministry officials have stated that India’s policy has been changed in line with other countries who have changed the criteria for discharge from ‘test-based strategy to ‘symptom-based strategy’ or ‘time-based ‘strategy. This is because studies, as well as ICMR’s laboratory surveillance data, has shown that COVID-19 patients usually turn negative after a median duration of 10 days. Recent studies have also suggested that the viral load peaks in the pre-symptomatic period (2 days before symptoms) and goes down over the next 7 days.
The Health Ministry has said that when the symptoms and signs of COVID-19 are resolved, and there is no fear of resurgence or subsequent transmission of infection, a person is said to have recovered from COVID-19.
The Health Ministry has said that available evidence in India does not indicate any increase in the risk of transmission from patients discharged based on the revised discharge criteria. The revised criterion also specifies that such patients must follow home isolation for seven days.
However, experts say that some patients could remain infectious beyond the 10 days of getting the symptoms.
“The home isolation element is a crucial part of the discharge policy and there is a need for people to understand that. Once you are discharged, it may not necessarily mean you are not still infectious,” Dr Anant Bhan, Researcher, Global Health, Bioethics and Health Policy, tells TNM.
“I think the Health Ministry's calculation of 10 days is based on a median calculation of the time from when you show symptoms to the time you test negative. However, it’s important to remember that there could also be some people outside this range who remain infectious post the 10 days. I think this information should also be put out and reinforced in the public domain so that due care is taken post-discharge, including during the transfer to the home isolation venue, and at the home isolation venue, as well,” he adds.
Recently, there were two cases in Kerala where the test results of two patients continued to show positive for over 40 days despite their symptoms subsiding.
Patients in home isolation who are pre-symptomatic/very mild/mild confirmed cases of COVID-19 and do not have comorbidities have been asked to wear a triple-layer medical mask at all times. The patient must stay in the identified room and away from other people in the home, especially senior citizens and those with co-morbid conditions like hypertension, cardiovascular disease, renal disease, etc. They should maintain strict personal hygiene and self-monitor his/her health with daily temperature monitoring and report promptly if any deterioration of symptoms.
“A key concern is for those individuals who might not have the facility to effectively home isolate for seven days post their discharge. This would be the case for example in individuals who live with large/joint families with limited space at home, such as areas of high population density, like slums. The challenges will be to ensure home isolation for those individuals and for them, we might need a step down isolation facility arranged by the government post their discharge,” Dr Anant Bhan adds.
The Health Ministry has stated that as per the latest revised discharge policy, there is no need for testing prior to discharge of all presymptomatic/very mild/mild confirmed cases of COVID-19 after 10 days of symptom onset and no fever for 3 days. Therefore it stands to reason that no testing is also needed for patients undergoing home isolation (pre-symptomatic/very mild/mild confirmed cases) after the home isolation period is over.
As detailed above, as far as testing is concerned, there is no need for testing after the home isolation period is over. However, (as the current discharge policy advises patients to remain in home isolation for a 7 day period after discharge), the period of home isolation would end after 17 (10+7) days of symptom onset and no fever for 10 (3+7) days.
USA: According to the United States’ Centre for Disease Control and Prevention (CDC), a patient can be discharged if: at least 3 days (72 hours) have passed since recovery, which means if there is no fever without any medications and there is no respiratory symptoms (e.g., cough, shortness of breath); or if at least 10 days have passed since symptoms first appeared. The CDC has also said that two negative RT-PCR test results can also be used to support the discharge of the patient
Italy: According to the Italian Health Ministry, a COVID-19 patient can be considered cured after the resolution of symptoms (fever, rhinitis, cough, sore throat, difficulty breathing, pneumonia) and after two negative swab tests for SARS-CoV-2 performed 24 hours apart.
European Union (EU): A guidance by the European Centre for Disease Prevention and Control (ECDC) states that for a clinically recovered patient, two negative RT-PCR tests from respiratory specimens at 24 hours interval at least eight days after onset of symptoms. Discharge can be based on clinical criteria if no testing is available, states the guidance, meant for public health institutes in the EU/EEA (European Economic Area) countries and the UK.
Singapore: In Singapore, there are several criteria for discharge: if a patient does not show signs of fever for 24 hours, has 2 negative RT-PCR tests, and at least 6 days have passed since the onset of the illness.
China: In April, According to the protocol, recovered COVID-19 patients should stay in quarantine for 14 days either at home or in an isolation centre for medical observation, the state-run Xinhua news agency reported. During the isolation period, those having recovered from the disease should take their temperatures daily and be on the lookout for fever and respiratory symptoms including cough and breathing difficulties, the protocol said.
(With PTI inputs)