|Year : 2020 | Volume
| Issue : 5 | Page : 230-237
Clinical management and suggested treatment for COVID-19 in the Indian sub-continent: A comparative study
Md Insiat Islam Rabby1, Farzad Hossain2, Munadi Al Islam3, A K. M Sadrul Islam4, Israt Jahan Akhi5, Syed Nazmul Huda6
1 Department of Mechanical and Manufacturing Engineering, Universiti Putra Malaysia, Selangor, Malaysia
2 Department of Mechanical and Production Engineering, Islamic University of Technology, Gazipur, Bangladesh
3 Department of Medicine, Dhaka Medical College Hospital, Dhaka, Bangladesh
4 Managing Director, The IBN SINA Pharmaceutical Industry Ltd, Dhaka, Bangladesh
5 Department of Physiotherapy, Bangladesh Health Professions Institute, Dhaka, Bangladesh
6 Lecturer of Accounting, Bangamata Sheikh Fojilatunnesa Mujib Science & Technology University, Jamalpur, Bangladesh
|Date of Submission||01-Sep-2020|
|Date of Decision||06-Sep-2020|
|Date of Acceptance||07-Sep-2020|
|Date of Web Publication||29-Oct-2020|
Md Insiat Islam Rabby
Department of Mechanical and Manufacturing Engineering, Universiti Putra Malaysia, Seri Kembangan, Selangor
Source of Support: None, Conflict of Interest: None
SARS-CoV-2 is a dangerous virus which first emerged in China in December 2019. Till now, it has affected more than 4215,497 people in 212 countries and territories. No drug or vaccine is currently recommended, but scientists and researchers are trying their best to identify potential medications and clinical management practices for this virus. The aim of this paper is to find and compare clinical management practices and suggest potential treatment options for COVID-19 in highly infected countries of the Indian sub-continent (India, Bangladesh and Pakistan). Necessary information has been collected from various clinical management guidelines for COVID-19, available at the health ministry websites of India, Bangladesh and Pakistan. Although clinical management practices vary from country to country, all of these countries utilise mechanical ventilation. Moreover, some potential drugs have been suggested by all countries that may be utilised for treatment but did not recommend any of the medications yet because all of them are under evaluation in various clinical trials. Hydroxychloroquine has been suggested by all of these countries but in different situations. All countries are trying their best to follow their government guidelines. In addition, it has been found that the recovery rate of patients from Bangladesh, India and Pakistan is 18.08%, 30.76% and 26.58%, respectively. Although all the suggested treatment protocols have potentiality against COVID-19, they can only be recommended in the treatment procedure after necessary experiments and investigations.
Keywords: Drugs, management, SARS-CoV-2, treatment, vaccine
|How to cite this article:|
Islam Rabby MI, Hossain F, Al Islam M, Sadrul Islam A K, Akhi IJ, Huda SN. Clinical management and suggested treatment for COVID-19 in the Indian sub-continent: A comparative study. Curr Med Res Pract 2020;10:230-7
|How to cite this URL:|
Islam Rabby MI, Hossain F, Al Islam M, Sadrul Islam A K, Akhi IJ, Huda SN. Clinical management and suggested treatment for COVID-19 in the Indian sub-continent: A comparative study. Curr Med Res Pract [serial online] 2020 [cited 2021 Dec 3];10:230-7. Available from: http://www.cmrpjournal.org/text.asp?2020/10/5/230/299518
| Introduction|| |
COVID-19 is a new ubiquitous virus which was first identified in December 2019 in China. Till now, the virus has spread all over the world. Around 62,938 confirmed cases have been reported in India till 11 May 2020; among them, 21,466 cases have received an outcome, 9.82% have died and 90.18% have recovered/discharged. Regarding the total number of confirmed cases of India, 3.35% have died and 30.76% have been cured, indicating that 65.89% of cases are still active as on 11 May 2020. Maharashtra, Gujarat, Delhi, Tamil Nadu, Rajasthan and Madhya Pradesh are the six highly affected states. The highest number of confirmed cases (32.14% comparing with the whole country) has been identified in Maharashtra and among the confirmed cases, 77.36% are still active, 18.79% recovered and 3.85% died. Moreover, the second highest number of confirmed cases (12.39% in comparison to the whole country) has been recorded in Gujarat and among the confirmed cases, 67.13% are still active, 26.82 recovered and 6.05% died. Around 14,657 confirmed cases have been reported in Bangladesh till 11 May 2019; among them, 2878 cases have received an outcome, where 7.92% of deaths and 92.08% of recovered/discharged cases have been identified. Regarding the total number of confirmed cases in Bangladesh, 1.56% have died and 18.08% have been cured, indicating that 80.36% of cases are still active. The highest number of confirmed cases (81.15% comparing with the whole country) has been found in Dhaka division and all other divisions have 18.85% of confirmed cases. Moreover, the second highest number of confirmed cases (6.07% in comparison to the whole country) has been reported in Chattogram. Around 30,334 confirmed cases have been reported in Pakistan till 11 May 2020; among them, 8722 cases have received an outcome, where 7.56% of deaths and 92.44% of recovered/discharged cases have been identified. Regarding the total number of confirmed cases of Pakistan, 2.17% of deaths and 26.58% of cured cases can be identified, indicating that 71.25% of cases are still active. Sindh and Punjab are two highly affected provinces. The highest number of confirmed cases (37.85% comparing with the whole country) has been identified in Sindh and among the confirmed cases, 80.76% are still active, 17.59% recovered and 1.65% died. In addition, the second highest number of confirmed cases (36.57% in comparison to the whole country) has been reported in Punjab and among the confirmed cases, 60.05% are still active, 38.22% recovered and 1.73% died.
The principal objective of this paper is to analyse and compare nation-wise clinical management practices and suggested treatment options, especially in the three highly affected countries of the Indian sub-continent (India, Bangladesh and Pakistan). Till now, no reviews have been published that have discussed clinical management and suggested treatment for COVID-19 in the Indian sub-continent. Moreover, all the clinicians in these countries will get an idea about clinical management practices and suggested treatment options being followed.
- At least 2 or higher score in Quick Sepsis-Related Organ Failure Assessment
- Either a score of 4 or 3 in Confusion, Urea, Respiratory rate and Blood pressure criteria
- Infiltrates extensively on chest X-ray (CXR)
- Smaller than 30 ratios of PaO2/FiO2 or smaller than 65 PaO2 or PaCO2 is rising
- Presence of record regarding heart failure
- Presence of shock signs, that is cold, output of urine <0.5 ml/kg/h, mottled skin, delay in capillary refill, systolic blood pressure (BP) (SBP) <90 mmHg, clammy peripheries
- Critical illness.
When any of the following conditions is present accompanying with rapid progression of disease:
- Respiratory failure accompanying with the necessity of mechanical ventilation
- Inhalation cannot alleviate persistent hypoxia and acute respiratory distress syndrome (ARDS) through masks or nasal catheters
- Failure of organ where intensive care unit (ICU) monitoring is required
- Septic shock.
It is defined as shortness of breath accompanying with hypoxia and severe-to-moderate pneumonia that do not meet critical disease criteria.
- Breathing becomes rapid (breath/minute becomes ≥70 in the case of infants <1 year old, whereas it becomes ≥50 in the case of children more than 1 year old. Presence of depression, convulsions, coma, lack of consciousness and hypoxia
- Gastrointestinal dysfunction, problem in feeding and dehydration
- Elevation of liver enzymes and myocardial injury
- Rhabdomyolysis, coagulation dysfunction and other manifestations that indicate injuries to essential organs.
Here, symptoms are present accompanying COVID, that is dyspnoea, malaise, fatigue, fever, nasal congestion, cough (may or may not accompanying the production of sputum), sore throat, headache, anorexia and necessity of oxygen or findings through CXR.
- Asymptomatic infection or short-duration presence of upper respiratory symptoms (i.e. fever, sore throat and pharyngeal congestion)
- Reverse transcriptase-polymerase chain reaction (RT-PCR) test is positive for SARS-CoV-2
- No evidence of sepsis or abnormality in radiographic presentation.
It is defined as without any symptom and positive nasopharyngeal RT-PCR for SARS-CoV-2.
| Acute Respiratory Distress Syndrome|| |
Origin of oedema: Fluid overload or cardiac failure cannot completely explain the respiratory failure. Objective assessment is required (i.e. echocardiography) for excluding hydrostatic reason of oedema unless there is a risk factor.
- Chest imaging (radiograph, computed tomography [CT] scan or lung ultrasound): Bilateral opacities not completely explained by effusions, lung or lobar collapse or nodules
- Onset: Respiratory symptoms are worsening or new within a week's duration of the known clinical injury.
- Mild ARDS: PaO2/FiO2>200 mmHg and ≤300 mmHg accompanying continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP) ≥5 cmH2O or non-ventilated
- Moderate ARDS: PaO2/FiO2>100 mmHg and ≤200 mmHg accompanying PEEP ≥5 cmH2O or non-ventilated
- Severe ARDS: PaO2/FiO2≤100 mmHg accompanying PEEP ≥5 cmH2O or non-ventilated
- SpO2/FiO2≤315 suggests ARDS in the case of the unavailability of PaO2 and it includes no ventilate patients.
- CPAP or bi-level non-invasive ventilation (NIV) ≥5 cmH2O by the mask of full face
- Full face mask: Either SpO2/FiO2 is ≤ 264 mmHg, or SpO2/FiO2 is ≤300 mmHg
- Invasive ventilation of severe, moderate and mild ARDS
- Mild ARDS: Either oxygenation index using SpO2(OSI) ≥5 and < 7.5, or oxygenation index (OI) ≥4 and <8
Moderate ARDS: Either OSI ≥ 7.5 and <12.3, or OI ≥8 and <16.
- Severe ARDS: Either OSI ≥ 12.3, or OI ≥ 16.
A dysregulated host causes life-threatening dysfunction of organ and the host responds to proven or suspected infection, accompanying dysfunction of organ. Organ dysfunction signs: Lower amount of oxygen saturation, low BP or cold extremities, reduction of urine output, fast or difficult breathing, weak pulse, alteration of mental status, mottling of skin, fast rate of heart, laboratory evidence of acidosis, thrombocytopenia, coagulopathy, hyperbilirubinaemia or high lactate.
It includes systemic inflammatory response syndrome criteria ≥2 and proven or suspected infection. One of them must be abnormality of temperature or count of white blood cell.
Persisting hypotension in spite of resuscitation of volume. Vasopressors are required not only for maintaining the lactate level of serum <2 mmol/L but also for maintaining mean arterial pressure (MAP) ≥65 mmHg.
Any hypotension (SBP >2 standard deviation below normal or, <5th centile for age) or two/three from the following: tachycardia or bradycardia (heart rate [HR] >150 bpm or <70 bpm in children and HR >160 bpm or <90 bpm in infants), alteration of mental state, hypothermia or hyperthermia, an increment of lactate, tachypnoea, warm vasodilatation accompanying the bounding of pulses or prolonged capillary refill >2 s, purpuric rash or petechial or mottled skin and oliguria.
| Methods|| |
An online search string has been conducted through Google for health ministry websites of India, Bangladesh and Pakistan till 5 April 2020 to identify the clinical management guidelines of COVID-19 by the health regulatory authorities of India, Bangladesh and Pakistan. From the published database of health ministry websites of India, Bangladesh and Pakistan, three guidelines which stated the clinical management and treatment of COVID-19 were selected for this study. The recommended therapeutics, drugs and supportive care based on the clinical features of COVID-19-positive patients from these identified guidelines are described for the Indian subcontinent.
| Results and Discussion|| |
Clinical management of COVID-19 in India
Early supportive therapy and monitoring
- Provision of supplemental therapy of oxygen instantly to patients with shock, hypoxaemia, or respiratory distress and severe acute respiratory infection (SARI) has been suggested. Recommended titrate flow rates for reaching target SpO2 are ≥ 92%–95% in adults who are pregnant and 90% in adults who are non-pregnant. It has been suggested to initiate therapy of oxygen at 5 L/min. Children who have emergency signs (shock, central cyanosis, severe respiratory distress, obstruction or absence of breathing, convulsions or coma) have been suggested therapy of oxygen during resuscitation. In this case, the target SpO2 should be ≥ 94% and in all other cases, 90% SpO2 should be the target
- If no evidence is present related to shock, utilisation of conservative type of fluid management has been proposed in the case of patients with SARI. It is necessary to treat patients with SARI with intravenous fluids, as oxygenation may be worsened by aggressive fluid resuscitation, especially where mechanical ventilation is not easily available
- Providing empiric antimicrobials for treating all probable pathogens causing SARI and antimicrobials within 1 h for initial assessment of patients with sepsis has been encouraged. Though it can be suspected that the patient may have COVID-19, empiric antimicrobials should be appropriated by administering within an hour of sepsis identification
- Provision of systemic corticosteroids routinely in order to treat ARDS or viral pneumonia outside of the trial if they are not indicated for any other reason has not been recommended. Neither survival benefits nor the possibility of harms (delayed viral clearance, diabetes, psychosis and avascular necrosis) has been reported in the corticosteroid observational studies where patients were administrated with SARS
- Close monitoring of the patients with SARI for clinical deterioration signs, that is swiftly progressive sepsis and respiratory failure, and instantly applying interventions of supportive care has been encouraged. Safe, effective and timely application of supportive therapies is necessary for patients who develop COVID-19 manifestations severely
- Realising the comorbid conditions of the patients for tailoring the critical illness management and appreciating the prognosis have been proposed. The chronic therapies that should be temporarily stopped along with the chronic therapies that should be continued during the management of intensive care of SARI should be determined
- Early communication with family and patient has been suggested. For providing prognostic information and support, proactive communication is required with families and patients. It is necessary to realise the patient's preferences and values related to life-sustaining interventions.
Management of hypoxaemic respiratory failure and acute respiratory distress syndrome
- Severe 'hypoxaemic respiratory failure' should be recognised whenever 'standard oxygen therapy' is failed in a patient accompanying with respiratory distress
- Severe 'hypoxemic respiratory failure' should be recognised whenever 'standard oxygen therapy' is failed in a patient accompanying with respiratory distress. Patients may continue to have increased work of breathing or hypoxemia even when oxygen is delivered via a face mask with reservoir bag (minimum flow that is necessary for maintaining inflation of bag is 10–15 L/min and FiO2 should be within 0.60–0.95).
- Non-invasive mechanical ventilation or high-flow nasal catheter oxygenation (HFNO) has been proposed. If the alleviation of patients' hypoxaemia or respiratory distress is not possible in spite of providing 'standard oxygen therapy', 'non-invasive mechanical ventilation' or 'HFNO' should be considered. However, if worsening of the condition or no improvement of the condition is observed within 1 to 2 h of time duration, it is necessary to utilise 'invasive mechanical ventilation' and 'tracheal intubation' at the right time. Utilising HFNO can reduce the necessity of intubation in comparison to 'standard oxygen therapy'
- Utilising airborne precautions, an experienced and trained provider should perform the endotracheal intubation. During intubation, quick desaturation may be observed in patients who have ARDS (mainly in the case of the children who are young or people who are pregnant or obese). Pre-oxygenation along with 100% FiO2 should be done with duration of 5 min through 'bag-valve mask', 'a face mask with reservoir bag', 'HFNO' or 'NIV'. After airway assessment, it is necessary to appropriately perform rapid sequence intubation for identifying no signs of 'difficult intubation'
- For patients who have severe ARDS, prone ventilation is required for >12 h/day. Strong recommendation has been obtained for applying prone ventilation for paediatric patients and adults who have severe ARDS. However, suitable expertise and human resources are required for safe performance. Lower PEEP should be utilised in patients who have severe or moderate ARDS
- Patient should not be disconnected from the ventilator because it may create loss of atelectasis and PEEP.
Management of septic shock
- Septic shock should be recognised in adults in the case of confirmed or suspected infection and vasopressors are necessary for maintaining mean arterial pressure ≥65 mmHg and lactate <2 mmol/L whenever hypovolaemia is absent
- For defining shock, it is suggested to utilise both 'MAP' and 'clinical signs of perfusion' whenever lactate measurement is absent. It has been proposed that standard care should comprise quick recognition and some treatments (i.e. 'vasopressors' for hypotension, 'fluid loading' and 'antimicrobial therapy') within 1-h duration of recognition
- For resuscitation of adults from the septic shock, isotonic crystalloid should be provided at least 30 ml per kg in adults within the first 3 h of time duration. For resuscitation of children from the septic shock, rapid bolus should be provided from 20 ml/kg to 60 ml/kg within the first 1 h of time duration. Gelatins, starches or hypotonic crystalloids should not be utilised for resuscitation. Both Ringer's lactate and normal saline are included in crystalloids
- Vasopressors should be administered when persistence of shock is observed after or during resuscitation of fluids. The preliminary target of BP should be MAP ≥65 mmHg in the case of adults and 'age-appropriate targets' of children
- In the case of unavailability of 'central venous catheters', it has been proposed to provide vasopressors via a 'peripheral intravenous (IV)'. However, close monitoring and utilisation of a 'large vein' have been suggested in order to minimise the signs of 'local tissue necrosis' and 'extravasation'.
Other therapeutic measures
Whenever oxygenation indicators are progressively deteriorated for patients, glucocorticoids can be used for 3–5 days. Moreover, the dose should be equivalent to methylprednisolone 1–2 mg/kg/day. The dose should not be exceeded otherwise viral surge may occur because of immunosuppressive effects. For critical and severe pregnant cases, termination of pregnancy has been encouraged. Based on the mother's condition, it is necessary to consult with specialists of intensive care, neonatal and obstetrics. Fear and anxiety are often observed in patients and psychological counselling has been proposed to support them
No effective antiviral has been identified according to the presently available data. Though it is not considered an on-level indication, depending on the available data (i.e. some unregulated clinical trials), drugs that can be considered in patients whose diseases are severe and require ICU management are as follows:
- Hydroxychloroquine (suggested dose: 400 mg twice a day for 1 day, then 200 mg twice a day for 4 days)
- Combination of hydroxychloroquine and azithromycin (suggested dose: 500 mg once a day for 5 days).
These drugs should not be taken without appropriate monitoring and medical supervision because of possible side effects, that is QTc interval prolongation. Moreover, these drugs are currently not recommended for lactating and pregnant women nor for children <12 years old.
Clinical management of COVID-19 in Bangladesh
According to the Government database of Bangladesh, a specific treatment protocol is followed by Bangladesh for COVID-19 infection's treatment, which is shown in [Figure 1]. Consulting physicians via phone call has been suggested when the affected patient has no symptoms of pneumonia. Antihistaminics and paracetamol have been suggested when patients have cough, malaise, sore throat or fever and follow-up has been suggested after 14 days.
|Figure 1: Treatment protocol for COVID-19 in Bangladesh. GGO: Ground-glass opacity, PPE: Personal protection equipment, SARI: Severe acute respiratory infection, CT: Computed tomography, CXR: Chest X-ray, CRP: C-reactive protein|
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According to the Government database of Bangladesh, a specific process is followed by Bangladesh for drug treatment of SARI (COVID-19), which is shown in [Figure 2]. Hydroxycloroquine and remdesivir have been suggested as first-line treatment of mild and severe pneumonia in adults, respectively.
|Figure 2: Drug treatment for severe acute respiratory infection (COVID-19) in Bangladesh. SARI: Severe acute respiratory infection, ALI: Acute lung injury, ARB: Angiotensin II receptor blocker, NSAID: Non-steroidal anti-inflammatory drug, ARDS: Acute respiratory distress syndrome, MAP: Mean arterial pressure, IV: Intravenous|
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Clinical management of COVID-19 in Pakistan
Criteria for admission of confirmed or suspected COVID-19 patients
Mild disease and asymptomatic
It has been encouraged to manage mild and asymptomatic cases at home isolation. Home isolation criteria that should be fulfilled are as follows:
- Agree for isolation
- Separate bathroom and separate room for staying.
Patients who do not agree to stay at home isolation or do not fulfil proper home arrangement must be transferred to a 'dedicated isolation facility'.
However, for admission at a hospital, the following things should be considered when resources are available:
- People who are 65 years old or more than 65 years old
- Comorbid conditions: Uncontrolled diabetes, decompensated liver disease, heart failure, chronic kidney disease and structural lung disease
- Any kind of immunosuppression.
Whenever admission of patients becomes impossible, clear instructions should be provided so that people can call if any kind of worsening occurs.
Moderate, severe and critical disease
Hospital admission is suggested. If the disease is severe, preference should be given for a center that contains ICU or high-dependency unit. If negative-pressure room is available, critical patients should be placed, especially whenever 'aerosol-generating procedure (s)' can be anticipated.
Mild disease management
Supportive care should only be utilised for treatment in this case, and this includes 'antihistamines' for rhinorrhoea, 'oral hydration' for diarrhoea and 'acetaminophen' for fever.
Theoretical risk can be included with the utilisation of Angiotensin-converting enzyme (ACE)-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs) in COVID-19. There is no enough clinical data about this, therefore no strong recommendation can be made for continuing or avoiding these medications.
Currently, no particular treatment, that is hydroxychloroquine or chloroquine, is recommended in order to manage mild diseases.
Moderate disease management
For controlling intravenous fluids and fever, oxygen therapy along with supportive therapy through 'nasal cannula acetaminophen' should be continued if necessary. Antibiotics can be considered for lobar infiltrates, especially when 'white blood cell' count is high.
No particular anti-COVID-19 treatment is recommended currently according to studies for treating patients with confirmed or suspected COVID-19 infection. Any of the following treatments should be started depending on the best attainable evidence:
- Suggested dose: Chloroquine 500 mg, twice a day for duration of 10 days
- Suggested dose: Hydroxychloroquine sulphate 200 mg, thrice a day for duration of 10 days. QT-interval should be monitored on therapy, especially whenever some other drugs are taken that are responsible for prolonging the QT-interval.
Critical and severe disease management
Healthcare providers can manage critically ill patients who are affected by COVID-19. But for doing so, they should be in a group that is made up of at least a specialist of critical care, an expert of infectious disease and a pulmonologist.
- Empiric antibiotics should be thought about whenever there is a suspicion of 'secondary bacterial pneumonia'
- Conservative type of fluid management should be utilised in patients who are intubated with ARDS
- Cardiac impairment can be narrated, and diuresis can be thought about
- Neither systemic corticosteroids nor another adjunctive therapy should be provided in a high dose
- Mechanical ventilation can be implemented utilising 'lower inspiratory pressures' (plateau pressure should be <30 cmH2O) and 'lower tidal volumes' (predicted body weight should be within 4–8 ml/kg)
- Prone ventilation should be provided from 12 to 16 h of duration per day in the case of the availability of expertise in adults along with severe ARDS.
Other medicines under investigations
Unclear efficacy, limited availability and adverse effects of these medications should be considered. Before prescription, it has been suggested to consult with a specialist related to infectious diseases.
- Intravenous remdesivir
- Suggested dose: 200 mg once a day for 1 day, then 100 mg once a day for another 4–9 days.
- Intravenous tocilizumab
- Suggested dose: 4–8 mg per kg and a maximum of 800 mg once a day which can be repeated after 12 h in the case of poor response to the first dose. However, cumulative doses should not be more than 2 mg.
- Suggested dose: 400/100 mg twice a day for 14 days.
All of these countries suggested some potential drugs that may be applied for treatment, but we cannot recommend any of the medications yet because all of them are under investigations. Among the countries, India suggested hydroxychloroquine and a combination of hydroxychloroquine and azithromycin for severe disease management of COVID-19, but at the same time, they also suggested appropriate monitoring and medical supervision due to the possible side effects. On the other hand, Bangladesh suggested hydroxychloroquine as 1st-line treatment of mild pneumonia management. For severe disease management, they suggested remdesavir and lopinavir/ritonavir. Pakistan also suggested hydroxychloroquine for mild disease management like Bangladesh. However, Pakistan did not suggest any specific drug for severe disease management, but they are investigating remdesivir, tocilizumab and lopinavir/ritonavir.
This study has been designed based on the published clinical management guidelines for COVID-19 available at the health ministry websites of India, Bangladesh and Pakistan to study the clinical management system and treatment procedure of these three nations to fight against COVID-19. Our findings show that India provides broad descriptions and guidelines in a step-by-step treatment process for different clinical stages of COVID-19, compared to Bangladesh and Pakistan. Although all the three countries included mechanical ventilation, India describes more specifically about the use of mechanical ventilation depending on the clinical status of COVID-19 patients, whereas Bangladesh and Pakistan did not mention detailed information about the use of mechanical ventilation in their guidelines. In addition, out of these three nations, only guidelines from India include the values and preferences of patients regarding life-sustaining interventions. However, Bangladesh and Pakistan have also provided potential recommendations, which help them to fight against COVID-19 infection and achieve high recovery rate. The recovery rate of COVID-19 patients from Bangladesh, India and Pakistan is 18.08%, 30.76% and 26.58%, respectively.
Due to the limitation of time, clinical management and recommended treatment of COVID-19 have been analysed only in three countries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
2019 –n COV (SARS–COV-2) Infection Prevention Control (IPC) and Management in Healthcare Facilities. Ministry of Health and Family Welfare and DGHS. Available from: http://www.mohfw.gov.bd/
. [Last accessed on 2020 May 11].
[Figure 1], [Figure 2]