AMPATH Kenya COVID-19-Related Travel, Preparation and Procedures

Subject: AMPATH Kenya COVID-19-Related Travel, Preparation and Procedures

OverviewThe purpose of this document is to provide individuals considering a visit to the AMPATH Kenya site with the information needed to assess the current safety and feasibility of traveling to Kenya; prepare for their visit; and understand the procedures in place related to COVID-19 exposure, care and testing.

AudienceAny visitor to the AMPATH Kenya site, regardless of whether they plan to stay at IU House during their visit.

Background/Deciding to Travel●     Resources to manage COVID infections are very limited in Kenya. Critical care beds are extremely limited. There is no guarantee of being able to get admitted to the best hospitals in case of severe illness.

●     Strikes by medical professionals are not unusual and greatly affect the ability to access care.

●     3M N95 masks are not available in Kenya. The hospital supply of KN95 masks, face shields, gowns, etc. is limited. 3-ply masks and KN95 masks are available for purchase but the quality of all masks bought in Kenya is less certain.

●     All visitors are required to comply with all local laws, including a nighttime curfew and mask wearing when applicable. See the U.S. Embassy in Kenya website for further details. The latest Kenyan MOH guidelines can be found here.

●     COVID vaccination:

○     All travelers to Kenya over 12 years of age will be, at all ports of entry, required to show proof of either COVID-19 vaccination or a negative COVID-19 PCR test conducted no more than 72 hours before departure.

○     U.S. government requires that any non-immigrant, non-citizen be fully vaccinated against COVID-19 and provide proof of vaccination before boarding a flight to the United States. There are exemptions to this rule if traveling from a country with low vaccine rates, so please check the updated requirements.

●     Masks:

○     In public areas: Masks are no longer required in public outdoor spaces per national Kenya MOH recommendations, but are still encouraged in indoor public spaces.

○     In the hospital/clinical areas: It is required by hospital policy that surgical masks be worn at all times. If you are providing clinical care to patients with suspected TB or COVID-19 we recommend wearing an N95 mask.

○     At IU house: Mask wearing and social distancing will be dependent on the overall COVID risk as determined by the Executive Field Director based on case rates and Kenyan guidelines. Given visitors arriving/departing from countries that may have variable COVID-19 rates and exposure to patients on the wards, recommendations at IU house may be more conservative than current Kenyan or US recommendations.

●        Trips while in Kenya (applies to trainees only):

○     Trips outside of Eldoret for tourism, visiting friends and family, etc. are permitted. However, all trips must be approved by the appropriate supervising long-term faculty member prior to making travel arrangements.

○     All Trainees should keep in mind that the ability to travel may change depending on COVID-19 trends and government directives.

●        Costs: If your travel plans must change for any reason including isolation, quarantine, or worsening pandemic situation you will be charged at the same daily rate and AMPATH will not reimburse any additional fees incurred due to flight changes, extra meals, etc.

●        Your ability to remain in Kenya is at the discretion of our Kenyan hosts and AMPATH leadership. You may be asked to leave at any time if the risks due to COVID are deemed too great.

Preparation for Travel to Kenya

●        All travelers from IU:

○     See the IU Global Mobility Updates page for the latest guidance on university approval for travel. IUSM residents must also obtain GME approval. Contact Victoria Eder (vneder@iu.edu) for questions.

●     All visitors:

○        See the AMPATH Kenya Logistics Manual for information on obtaining an e-visa and completing the AMPATH Visitor Information Form at least 2 months prior to travel.

○        It is recommended that you bring at least one COVID rapid test.

○        If you have risk factors for severe disease from COVID-19, consider obtaining a course of Paxlovid prior to departure, as it is not readily available in Kenya. Molnupiravir is sometimes available in Kenya. You can discuss this with your primary care physician as part of travel planning.

●     Prior to purchasing plane tickets:

○        Consider current Kenyan COVID-19 directives. There currently is no COVID nighttime curfew, but this could change; make travel plans accordingly and check the US Embassy in Kenya website for any COVID-19 updates prior to booking travel and again just before departure

○        Verify the COVID testing requirements for each country through which you travel en route to Kenya. Some layover countries require rapid COVID antigen tests in addition to the PCR test needed for entry into Kenya. You should verify what is required for your specific itinerary when booking your flights and are strongly encouraged to check these requirements regularly as they may change without advance notice.

●     Medical and Evacuation Insurance:

○        All individuals traveling should research their health insurance coverage policies outside the US and keep this information with them while traveling. Keep in mind that most insurance companies require individuals to pay the cost of hospitalization care outside of the US out of pocket and then fill out paperwork for reimbursement later.

○        All short-term visitors and long-term faculty traveling to Kenya during the COVID pandemic are required to purchase the AMREF Flying Doctors “Bronze” insurance for $25/year to cover emergency COVID transportation services not covered by evacuation insurance. The plan can be purchased by following instructions on the AMREF website here.

●     Entry Requirements:

○        All travelers to Kenya over 12 years of age will be, at all ports of entry, required to show proof of either COVID-19 vaccination or a negative COVID-19 PCR test conducted no more than 72 hours before departure.

■     Vaccinated travelers are not required to take a PCR test before traveling to Kenya, but we strongly recommend pre-travel testing prior to travel for public health reasons.

○        All visitors must upload their vaccination certificate (or PCR test results, if applicable) to Global Haven prior to boarding.

■     If you have previously created a PanaBios/Trusted Traveler account to upload test results, you should be able to log into Global Haven with the same login information.

●     PPE:

■     We recommend that all visitors carry a physical copy of their certificate of vaccination in case of technical difficulties.

○     If you are doing clinical work, it is required that you bring your own supply of PPE.

■     Bring N95 masks, a supply of single-use “surgical” 3-ply masks, and reusable eye protection.

■     Disposable gloves are generally available on the wards, but you may want to bring your own.

■     Hand sanitizer is available for purchase, but it is also a good idea to bring your own supply.

○     Moi Teaching and Referral Hospital requires scrubs to be worn in all clinical areas. Bring your own supply (any color is fine).

After-Travel Logistics in Kenya 

●     As of June 12, the US government no longer requires individuals to complete a PCR test prior to travel to the US. Please check the latest Kenya exit requirements and entry requirements for your next destination prior to departing from Eldoret.

●     If testing is required for required for travel or any other reason:

○        The Kenyan government requires that all COVID-19 PCR tests for travelers be performed at select laboratories across the country that are affiliated with the Trusted Traveler/Panabios system. These labs generate a code that you must present prior to entering the JKIA-Nairobi airport. They also send you a test result document via email, which you can present at the airline check-in desk.

○        Travelers are required to cover all expenses related to departure COVID testing.

○        COVID tests must be obtained from Trusted Traveler (TT) certified labs. Our preferred TT certified testing center is the AMPATH Reference Lab, which conducts rapid COVID-19 PCRs.

■     Turnaround time for results is currently less than three hours when the Gene Expert machine is used. This may increase to 24 hours in the future so check with lab staff when making the arrangement.

■     Cost is 5,000 KES (~$40) and tests can be obtained during the week (lab is open 9AM -5PM). Arrangements can be made for weekend tests by calling Millicent at 0721-780010

■     The test result will be emailed to you with a Trusted Traveler (TT) code included. If you have a Kenyan cell phone number, the code can also be sent to you via text message.

Definitions 

Close contact: According to the WHO and CDC COVID quarantine guidance, a close contact is a person in any of the following situations from 2 days before and up to 14 days after the onset of symptoms in the confirmed or probable case of COVID-19:

○        face-to-face contact with a probable or confirmed case of COVID-19 within 1 meter and for more than 15 minutes cumulatively over 24 hours regardless of mask use

○        direct physical contact with a probable or confirmed case of COVID-19

○        direct care for an individual with probable or confirmed COVID-19 without using proper personal protective equipment

○        other situations, as indicated by local risk assessments.

Quarantine: Separation of an asymptomatic, exposed person from the rest of the community. At IU House, this means:

●     The person must be either in their own room/apartment or outside. If they go outside, they must be 6 feet from others at all times and must wear a mask even when outside.

●     The person will not be allowed to travel off IU House compound except for clinical duties and should not use taxis for transportation.

Isolation: Separation of an INFECTED person (regardless of severity of symptoms, even if asymptomatic) from the rest of the community. At IU House, this means:

●     The person may not leave the assigned room or apartment.

Asymptomatic Persons with Close-contact COVID ExposureAll based on the CDC guidelines, adapted for IU House and clinical personnel

FULLY VACCINATED PERSONS:

●     These guidelines are true regardless of if the contact was in the hospital setting, was a household contact:

○     Do not need to quarantine, but recommend strict masking and avoiding indoor dining with others for 5-7 days after exposure and until post-exposure test is negative. Use increased masking and precautions with vigilance in monitoring for symptoms for a duration of 10 days after exposure

○     Get tested 5-7 days after exposure, even if asymptomatic

○     May continue to work in clinical settings with appropriate PPE.

UNVACCINATED PERSONS

●     Any unvaccinated individual who is identified as having a high-risk COVID exposure will be required to quarantine in a designated quarantine room/apartment at IU House for 14 days.

●     The exposed individual will be required to self-monitor for symptoms and check temperature twice a day. They are required to report to the Medicine Team Leader or designated alternate physician if they develop fever or any symptoms consistent with COVID-19.

●     If the exposed individual develops any symptoms, COVID testing and care will be provided via the “IUH COVID Care” protocol below.

●     The exposed individual will be required to stay in quarantine for the length of time required by CDC guidelines. Meals and other essential items will be provided to the individual in quarantine as described in COVID Care protocols below.

Symptomatic or Confirmed Positive Persons: COVID Care Protocol for IU House●     If an individual has symptoms consistent with COVID, the individual will immediately be requested to move to the designated COVID isolation area or remain in their private room at all times.

●     The Medicine TL or other designated physician will arrange for a COVID test to be collected at IU House or at a testing facility as soon as possible.

○        Individuals will be responsible for covering the cost of their COVID test.

●     While waiting for the results of their COVID test, the individual will be required to remain in isolation.

○        If a rapid COVID test is obtained and the result is NEGATIVE, the individual will not

need to remain in isolation, but must follow stricter precautions until the PCR results are obtained. They must remain at IU House, wear a surgical mask at all times, and maintain 6 feet of distance from others. If the reflex PCR result is POSITIVE, then the individual will be isolated in the designated isolation area. If NEGATIVE, then the individual can resume normal activities.

■     If no follow-up test is completed, the individual must adhere to a minimum of five days of strict masking.

○        If a COVID PCR test is obtained and the result is NEGATIVE but symptoms are still highly suspicious of COVID, the Medicine TL or designated physician may require that the individual remain in isolation while a repeat COVID test is conducted.

●     The Medicine TL (or alternate physician designated by the Medicine TL) will provide daily home-based care and the infected individual will remain in isolation for 5 days (and until afebrile for at least 24 hour without use of antipyretic medications and improvement of respiratory symptoms), after which the infected person must adhere to masking at all times when not alone for an additional 5 days after positive COVID diagnostic test (based on CDC and Kenya MOH guidelines 3/11/2022). The infected individual must eat/drink at least 6 feet from others for the 5 days after their isolation time (days 5-10).

○        A stock of PPE will be kept in reserve at IUH for use by the Medicine TL, including N95 mask, gown, and gloves.

○        Monitoring will include a minimum of once daily recording oxygen saturation, temperature, and blood pressure.

○        The COVID patient will be requested to also check and document their own oxygen saturation using a finger probe at least 4 times daily, and blood pressure using an automatic cuff twice daily.

○        An oxygen concentrator will be kept at IU House in case hypoxia develops. The machine was checked for functionality on 4/13/2022 and confirmed to be able to provide 4L/min of oxygen.

○        If the COVID-positive individual requires oxygen supplementation (or has other need for hospitalization) the COVID hospitalization plan will be initiated, detailed below.

○        Oral dexamethasone will be kept in stock at IUH in case an individual develops hypoxia or severe disease.

●     Meals and/or essential supplies will be delivered to the isolation house, coordinated by an IUH administrator or designee and IUH kitchen staff. All prepared meals will be delivered outside the house on disposable plates. Standard IUH fees will be charged for all meals, or according to the standard fees for the individual’s room and board.

●     IUH staff will use cleaning protocols consistent with the Kenya MOH COVID home-based care guidelines after the infected individual has been released from isolation. (Appendix 1)

●     Anyone staying at IU House affected by COVID will not be allowed to travel during their isolation period.

Hospitalization/Medical Evacuation Protocol for COVID-positive Individuals●     If any COVID-positive individual receiving home-based care at IU House develops an oxygen requirement, or any other signs of severe disease, arrangements will be made to transfer them via ambulance or AMREF Flying Doctors Service for inpatient care at Aga Khan Hospital in Nairobi.

○        Communication about medical emergencies will follow the AMPATH Emergency protocols. The acting Field Director will oversee the emergency procedures and communicate with the Director of the IU Center for Global Health, who would then liaise with the other North American institutional leads as appropriate. Please refer to two supplemental documents titled AMPATH Kenya Emergency Protocol and AMPATH Emergency Contact Information for further details.

●     If a COVID-positive individual at IUH develops hypoxia or severe disease, they may be started on oral dexamethasone at the discretion of the Medicine TL/ treating physician while plans for a higher level of care are being coordinated. Dexamethasone will be kept in stock at IUH.

●     Aga Khan Hospital is the preferred hospital for COVID care for AMPATH visitors.

○        Hospital admission can be arranged with the assistance of our Aga Khan liaison Dr Wangari Siika, Anesthesiology, +254 708 612258

○        Aga Khan requires a payment of 1 million KSH/ $10,000 US dollars prior to accepting a patient. IUCGH has made emergency funds available for IU faculty/trainees that are available to expedite an emergency hospital admission. The individual being hospitalized is responsible for reimbursing IUCGH for any funds loaned as a payment to Aga Khan.

○        John Oguda, Managing Director of IIGH Kenya, will be responsible for approving use of these emergency funds and arranging transfer of funds to Aga Khan for admission.

○        In the event that Aga Khan hospital does not have capacity, the next preferred hospital is Nairobi Hospital in Nairobi. Other hospitals in Eldoret that provide COVID care but have limited data available on quality include Oak Tree, St Luke’s, Top Hill, Fountain, Mediheal, Eldoret Hospital, and MTRH.

●        Transportation to Nairobi will be arranged via AMREF flying doctors service by either ambulance or flight depending on evaluation of need by AMREF.

●        After admission to the hospital, Assist America (or provider of individual’s evacuation

coverage) will be contacted by the patient, or if incapacitated, by the Medicine TL to request evaluation of further need for higher level of care outside of Nairobi.

●        Per the Assist America website, evacuation services must be arranged by Assist America. No claims for reimbursement will be accepted. Assist America must make the arrangements for the services it provides and pays for. The decision for evacuation is determined by Assist America’s Consulting Physicians and Transport Director, together with the participant’s attending physician. In general, Assist America will not provide evacuation outside of Kenya unless it is deemed medically necessary. In cases where evacuation is determined to be merited, the location of evacuation will be determined by Assist America, but most often would be South Africa or Europe.

Important Contact Information●        Aga Khan Hospital liaison: Dr Wangari Siika, Anesthesiology, +254 708 612258

●        IIGH Managing Director: John Oguda, +254 721 821530

●        Executive Field Director, AMPATH Consortium: Dr. Bill Stauffer: +254 700646900, WhatsApp: +1 612-616-8707

●        AMREF Emergency Evacuation phone number: +254 20 699 2299

●        Assist America (IU faculty, resident and staff evacuation coverage):

○     Recommended to download the Assist America App from the Apple Store

○     Enter IU reference number 01-AA-STD-5201 and member name

○     Call 1-800-872-1414 within the U.S. or Call 1-609-986-1234 outside the U.S.

○     Email medservices@assistamerica.com

○     Please note that Assist America will not provide services if the participant is pregnant and beyond the end of the 28th week.

●     Academic Emergency Services (IUSM student evacuation coverage)

○        Group ID: GHS9999AHPCO MEMBERSHIP TYPE Global Medical and Travel Assistance Services

○        Contact from the U.S. or Canada: (855) 873-3555; outside the U.S. or Canada, dial the country access code followed by: 1 (610) 263-4660

○        hps://www.a.com/support_media/images/pdf/Country_Code_List.pdf.

○        If there is no access code, proceed with calling direct to: 1 (610) 263-4660 TOLL FREE 1(855) 873-3555 OUTSIDE THE US 1(610) 263-4660 EMAIL

assistance@ahpcare.com

APPENDIX 1: COVID-19 Room Cleaning Guidelines for IUH Staff 

These guidelines are for safe cleaning of surfaces/spaces after occupied by someone with COVID-19 infection. The risk of COVID-19 transmission via surfaces is extremely low, but out of an abundance of caution consider waiting 72 hours after the infected person has left the room prior to cleaning when possible. If more than 3 days have passed since the person who is sick

or diagnosed with COVID-19 has been in the space, no additional cleaning (beyond regular cleaning practices) is needed. If less than 3 days has passed since the person has occupied the space, use the following precautions:

●     Wear PPE including gloves, mask, gown, when cleaning the room. This is available for use from the IUH office.

●     Open windows and doors in area being cleaned if possible, to maximize ventilation.

●     Use a 0.5% chlorine bleach (sodium hypochlorite) solution to disinfect any utensils, dishes, and then clean with regular soap and water.

●     Use regular household soap/detergent to clean toilets and surfaces, then disinfect with a 0.5% sodium hypochlorite (bleach) solution.

●     Wipe all surfaces including doorknobs, tabletops, and faucets with bleach solution.

●     After cleaning is completed, dispose of gloves and mask in the waste bin marked “COVID-19.” Perform hand hygiene after removing PPE.

●     Hand hygiene consists of washing with soap and water, scrubbing for at least 20 seconds, or using an alcohol-based hand sanitizer.

●     Hang reusable gowns, spray with 0.5% bleach solution, and hang to dry for 72 hours before reusing. Perform hand hygiene again after spraying and hanging gown.

●     If handling dirty laundry from a person who is sick, wear gloves and a mask. Perform hand hygiene after handling dirty laundry or removing gloves.