The Indian Academy of Pediatrics organized an online meeting of subject experts on 27 July, 2020. A committee was formed comprising of pediatricians, pediatric and neonatal intensivists, and hospital administrators. The committee held various deliberations (online and via emails) and a final consensus was reached by November, 2020.

The guidelines are applicable for clinics, polyclinics, and level 1 hospitals.

A clinic is defined as a clinical establishment providing examination, consultation, and prescription to outpatients, including dispensing medicines by a single doctor, general practitioner, specialist, or a super-specialist doctor. A polyclinic is similar but managed by more than one doctor, general practitioner, specialist, or a super-specialist doctor. [2] A Level 1 (A) hospital is a general medical service with an indoor admission facility, provided by recognized allopathic medical graduate(s) and may also include general dentistry services offered by recognized BDS graduates. Example: Primary Health Care Centre (PHC), government and private hospitals, and nursing homes run by MBBS doctors. A Level 1 (B) hospital shall include all the general medical services provided at level 1(A) and indoor and OPD specialist medical services provided by doctors from one or more basic specialties, namely general medicine, general surgery, pediatrics, obstetrics and gynecology, and dentistry. [3]

The guideline will be discussed under these broad subheadings

1. Staff Skills Training and Education - The first step in organizing the OPD is the education of HCW on PPE, disease transmission, screening techniques, cohorting patients, and newer clinic management protocols. [4] The clinician should be prepared for HCW’s illness & subsequent quarantine by training the staff to multitask and alternating their duties. [5] In the Indian scenario, with constraints in the availability of skilled staff, prevention is the key.

2. Tele Consultation - With the legalization of teleconsultations, it is recommended wherever feasible. [6] It helps to identify patients who can be managed at home and those who need hospital care. It minimizes patient contact and is a useful triaging tool. The teleconsultation guidelines laid down by the government need to be followed [7].

3. Appointments and Patient Scheduling - Limit the number of patients per day. Walk-In consultations should be discouraged to avoid overcrowding. Patient segregation & triaging to be done while scheduling appointments [6].

4. Physical Distancing and Waiting Areas - Clinics should preferably have no waiting areas. However, when more than one person arrives, their seats should be at least 1 meter apart. [5,6] Open ventilation is encouraged here [refer section on HVAC]. In single room OPD chambers, it would be prudent to call one patient at a time; others can wait outside in the open air or their vehicles.

5. Patient Segregation - It is prudent to cohort children who are ill from the well-baby visits. Many clinics are operated only by the practicing doctor. However, it is recommended to have a helper who will assist in triaging, maintaining decorum, and educating patients. Preferably an initial screening should be followed by separation of those suspected of COVID-19 from others. These cases should not spend time in the waiting area and should be seen immediately. A separate entry, consultation place & exit, if feasible, will help. [4] As not all clinics have the facilities mentioned above, alternate precautions should be followed:

6. Patient Education and Awareness - All patients should follow respiratory hygiene and cough etiquette. Patients should be provided with tissues, contactless bins, contactless sanitizers, and wash areas. Display these instructions in prominent locations. Patient education is also the physician’s responsibility, hence putting educative posters, multimedia information at strategic points is useful. [4,6]

7. One Attendant and Personal Protection - Allow only one parent or guardian with the child. [5] Everybody, including children above two years, should wear a mask.

8. Well Ventilated - Follow the ventilation guidelines provided in this document.

9. Avoid Fomites - Remove toys, magazines, and any items that are likely to be shared between patients in the waiting area or consultation chambers. [4]

10. Novel Techniques - Innovative methods have been tried by various doctors and can be utilized.

PPE, along with other measures like engineering and administrative protocols, reduces the exposure of HCW to infectious agents, including the SARV-CoV2 virus. HCW has 11-fold higher chances of getting infected with the SARS-CoV2 virus than the general population. The use of PPE can reduce that risk by 60-80% when exposed to COVID-19 suspected or proven cases. Various components of PPE and its benefits are given in Supplementary Table I.

An essential part of PPE is the proper way of putting it on (Donning) and removing (Doffing) as the maximum chances of contamination and infection occur during doffing. The steps and sequence of donning and doffing of N-95 masks and PPE are given in Supplementary Table II. All PPE components, especially face masks are effective only when used in combination with frequent hand hygiene.

Every patient should be taken as a COVID-19 suspect unless proven otherwise. Appropriate PPE should be universally worn when attending to any patient, even in a non-COVID-19 centre.

Despite consistent evidence of contamination of various surfaces with SARS CoV 2 virus, especially in the hospital setting, there is no direct evidence of fomites being a cause of transmission. [12] However, it is imperative to follow some necessary sanitization precautions for the decontamination/disinfection of COVID-19, as given in Table I. These are based on the Hospital Infection Prevention and Control guidelines drafted by the National Centre for Disease Control and the WHO. [13]

Spraying, fogging, misting, or fumigation of rooms or surfaces is not recommended for COVID-19. Spraying of chemicals is harmful, affecting the mucus membrane, skin, and respiratory system. The recommended method is to wipe with a disinfectant soaked cloth

Patients, attendants, and HCW’s are advised to wash hands with soap and water in a washbasin with foot-operated or motion sensor adapted taps. Everyone should use Foot-operated hand sanitizer dispensers before entering the clinic.

The composition of sanitizers is 60-70% ethanol or isopropyl alcohol. Avoid methanol containing or non-alcohol based sanitizers. Foot operated and Contactless sanitizer delivery systems are safe and effective.

Maintaining the HVAC plays a vital role in providing a stress-free, comfortable, and safe environment for patients and health care workers. Maintaining indoor air quality is very important to prevent cross-contamination and hospital-acquired infections.

Air changes per hour　(ACR) are the number of total replacements of any room’s　air　in one　hour. If the　air　supply by the HVAC system in one　hour　is equal to the volume of the space, then it is called one　air　change　per hour. The number of air exchanges required to clean the air depends on the quantum of infected aerosol production. For example, a minimum of 12 ACR is needed in the Intensive Care Unit (ICU). In contrast, only 4 ACR is required for general wards, as the expected amount of aerosol production is different in both areas.

There are two ways to reduce the quantum of infection in contaminated air, either by ‘diluting’ the pathogen (dilution ventilation) or by removing the pathogen (exhaust ventilation). Dilution Ventilation is also called positive pressure isolation, required to prevent infection in an immunocompromised patient. Exhaust Ventilation is called negative pressure isolation and is used primarily to avoid a contaminated patient’s airborne disease [15] (Fig. 1).

Fig. 1 Principle of HVAC to prevent airborne spread.

Ways To Create Air Exchanges Via Exhaust Ventilation:

The airflow should be in the direction of clean to dirty and should not be directed towards the patient as it causes turbulence. (Fig. 2)

Fig. 2 Clinic setting - Placement of exhaust fan, one feet above the ground. Direction of air should be from clean to dirty (patient side). Flow of AC air should be directed towards celling.

Plasma purifiers are specialized newer technology air purifiers. Originally these purifiers were very large and cumbersome, however, with significant advancements in technology, they have become compact and a part of the HVAC with the ionization tubes mounted in the air conditioning, either in the unit itself or in the ductwork. These ionization tubes form ions (negatively or positively charged particles) as air circulates over them. The ions that are produced act in three ways to purify the air:

The viricidal properties of the Plasma purifiers may be used while installing the HAVAC in the clinics and small establishments. However further evidence is required regarding its efficacy during this pandemic.

Recommended HVAC Modifications For Healthcare Facilities:

Different recommendations for HVAC for various healthcare facilities are given in Supplementary Table III and Figs. 1,2 & 3.

There are various situations where a Non-COVID-19 facility is faced with a COVID- 19 challenge. The possible problems and recommendations are enumerated.

When patients admitted for unrelated/non-respiratory illness turn out to be COVID-19 positive

The decision on further /continued use of non-COVID-19 facilities where a single/multiple

A contact is a person who is likely to get the infection from a positive case through any of the following modes of transmission

Risk Assessment

The risk assessment of close contacts with COVID-19 patients is given in Table II.