CENTCOM COVID-19 Playbook for Operational Environments Version 2

This playbook is aimed at healthcare and public health providers and staff in the United States Central Command (USCENTCOM) Area of Responsibility (AOR). The USCENTCOM AOR is a medically austere operational environment where Role 3 (R3) is the highest level of medical capability.  All planning assumptions proceed from there.  This playbook is a concise source of key information, references, and materials for providers and healthcare leaders to easily review. The playbook is comprehensive but not all inclusive and does not negate the need for communication and information sharing with local, Joint Task Force (JTF), Service Component and USCENTCOM Headquarters (HQ) Command and Surgeon Cells.

RESOURCE:

Key Assumptions in an Austere Environment: Management of COVID-19 in Austere Operational Environments, Joint Trauma System (JTS) Clinical Practice Guideline (CPG), Special Edition V1.0, 14 Apr 2020, p. 3.

How to Use

This document provides key information in text and graphic images for rapid review.  The Table of Contents will link users to the topic they want to review, which will contain those key facts and figures and also link users to other resources that can provide greater detail.  Users are encouraged to use this playbook as a tool to connect to best practice resources that will augment existing clinical and military expertise and local, JTF, Service Component, and USCENTCOM guidance.

Key Definitions
  1. AE Patient Classification: A basic metric to convey patient acuity and level of infectivity to others.  Patient classification will be performed in accordance with Air Force Instruction 48-307, En Route Care and Aeromedical Evacuation Medical Operations, 09 Jan 2017.
  2. Airborne Spread: Spread of disease via small liquid particles (aerosols) that remain aloft for prolonged periods of time and may travel longer distances. Airborne precautions aim to mitigate this method of transmission.
  3. Antibody: Proteins produced by infected individual as part of their immune response to infection by the pathogen
  4. Antigen: Proteins or other cellular or chemical features associated with the pathogen (e.g., viral DNA, surface proteins, etc.)
  5. Contact Spread: Spread of disease via direct contact with an infected patient or contaminated surface. Contact Precautions aim to mitigate this method of transmission.
  6. Droplet Spread: Spread of disease via relatively large liquid particles that settle from the air quickly (within a few feet). Droplet Precautions aim to mitigate this method of transmission.
  7. Intermediate Care Ward (ICW): An inpatient nursing unit that typically accommodates patients requiring med surgical to progressive (step-down) – level care.  In pandemic conditions, this definition may broaden to incorporate levels of care similar to mass casualty.  Staffing considerations and KSAs will be commensurate with the roles required. The mission may require staff to increase their KSAs.  Additional considerations may be needed for patients requiring isolation.  In crisis environment, all staff are asked to work at the top of their license. 
  8. Isolation: The separation of an individual or group infected or reasonably believed to be infected with a communicable disease from those who are healthy in such a place and manner to prevent the spread of the communicable disease. Isolation is a medical term and ordered by a medical provider, but requires command support for successful execution.
  9. Pathogen: an organism that causes disease (e.g. virus, bacteria, fungus, or parasite). The term is also used to describe prions – non-living protein particles that display infectious behavior.
  10. Patient Under Investigation (PUI): A patient with signs and symptoms consistent with known possible presentations of COVID-19 with potential exposure to the virus. Potential exposure to the virus is defined as close contact with known or other suspected cases and/or travel through regions with widespread sustained transmission of COVID-19. In areas where COVID-19 is already widespread, symptoms alone may make the diagnosis of “PUI.” Confirmatory testing has not yet been performed or was initially negative but with continued high index of suspicion for COVID-19. All PUIs must be isolated.
  11. Quarantine: The separation of an individual or group that have been potentially exposed to a communicable disease, but is not yet ill, from others who have not been so exposed, in such manner and place to prevent the possible spread of the communicable disease. This is a form of Restriction of Movement (ROM) and is a command function that is medically supported. Quarantine is a commander’s responsibility.
  12. Social Distancing: The practice of reducing close contact between people to slow the spread disease. It includes limiting large group gatherings (no more than 10 persons, closed buildings and gathering spaces, cancelling events, and advising people to stay six feet apart as much as possible). Preparation of isolation berthing, including activities of daily living (e.g., hydration, food, hygiene, trash disposal) is addressed on pages 8, 9 of the DoD COVID-19 PMG Supplement Austere Operational Environments.
Acronyms and Abbreviations

AE - Aeromedical Evacuation

AFMES - Air Force Medical Examiner System

AOR - Area of responsibility

C2 - Command and Control

CJTF - Combined Joint Task Force

CCIR - Commander’s Critical Information Reporting

CCOP - Central Command Operating Procedures

CCSG - Command Surgeon

CONOPS - Concept of Operations

CONPLAN - Concept of Operations Pan

CSOC - Crisis Standards of Care

DHA - Defense Health Agency

EXORD - Executive Order

FFR - Filtering Facepiece Respirators

HIPAA - Health Insurance Portability and Accountability Act

HPCON - Health Protection Conditions

ICW - Intermediate Care Ward

KSA - Knowledge, Skills and Abilities

MS - Medication Safety

MSAT - Medical Situational Awareness in the Theater

MWR - Morale Welfare and Recreation

PHEO - Public Health Emergency Officer

PHEM - Public Health Emergency Management

PFA - Psychological First Aid

PMG - Patient Management Guide

PPE - Personal Protective Equipment

PS - Patient Safety

PUI - Person Under Investigation

QS - Quality and Safety

SIPRNet - Secret Internet Protocol Router Network

SME - Subject matter expert

TPMRC-E - Theater Patient Movement Requirements Center East

USCENTCOM – United States Central Command

USTRANSCOM - U.S. Transportation Command

VITAL-T - Virtual Inspection and LINKUP in Theater

VH - Virtual Health

USCENTCOM CONPLAN 1251-15, Regional Concept Plan for Preparation and Response for Pandemic Influenza and Infectious Disease (PI&ID) delineates the policies, actions, and requirements for the employment of military resources within the USCENTCOM AOR for PI&ID preparation and response. This plan is available for download on the USCENTCOM SIPRnet website. You can also reach the SIPRnet website through https://ccsg.nonrel.centcom.smil.mil/Private/SitePages/Home.aspx and click on the COVID 19 link. There will be links to EXORDS and instructions. Refer to G3 for assistance if copies of instructions are needed. 

Specific Health Service Guidance is delineated in the Annex Q to the USCENTCOM EXORD Novel Coronavirus Outbreak Response Operations in the above SIPRnet website.

USCENTCOM SIPRnet website:  https://ccsg.rel.centcom.smil.mil/sites/CCSG/THEATER%20MEDICAL%20POLICIES/Forms/AllItems.aspx

Coordination is essential between Command Staff, medical teams, and public health/preventive medicine assets.  Given the highly complex nature of the COVID-19 disease and need for subject matter expertise (SME), Commanders are encouraged to designate a COVID-19 response and planning team consisting of medical and public health/preventive medicine SMEs along with operational planners.Task Force Med Leaders are encouraged to coordinate with respective Surgeon teams and Force Health Protection assets to translate and communicate all guidance and policy down to the most forward units with attention to operational security and patient privacy laws. In order to facilitate a coherent Joint effort, the response should follow established DoD procedures as outlined in DODI 6200.03 Public Health Emergency Management (PHEM) Within the DoD, 28 Mar 2019 and DODI 6055.17 DoD Emergency Management (EM) Program, Change 3 effective 12 Jun 2019.  

All leaders should operate under a number of considerations/assumptions including (but not limited to):

  1. Command and Control (C2) authorities will remain unchanged unless otherwise directed. Combined Joint Task Force Surgeon (CJTF) and Component Surgeon cells should continue to collaborate and communicate closely with higher headquarter authority.
  2. Current USCENTCOM missions will continue, unless otherwise directed, throughout the COVID-19 pandemic, daily tasks may need to be reprioritized as required by a pandemic response to maintain surgical and critical care capabilities while minimizing spread of infectious disease in theater.  
  3. Leaders are encouraged to collaborate and delegate authority to improve comprehensiveness planning and operation activities. Subordinate leaders should be empowered to utilize their expertise and innovation within the boundaries set-forth by pre-established policy and guidance. The USCENTCOM Health Protection Condition (HPCON) Checklist, Joint Force Health Protection Team, COVID-19 Crisis Action Team will assist appropriate actions and is located at APPENDIX A.
  4. Communication is key for interdisciplinary COVID-19 planning and response. Limit jargon, clearly define all acronyms and unfamiliar terms, etc. Commanders should communicate key information to subordinate units.
  5. Logistical and patient movement channels are likely to be altered by the pandemic both in theater and at receiving Role IV CONUS and OCONUS facilities. These challenges must be overcome by clear communication and adaptive planning strategies.

RESOURCES

Refer to Headquarters, CJTF, and Component guidance for specific information and requirements with regards to operational planning guidance.

The U.S. Department of Health and Human Services provides, Critical Care Planning-COVID-19 Quick Notes, a two-page document which describes operationalization of the concept in three major categories: space, staff, supplies, and provision of critical care.

The Planning and Preparation section of the DoD COVID-19 Practice Management Guide (PMG), 14 April 2020, Version 2.0, pp3-5 and pp47-48.

COVID-19 Response and Prevention Planning-Knovel (Elsevier)

DODI 6200.03 Public Health Emergency Management (PHEM) Within the DoD, 28 Mar 2019

DODI 6055.17 DoD Emergency Management (EM) Program, Change 3 effective 12 Jun 2019.  

All USCENTCOM bases and facilities should establish a local and regional PACE (Primary-Alternate- Contingency-Emergency) plan for both operational and clinical communication incorporating social distancing and division of labor during the pandemic response period.

The USCENTCOM Component and CJTF teams may have prospectively published local and regional PACE plans for both operational and clinical consultation and communication.  Forward-stationed medical teams/medics should identify and test these options PRIOR to needing urgent consultation.

Division of labor and social distancing could strain all routine secure and unsecure DoD communication and collaboration platforms (i.e. teleconferencing video conferencing networks, remote access email), resulting in the incorporation of non-DoD unsecure platforms (e.g., Zoom, Skype, WhatsApp).  Operational security and patient privacy must be a primary consideration when selecting communication platforms, especially when using non-DoD platforms.

UPDATE 2.0: In answer to this challenge the DoD has established the Commercial Virtual Remote (CVR) environment that utilizes the approved Microsoft Teams platform to improve personnel connection and information sharing. This platform is approved for controlled unclassified information sharing and is noted HIPAA compliant. It  connects with individuals? regular NIPR email accounts for ease of communications and scheduling.  For more information on how to get connected visit https://www.cloud.mil/CVR/. 

RESOURCE

Refer to the Planning and Preparation section (p. 4) in the DoD COVID-19 Practice Management Guide, 14 April 2020, Version 2.0.

Documentation of patient care and movement should continue via the usual platforms (i.e. paper or electronic charts) as previously established at the local treatment facility. The appropriate ICD-10 codes, and symptoms (e.g. fever, cough and shortness of breath), should be entered as detailed as possible in order to capture these patients in Theater Medical Data Store (TMDS) and Medical Situational Awareness in the Theater (MSAT) and future databases and overall future performance improvement opportunities.

JTS has published the ICD-9 and ICD-10 Codes to accompany the new COVID-19 registry under development. The codes can be found on the JTS website. https://jts.amedd.army.mil/assets/docs/education/COVID-19_ICD-9_ICD-10_Codes.pdf

Please ensure that outpatient encounters are closed at the end of the patient encounter (i.e. when the patient departs medical facility). 

All patients, staff, and support personnel with symptoms (fever, cough, shortness of breath) should be tested for COVID-19 using the available confirmatory diagnostic test.

All persons who test positive need to be moved into isolation and prepared for evacuation to OCONUS or CONUS locations as designated for the evacuation plan per that region.

Command and medical teams are responsible for establishing a plan for patient tracking and re-unification (for family notification of patient status) locally.  In accordance with USCENTCOM regulations, local Commanders will including COVID-19 patient tracking as part of their Commander's Critical Information Reporting (CCIR).  Patient tracking for the USCENTCOM AOR will be accomplished using MSAT.   

The Joint Trauma System (JTS) is partnering with the Uniformed Services University of Health Sciences (USU) to develop a registry for COVID-19 patient data acquisition.  Detailed documentation is essential to assist key term triggers for audits.  If using hard copy/paper charting, all documentation should be uploaded as soon as possible.

The registry will ease tracking and monitoring the progress of this disease process, while evaluating the quality and possibility for improvement of delivery of care.  In the meantime, units should designate a person responsible for tracking and monitoring the COVID-19 patient care and patient movement.

JTS and USU host biweekly e-conferences focused on COVID-19 PI.  These conferences are a forum to discuss issues affecting care of these patients.  For information email:  DHA.JBSA.j-3.List.JTS-PIP@mail.mil (JTS PI team).

Intermediate and after action reviews for provide an important source for sharing best practices and innovative ideas to enhance performance improvement:

  1. TF MED 14 COVID-19 Nursing Document (LINK)
  2. COVID-19 Monitoring and Response Among U.S. Air Force Basic Military Trainees ? Texas, March?April 2020, MMWR, 05 June 2020

Transport guidance has changed frequently and is ever changing with current environment.  Check with local G3 to ensure most current guidance is followed.  As of the date of this publication:

  • All symptomatic patients? inpatient or outpatient on a base should be prepped for evacuation. Commander may grant exception to stay in AOR on a case by case basis.
  • Host Nation admitted patients may remain in hospital at commander?s discretion.
  • Navy Afloat remains on ship unless ships capability is in danger of being exceeded (either by volume or the severity of the patient.)
  • Asymptomatic COVID+ should stay but a commander may decide to evacuate.

The U.S. Transportation Command (USTRANSCOM) Instruction 41-02, 11 July 2019 outlines Patient Movement of Contagious and potentially exposed casualties. (Instruction 41-02 is attached.) This playbook is a summary that pertains specifically to COVID-19. Early and close coordination of these movement requests with the appropriate Theater Patient Movement Requirements Center Europe (TPMRC-E) is crucial.

To ensure correct resource allocation and transport prioritization, units should refrain from using locally-derived patient categorization.  Patient classification should remain IAQ AFI 48-307, En Route Care and Aeromedical Evacuation Medical Procedures, 9 January 2017.

Movement of multiple COVID-19 patients will be performed using a DoD certified and approved contagious patient movement system.Planning considerations must take into account downtime for decontamination of aircraft following COVID-19 patient evacuation. Upon consultation and appropriate approvals, capabilities developed outside of the DoD for moving patients exposed to or infected with COVID-19 may be used for approved missions via commercial aircraft. The sending MTF must coordinate movement with TPMRC-E for both intra and inter-theater PM.

Refer to local, CJTF, Component, and USCENTCOM guidance for specific knowledge on Operational Planning assumptions, considerations and guidance located on the USCENTCOM Surgeon (CCSG) SharePoint at:  https://ccsg.nonrel.centcom.smil.mil/Private/SitePages/Home.aspx

There is a need for a standardization of language for documenting and communicating patient condition. The table below presents the best recommendation for that standard language to ensure correct considerations for patient safety in movement.

Categorization Tool for Patient Assessment Documentation

 

COVID-19 is a respiratory virus that requires up to advanced droplet (droplet/airborne) precautions depending on the risk of activity (below).  All re-use and extension of PPE MUST be done in accordance with CDC, JTS, and USCENTCOM best practices and guidance.

RESOURCES:

National Ebola Training and Education Center (NETEC) Personal Protective Equipment (PPE) for COVID-19 video (17:50)

USCENTCOM Infection Prevention and Control Policy in a Deployed Setting (June 2019) pp. 19-23 or service component site such as: https://portal.arcent.swa.army.mil/covid19opt/SitePages/Home.aspx

USCENTCOM Policy for the Decontamination and Reuse of Filtering Face piece Respirators (FFR) Example: N95

USCENTCOM policies align with CDC guidance.  Capabilities are limited in the AOR by the types of equipment available. Follow CDC link for updated guidance:

Employed cleaning protocols should ensure adequate sanitization in all environments, including quarantine/isolation/patient care areas, as well as all workspaces and quarters.  All non-dedicated, non-disposable patient care medical equipment should be cleaned and disinfected according to manufacturer?s instructions and facility policies.

Disinfectants for Use against SARS-CoV-2 (cause of COVID-19)

Doorway Management: Strategic opening and closing of doorways can prevent viral transmission.  Opening high-flow doorways in hallways can reduce the number of high-touch surfaces in a facility, while closing the doors of individual office spaces can reduce cross-contamination of virus across office spaces.  Doorway management approaches MUST consider operational security, facility security, safety, and privacy guidelines.

  • Entrances/Exits: Hand sanitizer dispensers should be placed near entryways.
  • Bathroom Entrances/Exits: Hand washing signs should be clearly posted.  When possible, position trash cans inside bathrooms near the door to allow paper towel use and disposal for no-touch exit. 

RESOURCES:

USCENTCOM Infection Prevention and Control Policy in a Deployed Setting (CCOP-02)

CDC Cleaning and Disinfecting Your Facility

Cleaning and Disinfecting for Households

Isolation areas will need to be established in accordance with best practice and other applicable guidance. Because known sick and infected patients will be localized in this location, placement and establishment of these areas MUST take into consideration the following issues:

  • The protection of both medical facilities (non-COVID infected patients) and general population areas.
  • Ensuring that patients and designated COVID-19 care providers can transition to and from: medical facilities, medical evacuation platforms, and sleeping/hygiene areas without endangering the general population.
  • Safety guidelines (e.g., PPE-required areas) that are clearly marked and well-understood by all (consider language, education, and literacy barriers).

RESOURCE:

DoD COVID-19 Practice Management Guide, 14 April 2020, version 2.0. pp. 11, 48

DoD Management of COVID-19 in Austere Operational Environments, 14 April 2020 version 1.0, pp.5-8

Units will investigate and proactively plan inpatient and outpatient surge capabilities within their existing resources.  Special consideration should be given to preventing cross-infection of the patient population.  A sample checklist to assist with surge capability planning at the role 1, 2, 3 level is at Appendix A.

CSOC are guidelines that are applied when a pervasive or catastrophic disaster makes it impossible to achieve the usual standards of care.

The National Academies Press released an article from the National Academies of Sciences, Engineering and Medicine entitled, Rapid Expert Consultation on Crisis Standards of Care for the COVID-19 Pandemic.  This expert guide assists the provider in establishing a rationale for the implementation of crisis standards of care.  This PDF can be located at the following link: https://www.nap.edu/catalog/25765/rapid-expert-consultation-on-crisis-standards-of-care-for-the-covid-19-pandemic-march-28-2020

Additional assistance in developing and implementing this crisis standards of care can be accessed in the milBook under: https://www.milsuite.mil/book/groups/covid-19-clinical-operations-group

Critical Resource Conservation

There are limited resources for both the treatment and the diagnosis of COVID-19.  Within the framework of responding to a global crisis, there must be evaluation and conservation of critical resources in terms of personnel, supplies and equipment.  This section offers the resources for establishing a protocol for resource management with the focus on conservation.  This is a broad approach and should be tailored to the resources of the facility for which the provider is managing.

RESOURCES:

USCENTCOM Policy for the Decontamination and Reuse of Filtering Facepiece Respirators (FFR) Such as the N95, (CAC required)

CDC Strategies for Decontamination and Reuse  

CDC Strategies to Optimize the Supply of PPE and Equipment

 

The below table published by New England Journal of Medicine is a community standard consensus opinion of values.

  1. Unless temporary, requires state empowerment, clinical guidance, and protection for triage decisions and authorization for alternate care sites/techniques. Once situational awareness achieved, triage decisions should be as systematic and integrated into institutional process, review, and documentation as possible.
  2. Institutions consider impact on the community of resource use (consider ?greatest good? versus individual patient needs?e.g., conserve resources when possible), but patient-centered decision-making is still the focus.
  3. Institutions (and providers) must make triage decisions?balancing the availability of resources to others and the individual patient?s needs?shift to community-centered decision-making
Ethical Considerations

During a local, regional, national and global crisis, many decisions may require ethical considerations. These decisions are best managed in a multidisciplinary/multi-level command structure setting employing a good, better, best approach. Additional resources are listed below.

RESOURCES:

Ethics of Clinical Research during a Pandemic, DoD COVID-19 Practice Management Guideline, 14 April 2020:                

pp. 28-31 for Clinical Trials and Research during Pandemics                

pp. 38-40 for Palliative Care

Scarce Resource Management and Crisis Standards of Care. Overview and Materials

Crisis Standards of Care: A Toolkit for indicators and Triggers; Board on Health Sciences Policy; Institute of Medicine

Medical triage is a familiar concept for all military medical personnel.  The primary goal of saving as many lives as possible remains the same for pandemic disease triage.  However, the operational concepts shift to two main ideas:

  1. Identifying and cohorting infectious or potentially infectious persons as soon as possible.
  2. Identifying infected individuals who are most likely to rapidly deteriorate/require prolonged advanced medical care to prioritize medical evacuation.

RESOURCES:

DoD COVID-19 PMG, Clinical Management of COVID-19, 14 Apr 2020, pp. 4-5, pp. 9-10

COVID-19 Austere Practice Management Guide, 14 April 2020, pp.4-5, 23-24

CDC Information on Contact Tracing and Epidemiologic Interviewing 

Case Example: Patient intake and triage approach used by TF Med 14

The trauma and COVID-19  screening and treatment locations were separated to minimize exposure. A speaker phone was placed outside the hospital entrance for direct access to the Patient Administration Department (PAD) line. Patients answered a series of questions to dictate their course. If COVID-19 was suspected and the patient was stable, they would wait to be assessed in the COVID-19 screening trailer located 50 meters from the hospital entrance. For patients deemed unstable, the evaluation would be conducted within the COVID-19 ICU (C-ICU). Pending the results of the provider’s assessment, the patient would either go into quarantine in the respective base location or get admitted to the COVID-19 portion of the medical footprint. Those that were able to be quarantined were evaluated at various intervals and provided meals by the hospital staff until release criteria was met.

Standard hospital infection prevention and control procedures will be implemented immediately in accordance with practice guidelines and best practice principles. Isolation (aka Transmission-Based Precautions) and Quarantine protocols are ?step above? infection prevention and control measures employed in an epidemic/pandemic situation.

RESOURCES:

Routine Infection Control and Prevention Principles: USCENTCOM Infection Prevention and Control Policy in a Deployed Setting

CDC Infection Prevention Guidelines webpage

Quarantine and Isolation Procedures: Management of COVID-19 in Austere Operational Environments, 14 April 2020, pp. 5-10

Outside of medical setting personnel must practice basic public health and infection prevention guidelines that focus on:

  • Social Distancing
  • Shelter-In-Place Activities
  • Hygiene and General Protection Measures

RESOURCES:

Non-Medical Infection Control, USCENTCOM Infection Prevention and Control Policy, pp. 17-18. CAC required

CDC How to Protect Yourself and Others

CDC Cleaning and Disinfecting Your Facility

CDC Cleaning and Disinfection for Households

Social Distancing

Social Distancing is the practice of maintaining a minimum amount of separation between individuals and all other persons outside of their routine close contacts.  Routine close contacts are those groups that routinely experience a close contact environment.  Examples include roommates in barracks/quarters, family members in the same household, and teams that routinely experience unavoidable close contact in execution of daily duties (e.g., medical staff).  For social distancing consider the following:

  1. Ensure that all personnel can maintain at least 6-ft spacing between themselves at all times.
  2. Ensure the lowest possible number of personnel in duty spaces (as needed to execute mission) and prevent (as much as possible) sharing of work spaces and equipment:
  • Reduce the number of personnel in duty areas by instituting teleworking, day-on/off or week-on/off.
  • Cohort all personnel into specific teams and ONLY persons from that team will work at the same time.
  • Hand-overs will be done remotely or with a limited person(s) from the departing team.
  • Each team cleans and disinfects the space, ESPECIALLY high touch surfaces prior to departing (See Hygiene and General Protection, below).
Shelter-in-Place Restrictions

Shelter-in-Place Restrictions require that all personnel limit their activity to quarters and their designated duty location (ONLY during their scheduled work period).  This mandates NO social gathering or non-essential activities outside of personal areas AND closure of non-essential facilities (e.g., MWR, shoppettes).  Essential activities/facilities include dining facilities (See Food Safety and Food Service section for more information **INSERT LINK**),duty activities (as scheduled), medical care, and personal laundry.

Hygiene and General Protection Measures

Hygiene and General Protection Measures.  All personnel should maintain an elevated awareness of personal hygiene and routine cleaning practices that will prevent the spread of the virus including hand hygiene, routine wear of face coverings outside of personal areas, daily personal hygiene and grooming, cleaning/disinfection of high touch surfaces and common areas.

Outbreak response requires advanced staffing approaches to ensure safety and well-being of staff and patients, while limiting the spread of infectious disease. Facility managers should identify and assign essential personnel as per operational planning.  Plans should identify tiered strategy planning and minimal risk approach.  The tiered staffing strategy for pandemic (below) will be applied and tailored according to local resources and manning.  Exact staffing plans and staffing ratios will depend on personnel, resources, and mission requirements. Additional considerations include:

  1. Designated and/or specialized COVID-19 care team separate from combat operations
  2. Designate runners to ancillary services to reduce donning/doffing activities and protecting PPE supplies
  3. Consider assigning and training non-medical personnel to assist as runners, computer and administrative activities (e.g. transcribing notes for records, scanning/uploading patient files, etc.), and assisting with patient registration/screening (frontline).
  4. Special consideration of work/rest cycles for  prolonged management of potentially overwhelming numbers of critical care patients
Case Example

Case Example: Staffing Approach used by TF MED 14

A tiered approach assisted strategic staff management. Pandemic staffing ratios were used as a guideline, but modified based on tactical patient care/workload.  Permitting unit skill sets, nursing personnel were categorized into COVID19 and Trauma teams. A minimum of two staff members were required on shift regardless of census and a critical care nurse for Rapid Response. 

COVID-ICU

RESOURCE:

Staff, COVID-19 Practice Management Guidelines V2.0, 14 April 2020 pp. 5-8

TF MED 14 COVID-19 Nursing Document (LINK)

Cross-training/Up-training

All healthcare personnel should be up-trained and practice at the top of their licensure. All healthcare personnel should familiarize or review how to conduct certain critical activities (in case of personnel shortages):

  1. Use of critical care medications and ward stock
  2. Daily preventative maintenance checks and services (PMCS) of critical equipment
  3. Oxygen burn rate for patient usage and refill plan

The following are recommended critical care topics for providers to review and drill improve response and success in managing COVID-19 critical patients:

  1. Code Blue management of COVID-19 patient
  2. Rapid Sequence Intubation roles of nursing staff
  3. Ventilator management and ABG interpretation
  4. Titration of critical care medications and side effects
  5. PPE donning and doffing
  6. RRT parameters
  7. Prone of a patient in an austere environment
  8. Working knowledge of critical equipment (POGS, EDOCS)
  9. Unit specific SOPs

Units should conduct practice drills: PPE donning/doffing, patient procedures, transfers, proning, Code Blue, etc.

Leadership should consider cross-training non-medical personnel to assist clinical staff as appropriate and allowable.  Non-medical personnel must perform Just-in-Time Training: DHA US-001 HIPAA and Privacy Act Training. CAC required.

RESOURCES:

Skill Building/Training, DoD COVID-19 Practice Management Guidelines, 14 April 2020. pp. 5-8  

The Elsevier, COVID-19 Health Care Hub provides clinical toolkits, podcasts, expert opinions and many other tools for providers and staff in the COVID-19 response. 

Society of Critical Care Medicine provides free COVID-19 Resources for Non-ICU Clinicians.  Topics include:

  • Recognition and Assessment of the Seriously Ill Patient
  • Critical Care for the Non-ICU Nurse
  • Airway Management
  • Airway Assessment and Management
  • Diagnosis and Management of Acute Respiratory Failure
  • Mechanical Ventilation
  • Prone Positioning
  • Diagnosis and Management of Shock

There are also resources for care of older adults and children. The web-based resources are free but require initial completion of a basic online form. https://www.sccm.org/COVID19

Individual risk assessment and fitness for duty should be determined with the support of serology testing results, if available and updated staff medical records.

  • All healthcare workers should engage in appropriate education, training and policies to comply with infection prevention and control.
  • If possible, perform serologic and other testing for COVID-19 on healthcare workers with common symptoms and who have had likely exposures to COVID-19 patients.
  • Healthcare workers with serological evidence of COVID-19 should have protective antibodies and may return to duty. However, it?s unclear whether subsequent "waves" of COVID-19 may occur and it is still unknown how protective the presence of antibodies on serologic testing may be in preventing repeat infection.
  • Healthcare workers who are ill should not be involved in direct patient care.

RESOURCES:

CDC Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19.   

Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers

Additional Training, Resources, and Tools are listed at Appendix B

All testing recommendations prioritize testing for persons with consistent with COVID-19. There are no DOD or CDC recommendations on screening the general population for asymptomatic infection with COVID-19. Until this becomes available, facilities should follow the guidance of USCENTCOM HQ and local Command and Surgeon teams.

At this time the focus of diagnostic testing for COVID-19 are patients who demonstrate symptoms, (fever, cough, shortness of breath) and those who are at high risk for infection or potential complications (healthcare workers, elderly, or patients with known medical comorbidities, and who are immunocompromised). Please refer to the laboratory section of this document for guidance on performing testing. 

There is no cure or vaccination for COVID-19.  The treatment available now remains supportive care, which includes antipyretics, supplemental oxygen, and potentially mechanical ventilation.  All medications currently used in the treatment of COVID-19 are off-label or are a part of research study protocols.

COVID-19 has manifested primarily as a significant respiratory infection that can rapidly deteriorate into a severe pneumonitis, requiring supplemental oxygen and potentially mechanical ventilation.  The severity seems to primarily affect the elderly population, and those with underlying medical comorbidities.  However, this virus has also affected otherwise young healthy individuals.  Providers must be aware and monitor all patients for potential rapid deterioration and intervene as soon as possible.

The DoD developed the DoD COVID-19 Practice Management Guidelines to assist providers throughout the DoD with comprehensive care for treatment and management of COVID-19.

With the decreased availability of staff and resources in the austere setting, a supplement to the DoD PMG for COVID-19 contains a section for considerations in the austere environment, under the same link immediately above.

Due to the global nature of this pandemic, as well as the infectivity of COVID-19, there are many special considerations when planning to evacuate patients from downrange.  It is recognized that the DOD?s usual protocols and ability to evacuate patients has been severely limited.  Patients may require treatment over a prolonged time (possibly several days) prior to evacuation to a higher echelon of care.  It is a priority for the downrange provider to plan for longer than expected care.  The DoD PMG for COVID-19 and the CPG for austere locations referenced previously, are useful tools.  Additionally, the JTS prolonged field care guidelines, while not specific to COVID-19, are useful for prolonged field care and can be found here:

RESOURCES:

Nursing Care Prolonged Field Care 22 Jul 2018

Documentation Prolonged Field Care 13 Nov 2018 

Discharge

Discharging a patient from Transmission-Based Precautions (AKA Isolation) has been based on either testing strategies or time based.  Patients can move through the various levels of care (mild outpatient self care, moderate ward level care and severe ICU level care) but must remain in isolation and follow transmission-based precautions (TBP) during this entire time.  A patient can be discharged from TBP once their symptoms improve AND their fever resolves AND they have two negative PCR tests which are 24hrs apart (test based strategy).  Alternatively, a time based strategy may be used which requires patients to have recovered (fever free off antipyretics AND improvement in symptoms) for 72 hours and at least 10 days have elapsed since symptoms first started.  Below is a diagram of several time based scenarios.

Listed below are emergency telehealth resources which forward-stationed medical teams/medics can use for assistance or clarification on any topics or concerns:

VITAL-T Program

Virtual Inspection and LINKUP in Theater (VITAL-T) provide ?real time? virtual access to Quality and Safety (QS) expertise through Virtual Health (VH) capabilities for Infection Prevention and Control (IPC), Patient Safety (PS), and Medication Safety (MS).

Submit a Vital-T Consult in 2 Easy Steps

  1. Contact us for questions or to arrange a Virtual Consult or Service with the appropriate QS expert
  2. Email: usarmy.jbsa.medcom.list.medcom-vitalt@mail.mil or 24-hour VITAL-T hotline: 210-307-0923

During the COVID-19 crisis, consult services could be conducted using any of the following approved means (the optimal means for connection will be individualized):

  1. Google Duo
  2. Skype
  3. FaceTime
  4. Adobe Connect

AD.VI.SOR

AD.VI.SOR Advanced Virtual Support for OpeRational Forces program is specifically designed for operational virtual health support. Phone: 833-238-7756; Email: dod.advisor_office@mail.mil

Additionally, many Virtual Critical Care Consultation (VC3) service providers have deployed to austere settings before and can help work through the unique problems faced in austere settings

DHA Infection Prevention and Control Tiger Team

The DHA Tiger Team is an alternative source for infection prevention and control reach-back, which is overwhelmed in the current situation. The team will review received questions on a daily basis and work to develop a response within 1-2 business days. dha.ncr.clinic-support.list.ipc-group@mail.mil

Local USCENTCOM ADVISORS for Urgent Needs

379 EMDG SGH:  DSN 318-455-5042 or cell 011-974-5080-3442

379 EMDG Help Line (answered 24/7):  DSN 318-455-1000

455 EMDG:  DSN 318-481-4664

KAF:  DSN 318-421-6339,  Intensivist: CDR Carl Riddick via WhatsApp at 503-539-7167

CRNA:  CDR Diane Howell via WhatsApp at 631-402-3060

Kabul:  DSN 318-449-9259

BDSC:  DSN 318-239-2033,  Intensivist: LTC Sally Delvecchio

USMH-K:  318.430.2508

USCENTCOM Preventive Medicine Physicians: Col(s) Vinh Tran, DSN 312-529-0348;                          MAJ(P) Fred Hauser, DSN 312-529-0361

USCENTCOM Pharmacist: MAJ Franklin Small, DSN: 318-480-5094/SVOIP: 308-430-6834

PHEO: MAJ Brandon Aden, DSN is 318-480-6087; SOVIP is 308-430-8507

As a final alternative, the following MEDCENs below may be contacted (ask for the on-call critical care staff)

**Note: MEDCENS may be intensively involved in COVID-19 response locally. Personnel should exhaust all local, regional, and USCENTCOM reach back and all dedicated Telehealth resources PRIOR to calling MEDCENs.

 

Landstuhl Regional Medical Center, Germany. DSN: 314-590-7141 Intensive Care Unit

Walter Reed National Military Medical Center, MD. (301) 295-4611, option 4 Command Duty (301) 295-4810 Emergency Room

Madigan Army Medical Center, Fort Lewis, WA (DSN 782) (253) 968-1110 Information Desk

Brooke Army Medical Center, Fort Sam Houston, TX (DSN 429) (210) 916-0808 Emergency Room

Naval Medical Center Portsmouth, NS Norfolk, VA (DSN 377) (757) 592-5473 Critical Care (757) 953-1365 Emergency Room

Eisenhower Army Medical Center, Fort Gordon, GA (DSN 773) (706) 787-6938/6019 AOD (706) 787-6039 Emergency Room

David Grant Medical Center, Travis Air Force Base, CA (DSN 799) (707) 423-3040 ICU or (707) 423-3825 Emergency Room

Tripler Army Medical Center, HI (DSN 433) (808) 433-6661 Information Desk (808) 433-4032 ICU or (808) 433-3707 Emergency Room

William Beaumont Army Medical Center, Fort Bliss, TX (915)892-6880 House Supervisor or (915) 742-2139 ICU

Keesler Medical Center, Keesler AFB, MS (DSN 591) (228) 376-0500 Emergency Room

Leaders must consider the behavioral health and mental/physical resiliency of health providers and staff responding to an outbreak, as well as that of COVID-19 patients and the general population, who are experiencing major life-style changes and isolation.  A number of tools and resources have been provided for leaders to respond to behavioral health concerns and improve resiliency.  Forward stationed medics/medical teams are encouraged to reach back locally to Role 2/Role 3 facilities, where behavioral health resources may be stationed, utilize chaplain services, and telehealth resources to connect persons in need with help.

Special considerations for behavioral health during the COVID-19 pandemic include:

  1. Prolonged isolation of COVID-19 designated staff and patients isolation
  2. Disruption of non-duty activities and resiliency behaviors (e.g. physical activity, rest/relaxation)
  3. Risk for minimal work/rest cycles due to potentially overwhelming numbers
  4. Moral stressors of triaging patients to receive care in pandemic environment
  5. Fear response for novel or unfamiliar risks/threats

 

RESOURCES:

Mental Health and Wellness in COVID-19 Clinical Management (patients, providers) - COVID-19 Practice Management Guide 14 Apr 2020- pp. 49-50

Resiliency/Well-Being ? Stress and Coping, CDC Mental Health and Resiliency during COVID-19

Leadership checklist to mitigate team stress is located at Appendix C.

Leadership checklist to promote team sleep is at Appendix D.

Navy Leader?s Guide for Managing Sailors in Distress ?The purpose is to help Leaders recognize distress related behaviors, provide support to Sailors within the unit, and collaborate with Navy helping agencies to meet the needs of distressed individuals.

The DoD and VA offer the below mobile apps for mental health guidance.  

Provider Resilience: Through psychoeducation and self-assessments, Provider Resilience gives frontline providers tools to keep themselves productive and emotionally healthy as they help our nation?s service members, veterans, and their families. Apple version. Android version.

Psychological First Aid (PFA): PFA Mobile was designed to assist responders who provide psychological first aid (PFA) to adults, families, and children. Apple version. Android version.

Other apps can be viewed by downloading the below brochure at https://health.mil/Reference-Center/Publications/2019/08/28/DoD-and-VA-Mobile-App-Clinicians-Guide.  Brochure does not provide links to the apps.

All U.S Military Service Members and U.S. Civilian personnel who die in an Operational Environment are under the medico-legal jurisdiction of Armed Forces Medical Examiner System (AFMES) in accordance with Title 10 U.S. Code 1471.  If a death occurs, immediately notify AFMES at (202) 409-6811.  All medical intervention should remain in place.  Contact mortuary affairs for further guidance on the handling of the decedent.  Secure clothing, personal protective gear, and medical/treatment records.  These should accompany the decedent to mortuary affairs.

RESOURCE:

Safety and Health Guidance for Mortuary Affairs Operations: Infectious Materials Technical Guide 195A, November 2015.

Ancillary service personnel will practice previously described infection prevention and COVID-19 medical management control measures.

Goals are to reduce the impact of exposure risks and preserve access to medications. Pharmacists will support ongoing clinical evaluation studies and treatment protocols for emerging therapeutics.

RESOURCE:

DHA COVID-19 Response CONOPS. See CONOPS attachment.

Once providers deem a diagnostic study necessary, take measures to minimize risk of cross contamination of equipment and environment.  Equipment (including wheels) and X-ray cassettes shall be wiped down prior to entering and exiting patient care areas.  Use disposable X-ray cassette protective sleeves or other type of similar barrier material for portable chest X-ray capability and equipment.  Portable machines should be positioned so as to prevent contact with the patient whenever possible.

Frequently Asked Questions about Biosafety and COVID-19Appropriate PPE and infection control/prevention procedures to prevent blood borne pathogen and aerosol exposure will be employed.  Patient screening may include nasopharyngeal swab specimens (most common) or tracheal aspirates from intubated patients.

Testing capability may include: I-STAT ABG or VBG, Rapid Flu test, Rapid Dengue test, respiratory pathogen film array (BioFire), and COVID-19 polymerase chain reaction (PCR) test.

RESOURCES:

Nasopharyngeal swab technique training video (7:19)

Management of COVID-19 in Austere Operational Environments, 14 Apr 2020, pages 6, 7  

DoD COVID-19 PMG, 14 Apr 2020, p 11, 12

Frequently Asked Questions about Biosafety and COVID-19

Employed cleaning protocols should ensure adequate sanitization in all environments, including quarantine/isolation/patient care areas, as well as all workspaces and quarters.  All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer?s instructions and facility policies.

  • Routine Cleaning and Disinfection Procedures: Use cleaners and water to pre-clean surfaces prior to applying an EPA-registered (Environmental Protection Agency), hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product?s label.
  • High Touch Surfaces: In addition to standard environmental cleaning, employ routine cleaning of high-touch surfaces: tables, chair arm rests, doorknobs, light switches, countertops, handles, desks, phones, keyboards, mouse devices, toilets, faucets, sinks, etc.
  • Bathroom Entrances/Exits: When possible, position trash cans inside bathrooms near the door to allow no-touch exit. Hand washing signs should be placed in entryways.

RESOURCES:

List of Disinfectants for Use Against SARS-CoV-2

Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Healthcare Settings, 10. Implement Environmental Infection Control

Force Health Protection

Force Health Protection (FHP) assets ? including public health, preventive medicine, and veterinary services ? are important stakeholders and subject matter experts on issues of infectious disease control (including zoonotic disease), sanitation, food protection and safety, and water systems protection & safety. Veterinary Services (VS) are additionally important subject matter experts in animal medicine and husbandry, human-animal bond, and agricultural systems. Where available, FHP personnel should be consulted regarding these issues but there are several forums and toolkits available for FHP- and VS-related issues. This information in this section is provided to supplement (but does not supersede) the USCENTCOM/ARCENT and TRANSCOM policy and guidance. Any operational issues or challenges regarding FHP or the movement and care of authorized animals and animal-care personnel should be resolved through local, ARCENT, and USCENTCOM Command leadership.

_________________________________

RESOURCES:

DOD Veterinary Services COVID-19 Resource Page (https://www.milsuite.mil/book/community/spaces/armyveterinaryservices/one-health/emergent-health-events) ? Provides white papers, external links, situation reports (SITREPS) and other operational guidance related to food safety and protection, Force Health Protection (FHP), and animal medicine/animal health during the COVID-19 pandemic.

CDC COVID-19 and Animals (https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/animals.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fprepare%2Fanimals.html)

American Veterinary Medical Association (AVMA) COVID-19 webpage (https://www.avma.org/resources-tools/animal-health-and-welfare/covid-19)

__________________________________

 

Field Sanitation and Isolation. In many cases, isolation facilities will need to be rapidly established that may require alternative waste and hygiene approaches to protect the uninfected general population (e.g. alternative showering facilities, pit latrines, bed cans). FHP assets should be consulted to ensure best possible practices are being implemented and that all safety and handling precautions are implemented.

 

Food Safety and Food Service during the COVID-19 pandemic. There is still no evidence for concern that food and food packaging serves any role in transmission of COVID-19. Protection in dining facilities will focus on protection against direct human to human transmission and should include the following considerations.

  • A la carte dining options (e.g. deli and sandwich stations, omelet stations, etc.) should be suspended during the pandemic.
  • Fresh fruits and vegetables and deserts should not be presented in a salad bar format. These foods should be cleanly prepared and packaged in covered food containers.
  • Meal lines and dining areas should consider social distancing. Seating should be placed in appropriate distances and/or limitations on capacity should be implemented. Consider outdoor dining options and take out approaches.
  • Consider implementing servers instead of self service approaches or pre-plating or packaging meals to reduce contact during the serving process.

More information can be found on the DoD Veterinary Services COVID-19 Resource Page & .

Regarding the potential of COVID-19 to transmit between animals and humans (zoonotic potential). The COVID-19 virus is known to have zoonotic origins; believed to originate at a live animal and wet market in Wuhan, China. It appears that in rare situations, persons who are ill will the COVID-19 virus can spread the virus to their animal companions. The virus has been detected in felids (wild and domestic cats), canids (domestic dogs), and mustelids (ferrets and similar). It is unlikely that this virus will cause disease in healthy domestic animals and there is NO EVIDENCE to suggest that domestic animals serve any significant role in transmission of the virus to humans. Human-human transmission remains the primary source of transmission. However, given the possibility for zoonotic transmission of the COVID-19 virus, the following recommendations should be implemented:

  • Commanders should strictly enforce USCENTCOM General Order (GO) 1C (paragraph 2.g) that prohibits the adoption of unauthorized pets or mascots of any kind on DoD installations. Exceptions to this policy include authorized government owned animals (GOAs), including military working dogs (MWDs) and DoD Contracted Working Dogs, and installations where personnel live off-base and are authorized privately owned animals (POAs).
  • It is not recommended to routinely test animals for COVID-19 using BioFire or any other testing platform. The CDC provides guidance on testing animals for COVID-19. The CCSG team and ARCENT Command Veterinarian should be consulted PRIOR to any testing of animal patients for COVID-19.

---------------------------------

RESOURCES:

CDC Evaluation for SARS CoV-2 Testing in Animals https://www.cdc.gov/coronavirus/2019-ncov/php/animal-testing.html

DOD Veterinary Services COVID-19 Resource Page (https://www.milsuite.mil/book/community/spaces/armyveterinaryservices/one-health/emergent-health-events)

---------------------------------- 

Continuation of Veterinary Care. GOAs and authorized POAs should continue to receive veterinary medical care IAW DoD and contract specific guidelines at local VS locations (veterinary treatment facility or similar). Any currently understood possibility of zoonotic transmission DOES NOT exceed the harm caused by not ensuring care for these animals. Elective procedures and veterinary medical care activities should be cancelled for the duration, but standards of care for public health and readiness should be maintained IAW applicable policy, health certificate, and best practice guidelines (e.g. vaccination, emergency care, etc.).

Considerations for animal care personnel. VS personnel should routinely implement and train local non-VS animal care personnel in the principles and standards of infection control outlined in the NASPHV Compendium of Measures to Prevent Disease Associated with Animals in Public Settings and applicable infection control policy and best practices. Elective veterinary visits and procedures should be cancelled through the pandemic. Animal care personnel should remain aware of current shortages and high demand of PPE for their human medical counterparts and practice prudent PPE implementation when treating animals, conducting laboratory procedures, and routine husbandry practices during the COVID-19 pandemic. The  CDC makes recommendation on their website for PPE use when caring for animals . Working dog handlers that require isolation or quarantine should NOT conduct daily care for their dog. The Kennel Master, trainer, or other handlers should provide routine care for that dog until the assigned handler can return to duty.

RESOURCES: 

NASPHV Compendium of Measures to Prevent Disease Associated with Animals in Public Settings http://www.nasphv.org/Documents/AnimalContactCompendium2017.pdf

Interim Infection Prevention and Control Guidance for Veterinary Clinics Treating Companion Animals During the COVID-19 Response https://www.cdc.gov/coronavirus/2019-ncov/community/veterinarians.html

CDC Interim Guidance for Public Health Professionals Managing People With COVID-19 in Home Care and Isolation Who Have Pets or Other Animals https://www.cdc.gov/coronavirus/2019-ncov/php/interim-guidance-managing-people-in-home-care-and-isolation-who-have-pets.html

AVMA Interim recommendations for intake of companion animals from households where humans with COVID-19 are present https://www.avma.org/resources-tools/animal-health-and-welfare/covid-19/interim-recommendations-intake-companion-animals-households-humans-COVID-19-are-present

All disposable and non-durable medical supplies (including PPE) stock will be distributed and stocked IAW with pre-planning and role/location specific guidance.

Employ cleaning protocols to ensure adequate sanitization in all environments, including quarantine/isolation/patient care areas, workspaces and quarters.  All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to existing location and USCENTCOCM specific infection control policies, manufacturer guidelines, and best practice solutions.

The USCENTCOM Command Surgeon (CCSG) team is the main point of contact for this document at (813)-529-0345/0361/0362 (COMM/DSN) or centcom.macdill.centcom-hq.mbx.ccsg-clinops@mail.mil

The following resources are available for rapid access and review in preparing for or responding to COVID-19 patients locally:

  1. Current COVID-19 Resources: Policy, Military-specific, Clinical, etc. will be posted in the DoD COVID-19 Clinical Operations Group site https://www.milsuite.mil/book/groups/covid-19-clinical-operations-group
  2. DoD Instruction for Public Health Emergency Management (PHEM) within the DoD. DoD6200.03 (28 March 2019) https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/620003p.pdf
  3. Joint Trauma System (JTS) Clinical Practice Guidelines (CPGs) (https://jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs)
  4. The Elsevier, COVID-19 Health Care Hub provides clinical toolkits, podcasts, expert opinions and many other tools for providers and staff in the COVID-19 response.
  5. The Elsevier Engineering resources for the COVID-19 response https://www.elsevier.com/connect/engineering-resources-for-the-covid-19-response
  6. Infection Prevention and Control Policy in a Deployed Setting and USCENTCOM Surgeon (CCSG) Clinical Operations SharePoint site (CAC Required) (https://inteshare.inteling.gov/sites/ccsg/SitePages/CCSG-CLINOPS.aspx)
  7. The COVID-19 Clinical Operations Group has prepared a the following MilSuite group page (CAC Required) https://www.milsuite.mil/book/groups/covid-19-clinical-operations-group
  8. The US DoD Coronavirus Rumor Control should be used to clarify points of confusion and prevent decision making based on misinformation (https://www.defense.gov/Explore/Spotlight/Coronavirus/Rumor-Control/fbclid/I/)
  9. The Centers for Disease Control and Prevention, COVID-19 webpage (https://www.cdc.gov/coronavirus/2019-ncov/index.html)
  10. National Institute of Health, COVID19 webpage https://covid19treatmentguidelines.nih.gov , site updated 21 April 2020.

DOWNLOAD CENTCOM COVID-19 Playbook for Operational Environments Version 2

Download 10 JUN 2020 version of CENTCOM COVID-19 Playbook for Operational Environments

READ FULL PDF