● Health workers are at the front line of the COVID-19 outbreak response and as such are exposed to hazards that put them at risk of infection including pathogen exposure, long working hours, psychological distress, fatigue, occupational burnout, stigma, and physical and psychological violence. Your rights include:

○ Working in a facility where all the necessary preventive and protective measures are taken to minimize occupational safety and health risks;

○ Access to information, technical updates, instruction, and training on occupational safety and health, including:

• Refresher training on infection prevention and control (IPC);

• How to use, put on, take off and dispose of personal protective equipment (PPE).

○ Adequate infection prevention and control (IPC) and PPE supplies (masks, gloves, goggles, gowns, hand rub (sanitizer), soap and water, cleaning supplies) in sufficient quantity.

○ Tools to assess, triage, test, and treat patients, and to share IPC information with patients and the public.

○ Appropriate security measures at health care facilities, as needed, for personal safety.

○ A blame-free environment where incidents such as exposure to blood or bodily fluids from the respiratory system, or cases of violence, can be reported and measures for immediate follow up, including support to victims, are adopted.

○ Information on self-assessment, symptom reporting, and staying home when ill.

○ Appropriate working hours with breaks.

○ To remove yourself from a work situation where you believe it presents an imminent and serious danger to your life or health, and protection from any negative consequences if this right is evoked.

○ To not return to a work situation where there has been a serious danger to life or health until any necessary remedial action has been taken.

○ Compensation, rehabilitation, and curative services if infected with COVID-19 following exposure in the workplace.

○ Access to mental health and counselling resources.

○ Cooperation with management and my representatives.

● To assess if you are at high risk of developing severe illness from COVID-19, please refer to this section.

● For pregnant women, please refer to this section to assess your risk level.

● To the extent feasible, healthcare facilities should consider prioritizing healthcare workers who are not at higher risk of developing severe illness and who are not pregnant to care for confirmed or suspected COVID-19 patients.

○ If staffing shortages make this challenging, facilities could consider restricting high risk and pregnant healthcare workers from being present for higher risk procedures (e.g. aerosol-generating procedures).

○ Healthcare workers concerned about their risk should discuss their concerns with their supervisor or occupational health services.

● As a health worker, your responsibilities include:

○ Following established occupational safety and health procedures, avoid exposing others to health and safety risks, and participate in employer-provided occupational safety and health training.

○ Providing or reinforcing accurate IPC and public health information, including to concerned people who have neither symptoms nor risk.

○ Putting on, using, taking off, and disposing of PPE properly.

○ Using provided protocols to assess, triage, and treat patients.

○ Treating patients with respect, compassion, and dignity.

○ Maintaining patient confidentiality.

○ Swiftly following established public health reporting procedures of patients presumptive for or confirmed to have COVID-19 .

○ Self-monitoring for signs of illness, self-isolating and reporting illness to managers, if it occurs.

○ Advising management if they are experiencing signs of undue stress or mental health challenges that require supportive interventions.

○ Reporting to their immediate supervisor any situation which they have reasonable justification to believe presents an imminent and serious danger to life or health.

● Decisions about return to work for healthcare workers with confirmed or suspected COVID-19 should be made in the context of local circumstances.

● CDC provides guidelines on the return to work for healthcare personnel with confirmed or suspected COVID-19 that contains information on:

○ Return to work criteria for healthcare workers with confirmed or suspected COVID-19.

○ Return to work practices and work restrictions.

○ Strategies to mitigate healthcare personnel staffing shortages.

● Symptom-based strategy for when health-care workers can return to work:

○ Health care workers with mild to moderate illness that are not severely immunocompromised:

• At least 10 days have passed since symptoms first appeared, and

• At least 24 hours have passed since last fever without the use of fever-reducing medications, and

• Symptoms have improved.

• Mild Illness is defined as individuals who have any of the various signs and symptoms of COVID 19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging.

• Moderate Illness is defined as individuals who have evidence of lower respiratory disease by clinical assessment or imaging and a saturation of oxygen (SpO2) ≥94% on room air at sea level.

○ Healthcare workers who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since their first positive viral diagnostic test.

○ Healthcare workers with severe to critical illness or who are severely immunocompromised:

• At least 10 days and up to 20 days have passed since symptoms first appeared, and

• At least 24 hours have passed since last fever without the use of fever-reducing medications, and

• Symptoms have improved.

• Consider consultation with infection control experts .

• Severe Illness is defined as individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level (or, for patients with chronic hypoxemia, a decrease from baseline of >3%), ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%.

○ Healthcare workers who are severely immunocompromised but who were asymptomatic throughout their infection may return to work when at least 20 days have passed since the date of their first positive viral diagnostic test.

○ Test-based strategy.

• Except for rare situations, a test-based strategy is no longer recommended to determine when to allow healthcare workers to return to work.

• A summary of current evidence and rationale for these changes is described in a Decision Memo.

● After returning to work, healthcare workers should:

○ Wear a face mask at all times while in the healthcare facility until all symptoms are completely resolved or at baseline.

○ Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen.

● Responsibilities are outlined in a guidebook for Prehospital Emergency Medical Services (EMS) during the COVID-19 pandemic that addresses the functions of pre-hospital EMS: dispatching, pre-transport/on scene EMS, transport, post-transport, administration (911/EMS), and special considerations.

● EMS practices should be based on the most up-to-date clinical recommendations and information from appropriate public health authorities and EMS medical direction about COVID-19.

● General responsibilities of Dispatchers include:

○ Further screen Patients Under Investigation (PUI) with fever and/or signs/symptoms of lower respiratory illness, assessing for travel and contact history.

○ Allocate resources according to disease severity with Advanced Life Support (ALS) ambulance for severe cases and Basic Life Support (BLS) for mild cases.

○ Prepare a protocol for pre-arrival instructions to callers that includes turning on adequate lighting, gathering patients’ medications and controlling domestic animals.

○ When COVID-19 is suspected in a patient needing emergency transport, prehospital care providers and healthcare facilities should be notified in advance that they may be caring for, transporting, or receiving a patient who might have COVID-19.

● General responsibilities of on-scene EMS providers include:

○ Assessment of the patient should begin at 1-2 meters (3-6 feet) if possible.

○ If the patient's condition allows, the patient may be directed to meet the EMS crew at an appropriate location outside or in a more ventilated area.

• Patient contact should be minimized to the extent possible until a cloth face covering or face mask is on the patient.

• Patients and family members should be wearing their own cloth face coverings (if tolerated) prior to the arrival of the EMS personnel and throughout the duration of the encounter, including during transport. If they do not have a cloth face covering, they should be offered a cloth face covering or face mask, as supplies allow.

• Face masks and cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

○ If the PUI is a confirmed or suspected COVID-19 case, appropriate personal protective equipment (PPE) must be worn prior to further evaluation (also see Section 2 of this guidebook for PPE details or here).

○ EMS personnel should wear a face mask at all times while they are in service, including in break rooms or other spaces where they might encounter co-workers.

○ EMS personnel should consider continuing to wear the same respirator or face mask (extended use) throughout the entire work shift, instead of intermittently switching back to their cloth face covering.

• For EMS personnel, the potential for exposure to COVID-19 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in break rooms, co-workers or visitors in other common areas, or other exposures in the community.

○ All providers must perform hand hygiene before and after all patient care activities, which is to wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol.

• Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

• Wash hands with soap and water when they are visibly soiled.

• When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently.

○ PPE should be removed in an appropriate doffing area to prevent secondary contamination.

○ Providers must exercise caution when performing aerosol-generating procedures and perform them only if medically necessary.

• An N-95 or higher-level respirator should be worn in addition to other PPE.

• If performing aerosol-generating procedures, providers should consider having the patient compartment exhaust vent on high.

○ Providers should avoid opening compartments and cabinets unless essential to patient care.

• Equipment needs should be anticipated and the appropriate tools removed from cabinets prior to placing the patient in the vehicle.

○ After pre-arrival notification, EMS providers should continue to communicate with the designated point of contact at the receiving facility with updates on the patient’s condition and ETA to facilitate reception of the patient immediately upon arrival.

● CDC has developed recommendations for DHCP during the COVID-19 pandemic.

● As a DHCP, your preventive responsibilities include:

○ Postponing elective procedures, surgeries, and non-urgent dental visits.

○ Telephone screening of all patients for signs or symptoms of respiratory illness (fever, cough, shortness of breath) and avoid dental care if the patient reports signs or symptoms of a respiratory illness.

○ Telephone triaging all patients in need of emergency dental care to assess whether treatment can be delayed.

○ Actively screening everyone (both patients and DHCPs) on the spot for fever and symptoms of COVID-19 before they enter the dental setting.

○ Implementing source control (require face masks or cloth face coverings) for everyone entering the dental setting (both patients and DHCP), regardless of whether they have COVID-19 symptoms.

○ Sending patients that arrive at your facility with presumptive or confirmed COVID-19 home (if not acutely sick) or to a medical facility (if acutely sick)

○ Implement Universal Use of personal protective equipment (PPE)

• DHCP should implement the use of universal eye protection and wear eye protection in addition to their surgical mask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters, including those where splashes and sprays are not anticipated in areas where there is moderate community transmission.

○ Establish administrative controls and practices

• • • • • • • • Limit clinical care to one patient at a time, whenever possible.

              • Set up operatories so that only the clean or sterile supplies and instruments needed for the dental procedure are readily accessible. All other supplies and instruments should be in covered storage, such as drawers and cabinets, and away from potential contamination.

              • Any supplies and equipment that are exposed but not used during the procedure should be considered contaminated and should be disposed of or reprocessed properly after completion of the procedure.

● If a patient without COVID-19 requires emergency dental care:

○ Avoid aerosol-generating procedures whenever possible.

○ Use the highest level of personal protective equipment (PPE) available.

○ If the minimally acceptable combination of a surgical mask and a full-face shield is not available, refer the patient to a clinician who has the appropriate PPE.

○ Practice strict adherence to hand hygiene before and after contact with patients. Wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol.

• Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

• Wash hands with soap and water when they are visibly soiled.

• When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently.

○ Clean and disinfect room and equipment according to the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings and the Guidelines for Infection Control in Dental Health-Care Settings - 2003.

● If a patient with a confirmed or presumptive COVID-19 requires emergency dental care:

○ Dental treatment should be provided in a hospital or other facility that can treat the patient.

○ Airborne Precautions (an isolation room with negative pressure relative to the surrounding area and use of an N95 filtering disposable respirator for persons entering the room) should be followed.

● Healthcare facilities and employers, in collaboration with human resources and occupational health services, should plan and prepare for potential staff shortages by:

○ Understanding their staffing needs and the minimum number of staff needed to provide a safe work environment and patient care.

○ Remaining in communication with local healthcare partners that can identify additional healthcare staff (e.g. hiring additional health workers, recruiting retired health workers, using students or volunteers), when needed.

● Strategies for healthcare workers include:

○ Cancelling all non-essential procedures and visits.

• Shift healthcare workers who usually do non-essential procedures to support other patient care activities.

• Facilities need to ensure that these healthcare workers have received the appropriate orientation and training to work in these areas that are new to them.

○ Attempt to address social factors that might prevent healthcare workers from reporting to work, such as transportation or housing if healthcare workers live with vulnerable individuals.

○ Request that healthcare workers postpone elective time off from work.

● If necessary, healthcare workers who have had an unprotected exposure to COVID-19 but are not known to be infected may continue to work.

○ These healthcare workers should still report symptoms and temperatures every day before work and wear a face mask for 14 days after the exposure event.

○ If the healthcare worker develops even mild symptoms, they must cease patient care activities and notify their supervisor prior to leaving work. These individuals should be prioritized for testing.

○ If the healthcare worker is tested and found to be infected with COVID-19, they should be excluded from work until they meet all return to work criteria (unless they are allowed to work as described below).

● If shortages continue despite implementing the strategies above, facilities may develop criteria to determine if a healthcare worker with presumptive or confirmed COVID-19 (who are well enough to work) could return to work in a healthcare setting before meeting all return to work criteria.

○ Considerations include:

• Where the healthcare workers are in the course of their illness.

• The types of symptoms they are experiencing.

• Their degree of interaction with patients and other healthcare workers in the facility. For example, are they working in telemedicine services, providing direct patient care, or working in a satellite unit reprocessing medical equipment?

• The type of patients they care for (e.g. immunocompromised patients). These healthcare workers should be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology).

○ Facilities should consider prioritizing their duties in the following order:

• Perform job duties where they do not interact with others, such as telemedicine.

• Provide direct care only for patients with confirmed COVID-19, preferably in a cohort setting.

• Provide direct care for patients with presumptive COVID-19.

• As a last resort, allow healthcare workers with confirmed COVID-19 to provide direct care for patients without presumptive or confirmed COVID-19.

○ Face masks should be worn even when they are in non-patient care areas such as break rooms.

• If they must remove their face mask, for example to eat or drink, they should separate themselves from others.

○ The healthcare worker should self-monitor for symptoms.

● Testing of healthcare workers can be considered in four situations:

○ Testing healthcare workers with signs or symptoms consistent with COVID-19.

○ Testing asymptomatic healthcare workers with known or suspected exposure to COVID-19.

○ Testing asymptomatic healthcare workers without known or suspected exposure to COVID-19 for early identification in special settings (e.g., nursing homes).

○ Testing healthcare workers who have been diagnosed with COVID-19 to determine when they are no longer infectious.

● Viral tests (authorized nucleic acid or antigen detection assays) are recommended to diagnose acute infection.

○ Testing practices should aim for turnaround times of less than 24 hours in order to facilitate effective interventions.

○ Testing the same individual more than once in a 24-hour period is not recommended.

● Healthcare workers undergoing testing should receive clear information on:

○ The purpose of the test.

○ The reliability of the test and any limitations associated with the test.

○ Who will pay for the test and any next steps related to the results.

○ Who will receive the results.

○ How the results may be used.

○ Any consequences for declining testing.

● There are four scenarios to consider for transmission of COVID-19: no cases; sporadic cases; cluster of cases; and community transmission.

○ WHO’s Critical Preparedness, Readiness and Response Actions for COVID-19 recognizes countries could experience one or more of these scenarios at the sub-national level at the same time. Areas may shift in both directions between the four scenarios. The guidance document outlines activities to prepare and respond to all transmission scenarios.

• WHO’s guidance on immediate public health interventions includes a summary table, irrespective of transmission scenario that identifies the necessary assessments, protocols, and policies to establish, modify, or reinforce for COVID-19.

○ Information on designating COVID-19 treatment areas and maintaining essential health services is also provided.

● If there is no transmission of COVID-19 in your area, the WHO recommends:

○ Setting up screening and triage protocols at all points of access to the health system.

○ Educate and actively communicate with the public through risk communication and community engagement.

○ (Re)train staff in clinical management specifically for COVID-19.

○ Set up COVID-19 telephone hotline and referral system to refer patients to the appropriate destination for clinical assessment and/or testing as per local protocol.

○ Set up COVID-19 designated wards in health facilities.

○ Conducting active case finding, contact tracing and monitoring, quarantine of contacts, and isolation of suspected cases.

○ Maintain essential health services.

○ Start preparing for next scenarios (sporadic cases, clusters of cases, community transmission).

● WHO’s Operational considerations for case management of COVID-19 in health facility and community: interim guidance explores two potential pathways a patient will take if they are referred for treatment by their primary doctor or other medical professional: screening and triage, and hub and spoke model (community transmission).

● Screening and triage for early recognition of patients presumptive for COVID-19, and rapid implementation of source control measures.

○ It is critical to screen all persons at the first point of contact with the health-care facility as well as inpatients presumptive for COVID-19 to allow for early recognition, followed by their immediate isolation/separation.

○ Healthcare facilities without enough single isolation rooms in emergency departments should designate a separate, well-ventilated area where patients presumptive for COVID-19 can wait. This area should have:

• Benches, stalls or chairs placed at least 1-2 meters (3-6 feet) apart.

• Dedicated toilets, hand hygiene stations, and trash bins with lid for disposal of paper tissues used for respiratory hygiene or after hand washing.

○ To prevent transmission of COVID-19 in health-care facilities, it is necessary to promptly detect inpatients presumptive for COVID-19, who were missed by screening and triage efforts or became infected within the facility.

• This can be quite challenging given the high numbers of acute respiratory infections and the atypical clinical presentations of COVID-19.

● Applying standard precautions for all patients to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They represent the basic level of infection control precautions that should be used at all times in the care of all patients. Standard precautions include, but are not limited to:

○ Hand hygiene: For optimal hand hygiene performance, health workers should perform hand hygiene according to the WHO’s My 5 Moments for Hand Hygiene approach in the:

• Before touching a patient.

• Before any clean or aseptic procedure is performed.

• After exposure to body fluid.

• After touching a patient, and after touching a patient's surroundings.

• Hand hygiene includes washing hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol.

  • • Alcohol-based hand rub products are preferred if hands are not visibly soiled; wash hands with soap and water when they are visibly soiled.

○ Use of appropriate PPE according to risk assessment, environmental cleaning, and safe waste management.

○ Respiratory hygiene:

• Display graphic information on the need to cover nose and mouth with a tissue or bent elbow when coughing or sneezing.

• Perform hand hygiene after contact with respiratory secretions or objects that may be potentially contaminated with respiratory secretions.

• Give patients who are presumptive for COVID-19 a medical mask to wear.

○ Rational and correct use of PPE to reduce exposure to pathogens. The effectiveness of PPE strongly depends on:

• Staff training on putting on and removing PPE.

• Prompt access to sufficient supplies.

• Appropriate hand hygiene.

• health worker compliance.

• Regular monitoring and feedback by IPC personnel.

○ Environmental cleaning: All surfaces in healthcare facilities should be routinely cleaned and disinfected, especially high-touch surfaces, and whenever visibly soiled or if contaminated by body fluids.

• In settings where presumptive or confirmed COVID-19 patients are admitted, frequency depends on type of patient areas and surfaces.

• Clean surfaces thoroughly with water and detergent.

• Apply a disinfectant solution. For COVID-19, either 0.1% (1000ppm) sodium hypochlorite or 70-90% ethanol are effective. However, if there are large spills of blood or body fluids, a concentration of 0.5% (5000ppm) sodium hypochlorite should be used.

• Contact time of a minimum of 1 minute is recommended for ethanol, chlorine-based products and hydrogen peroxide ≥0.5%.

• After appropriate contact time, disinfectant residue may be rinsed off with clean water if required.

○ Waste Management: Healthcare waste produced during the care of patients with suspected or confirmed COVID-19 is considered to be infectious and should be collected safely in clearly marked lined containers and sharp safe boxes. To safely manage health-care waste, facilities should:

• Assign responsibility and adequate human and material resources to segregate and dispose of waste.

• Treat waste preferably on-site, and then safely dispose of it. If waste is moved off-site, it is critical to understand where and how it will be treated and disposed.

• Use appropriate PPE (boots, long-sleeved gown, heavy-duty gloves, mask, and goggles or a face shield) while managing infectious waste and perform hand hygiene after taking off the PPE.

• Prepare for increases in the volume of infectious waste during the COVID 19 outbreak, especially through the use of PPE.

● Implement additional precautions

○ Isolation and cohorting of patients with presumptive or confirmed COVID-19 using the following principles:

• Designate a team of health workers, where possible, for care of patients with presumptive or confirmed COVID-19 to reduce the risk of transmission.

• Restrict the number of health workers in contact with each COVID-19 patient.

• Patients should be placed in well ventilated single rooms if feasible. When single rooms are not available or the bed occupancy rate is anticipated to be at 100% or more, presumptive or confirmed COVID-19 patients should be grouped together (cohorted) in adequately ventilated areas with beds placed at least 1-2 meters (3-6 feet) apart.

• Avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment.

• If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and give the patient a medical mask to wear if tolerated.

• Ensure that health workers who are transporting patients perform hand hygiene and wear appropriate PPE.

• Equipment should be either single-use and disposable or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared between patients, clean and disinfect it each time it is used by another patient (by using ethyl alcohol 70%).

• Maintain a record of all staff entering the patient’s room.

○ Use contact and droplet precautions before entering the room where presumptive or confirmed COVID-19 patients are admitted. The following principles should be used:

• Perform hand hygiene before putting on and after removing PPE.

• Use appropriate PPE: medical mask, eye protection (goggles) or facial protection (face shield) to avoid contamination of mucous membranes, clean, non sterile, long-sleeved gown, and medical gloves.

• In areas with COVID-19 community transmission, healthcare workers and caregivers working in clinical areas should continuously wear a medical mask during all routine activities throughout the entire shift.

• It is not necessary for healthcare workers and caregivers to wear boots, coverall and apron during routine care; extended use of medical mask, gown and eye protection can be applied during the care of COVID-19 patients given PPE shortages.

• For a COVID-19 patient who is infected with a multi-drug resistant organism (e.g. Clostridioides difficile), a new set of gown and gloves are needed after caring for such patients.

• Healthcare workers should refrain from touching their eyes, nose or mouth with potentially contaminated gloved or bare hands.

• Notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival.

• Frequently clean and disinfect surfaces with which the patient is in contact.

○ Health workers performing AGPs or in settings where AGPs are performed among presumptive or confirmed COVID-19 patients (e.g. intensive care units or semi-intensive care units) should:

• Perform procedures in an adequately ventilated room.

• Use appropriate PPE: wear a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.

• It is critical that when health workers put on a disposable particulate respirator, they should always perform the required seal check to ensure there is no leakage.

• Note that if the wearer has a beard or other thick facial hair this may prevent a proper respirator fit.

• Other PPE items include eye protection (i.e. goggles or a face shield), long-sleeved gown and gloves. If gowns are not fluid resistant, health workers performing AGPs should use a waterproof apron if the procedure is expected to produce a large volume of fluid that might penetrate the gown.

• In the intensive care units, where AGPs are frequently performed, the health worker may choose to wear a particulate respirator throughout his or her shift, in areas of community transmission.

• Keep the number of persons present in the room or unit to the absolute minimum required for the patient’s care and support.

● Implement administrative controls: Administrative controls and policies for the prevention and control of transmission of COVID-19 within the healthcare facility include, but may not be limited to:

○ Establishing sustainable IPC infrastructures and activities.

○ Educating patients’ caregivers; developing policies for early recognition of patients with presumptive COVID-19.

○ Ensuring access to laboratory testing for COVID-19 detection.

○ Preventing overcrowding, especially in the emergency department.

○ Providing dedicated waiting areas for symptomatic patients.

○ Planning for (e.g. repurposing of other wards) and isolating COVID-19 patients.

○ Ensuring adequate supplies of PPE.

○ Ensuring adherence to IPC policies and procedures in all aspects of health care.

● Implement environmental and engineering controls: environmental and engineering controls are an integral part of IPC and include standards for adequate ventilation according to specific areas in health-care facilities, adapted structural design, spatial separation, as well as adequate environmental cleaning.

○ Ventilation rates within defined spaces in healthcare facilities are generally addressed by national regulations. In healthcare facilities, large quantities of fresh and clean outdoor air are required both for the benefit of their occupants and the control of contaminants and odours by dilution and removal.

○ There are three basic criteria for the ventilation:

• Ventilation rate: the amount and quality of outdoor air provided into the space.

• Airflow direction: the overall airflow direction in a building and between spaces should be from clean-to-less clean zones.

• Air distribution or airflow pattern: the supply of air that should be delivered to each part of the space to improve dilution and removal of airborne pollutants generated in the space.

○ In this context, patient areas require that specific ventilation requirements are met. Any decision on whether to use natural, hybrid (mixed-mode) or mechanical ventilation should take into account climate, including prevalent wind direction, floor plan, need, availability of resources, and the cost of the ventilation system.

• Each ventilation system has its advantages and disadvantages, as described in WHO’s manual on severe acute respiratory treatment centres.

● Actively screen everyone (healthcare personnel, patients, visitors) for fever and symptoms of COVID-19 before they enter the healthcare facility.

○ For visitors and patients, provide them with a cloth face covering. Medical face masks, if available, should be reserved for healthcare workers.

● Triage all patients at admission and immediately isolate patients with presumptive COVID-19.

● Advise all patients to cover their mouth and nose with their bent elbow or tissue when they cough or sneeze (respiratory hygiene. Then advise that they dispose of the used tissue immediately and wash their hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol.

● Offer a medical mask to patients with presumptive COVID-19 while they are in waiting/public areas or in cohorting rooms.

● Perform hand hygiene following the WHO’s My 5 Moments for Hand Hygiene approach. Hand hygiene includes:

○ Wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol.

○ Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

○ Wash hands with soap and water when they are visibly soiled.

○ When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently.

● Avoid touching eyes, nose, or mouth with potentially contaminated gloves or bare hands.

● Avoid moving and transporting patients out of their room unless medically needed.

○ If transport is required, use predetermined transport routes to minimize exposure for staff and other patients.

● Routinely disinfect surfaces with which the patient is in contact.

● Wear appropriate personal protective equipment (PPE). If PPE is in short supply at your facility, see the following recommendations on how to adapt.

● Airborne-generating procedures are associated with an increased risk of transmission of COVID-19. Take extra caution when performing these procedures.

● If you start coughing, sneezing or develop fever after you have provided care, report your illness immediately to the concerned authority and follow their advice.

● Limit the sick person’s movement around the house and minimize shared space.

○ If possible, use a separate bedroom and bathroom.

● If you have to share space, make sure the room has good airflow.

○ To increase air flow, open the window and turn on a fan (if possible).

○ Tell other household members to stay and eat in a different room or, if that is not possible, maintain a physical distance of 1 - 2 meters (3 - 6 feet) from the ill person (sleep in a separate bed for example).

○ Additional guidance for crowded conditions is provided in this section of the document.

● Use dedicated linen and eating utensils for the ill person and avoid contact with or sharing of personal items in the immediate environment like toothbrushes, cigarettes, cutlery, crockery, linens, towels, phones, or electronics).

○ Guidance for cleaning and disinfecting when someone is sick is provided in this section.

● Limit the number of caregivers and ideally, assign one person as the caregiver who is in good health and has no underlying chronic or immuno-compromising conditions.

○ For more information about those at higher risk for severe illness, refer to the guidance here.

○ Caregivers and anyone who has been in close contact with someone who has COVID-19 should stay home and self- quarantine.

○ Caregivers should continue to stay home after care is complete. Caregivers can leave their home 14 days after their last close contact with the person who is sick (based on the time it takes to develop illness), or 14 days after the person who is sick meets the criteria to end home isolation.

● Avoid having visitors to your home, especially people at higher risk for severe illness, until the sick person has completely recovered, shows no signs of symptoms and meets the criteria to be released from home isolation.

● Everyone in the household should wash their hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol regularly, especially:

○ Before touching a patient.

○ Before any clean or aseptic procedure is performed.

○ After exposure to body fluid.

○ After touching a patient,

○ After touching a patient's surroundings.

○ After coughing or sneezing.

○ Before during and after you prepare food.

○ Before eating.

○ After using the toilet.

○ When hands are visibly dirty.

● A cough or sneeze should be covered with a flexed elbow or a disposable tissue that is discarded immediately after use. Immediately wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol.

● The ill person should wear a medical mask as much as possible, in particular when not alone in the room and when physical distance 1 -2 meters (3 - 6 feet) from others cannot be maintained..

○ The mask helps prevent a person who is sick from spreading the virus to others. It keeps respiratory droplets contained and from reaching other people.

○ It should be changed daily and whenever wet or dirty from secretions. Caregivers and household members should :

○ Wear a medical mask that covers their nose and mouth while in the same room with an ill person.

● Avoid touching their mask or face during use, and replace immediately if it becomes dirty or wet .

○ Discard the mask after leaving the room

○ Immediately wash their hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol afterward.

○ Avoid direct contact with the body fluids of the sick person, especially oral or respiratory secretions and stool.

○ Gloves, masks, and protective clothing (for example, plastic aprons) should be used when cleaning surfaces or handling clothing or linen soiled with body fluids.

○ If using utility gloves, clean them with soap and with 0.1% sodium hypochlorite solution. Please also refer to the guidance here.

○ Wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol before putting gloves and mask on and after their removal.

● Clean and disinfect surfaces that are frequently touched in the room where the patient is being cared for, such as bedside tables, bed frames, and other bedroom furniture at least once daily. Clean and disinfect bathroom and toilet surfaces at least once daily.

○ Guidance on precautions using disinfectants when caring for a loved one at home with COVID is provided in this section.

○ If your loved one is confirmed to have COVID-19 and you are dealing with soiled bedding, towels, and clothes, please refer to cleaning and disinfection guidance provided in this part of the document.

○ Further guidance is available in Best Practices for Environmental Cleaning in Healthcare Facilities in Resources-Limited Settings which was developed by CDC and ICAN in collaboration with WHO.

● Waste generated at home while caring for a COVID-19 patient during the recovery period should be packed in strong bags and closed completely before disposal and eventual collection by municipal waste services.

○ If such a service does not exist, waste may be buried.

○ Burning is the least preferred option, as it is bad for human health and the environment.

● Watch for warning signs and call their doctor if the person keeps getting sicker. For medical emergencies, call your country's emergency service and tell the dispatcher that the person has or might have COVID-19.

● See this section in the document for more information on caring for loved ones at home.

● Respirator (N95, FFP2, FFP3 or higher level respirator) or face mask (if a respirator is not available).

○ Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or presumptive COVID-19 or other situations where a respirator or face mask is warranted.

○ N95 respirators or respirators that offer a higher level of protection should be used instead of a face mask when performing aerosol-generating procedures.

● Eye protection

○ Goggles or a disposable face shield that covers the front and sides of the face are appropriate.

○ Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays.

○ Personal eyeglasses and contact lenses are NOT considered adequate eye protection.

○ Remove eye protection before leaving the patient room or care area.

● Gloves

○ Put on clean, non-sterile gloves upon entry into the patient room or care area.

○ Change gloves if they become torn or heavily contaminated.

○ Remove and discard gloves when leaving the patient room or care area, and immediately wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol.

• Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

• Wash hands with soap and water when they are visibly soiled.

• When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently;

● Gowns

○ Put on a clean isolation gown upon entry into the patient room or area.

○ Change the gown if it becomes soiled and dispose appropriately.

• Disposable gowns should be discarded after use.

• Cloth gowns should be cleaned after each use.

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● If there are PPE shortages in your facility, please refer to this section on strategies to optimize available PPE supplies.

● Additional recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed COVID-19 infection are available here and here.

● More than one donning method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example provided by CDC.

○ Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training).

○ Perform hand hygiene using hand sanitizer.

○ Put on an isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel.

○ Put on NIOSH-approved N95 filtering face piece respirator or higher (use a face mask if a respirator is not available).

• If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand.

• Respirator/face mask should be extended under the chin.

• Both your mouth and nose should be protected.

• Do not wear a respirator/face mask under your chin or store in a scrubs pocket between patients.*

• Respirator: Respirator straps should be placed on the crown of head (top strap) and base of neck (bottom strap).

• Perform a user seal check each time you put on the respirator.

• Face mask: Mask ties should be secured on the crown of head (top tie) and base of neck (bottom tie).

• If the mask has loops, hook them appropriately around your ears.

○ Put on a face shield or goggles.

• When wearing an N95 respirator or half face piece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator.

• Face shields provide full face coverage.

• Goggles also provide excellent protection for eyes, but fogging is common.

○ Put on gloves. Gloves should cover the cuff (wrist) of the gown.

• Healthcare personnel may now enter the patient room.

● More than one doffing (removal) method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of doffing provided by the CDC.

○ Remove gloves.

• Ensure glove removal does not cause additional contamination of hands.

• Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).

○ Remove the gown.

• Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied.

• Do so in a gentle manner, avoiding a forceful movement.

• Reach up to the shoulders and carefully pull the gown down and away from the body. Rolling the gown down is an acceptable approach.

• Dispose in trash receptacle.

○ Healthcare personnel may now exit the patient room.

○ Perform hand hygiene.

○ Remove face shield or goggles.

• Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head.

• Do not touch the front of the face shield or goggles.

• Remove and discard the respirator (or face mask if used instead of respirator). Do not touch the front of the respirator or face mask.*

• Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head.

• Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.

• Face mask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.

○ Perform hand hygiene after removing the respirator/face mask and before putting it on again if your workplace is practicing reuse.*

*Facilities implementing reuse or extended use of PPE will need to adjust their donning and doffing procedures to accommodate those practices.

● No. Current WHO guidance for healthcare workers caring for presumptive or confirmed COVID-19 patients recommends the use of contact and droplet precautions, in addition to standard precautions which should always be used by all healthcare workers for all patients.

● Use contact and droplet precautions before entering the room where presumptive or confirmed COVID-19 patients are admitted. The following principles should be used:

○ Perform hand hygiene before putting on and after removing PPE.

○ Use appropriate PPE: medical mask, eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes, clean, non sterile, long-sleeved gown, and medical gloves.

○ In areas with COVID-19 community transmission, health workers and caregivers working in clinical areas should continuously wear a medical mask during all routine activities throughout the entire shift.

• It is not necessary for health workers and caregivers to wear boots, coverall and apron during routine care; extended use of medical mask, gown and eye protection can be applied during the care of COVID-19 patients given PPE shortages.

• For a COVID-19 patient who is infected with a multi-drug resistant organism (e.g. Clostridioides difficile), a new set of gown and gloves are needed after caring for such patients.

○ Health workers should refrain from touching their eyes, nose or mouth with potentially contaminated gloved or bare hands.

○ Notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival.

○ Frequently clean and disinfect surfaces with which the patient is in contact.

● WHO provides a technical guidance package on rational use of personal protective equipment for COVID-19.

○ This document summarizes WHO recommendations for the rational use of PPE in health care and community settings, including the handling of cargo.

○ It is intended for those involved in the distribution and management of PPE, as well as public health authorities and individuals in health care and community settings to understand when PPE use is most appropriate.

● Wear a clean, non-sterile, long-sleeve gown, an N95 or higher-level respirator (or medical mask if respirator is not available), eye protection (i.e., goggles or face shield), and gloves.

○ Personal protective equipment (PPE) use can be minimized through patient self-collection while the healthcare provider maintains at least 1 - 2 meters (3 - 6 feet) of separation.

● Only perform NP and OP swab specimens collection from presumptive or confirmed COVID-19 patients if you are well-trained on the procedure.

● Conduct the procedure in a separate room.

● During NP specimen collection, ask the patients to cover their mouth with a medical mask or tissue.

● There is no available evidence that suggests cough generated via NP/OP specimen collection leads to increased risk of COVID-19 transmission via aerosols.

● Transport and movement of the patient outside their room should be limited to medically essential purposes.

● If transporting a COVID-19 patient, the receiving area should be notified in advance.

● If transport personnel must prepare the patient for transport (e.g., transfer them to the wheelchair or gurney), they should wear all recommended PPE when doing so.

● The patient should wear a face mask or cloth covering and be covered with a clean sheet.

○ According to the CDC, if the patient is wearing a face mask or cloth face covering, the healthcare worker only requires the use of a face mask.

○ Additional PPE for the healthcare worker should not be required unless there is an anticipated need to provide medical assistance during transportation (e.g. helping the patient replace a dislodged face mask).

● After arriving at their destination, the receiving personnel and the transporter should wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol.

○ Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

○ Wash hands with soap and water when they are visibly soiled.

○ When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently.

○ Wear all recommended PPE.

● Interim guidance for EMS personnel transporting patients with confirmed or suspected COVID-19 infection is available here.

● No. Disposable medical face masks are intended for a single use only.

○ After use of a disposable medical face mask you should remove the mask using the following techniques:

○ Remember not to touch the front of the mask.

○ Remove the mask by pulling the elastic ear straps or laces from behind.

○ Immediately dispose of the mask in an infectious waste bin with a lid.

○ Perform hand hygiene.

• Wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol.

• Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

• Wash hands with soap and water when they are visibly soiled.

• When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently.

● WHO provides a technical guidance package focused on advice on the use of medical masks in communities, at home and at healthcare facilities in areas with reported COVID-19 outbreaks.

○ It is intended for public health and infection prevention and control (IPC) professionals, healthcare managers, healthcare workers and community health workers.

● If your facility is in short supply of PPE, please see the following recommendations.

● In view of the global PPE shortage, strategies that can facilitate optimal PPE availability include:

○ Minimizing the need for PPE in health care settings

○ Ensuring rational and appropriate use of PPE

○ Coordinating PPE supply chain management mechanisms.

○ WHO provides guidance on these strategies here, along with effective environmental and administrative controls needed to improve the effective use of PPE.

● Based on current evidence, WHO carefully considered last-resort temporary measures in crisis situations to be adopted only where there might be serious shortages of PPE or in areas where PPE may not be available.

● WHO stresses that these temporary measures should be avoided as much as possible when caring for severe or critically ill COVID-19 patients, and for patients with known co-infections of multi-drug resistant or other organisms transmitted by contact (e.g. Klebsiella pneumoniae) or droplets (e.g. influenza virus).

● The following measures could be considered independently or in combination, depending on the local situation:

○ PPE extended use (using for longer periods of time than normal according to standards).

○ Reprocessing followed by reuse (after cleaning or decontamination/sterilization of either reusable or disposable PPE).

○ Considering alternative items compared with the standards recommended by the WHO.

○ Using PPE beyond the manufacturer-designated shelf life for a limited time when equipment is in good condition with no degradation, tears, or wear that could affect performance.

● WHO’s technical guidance package on rational use of personal protective equipment for COVID-19 provides detailed measures on the extended use, reprocessing, or use of alternatives for the following PPE:

○ Medical masks

○ Respirators (FFP2, FFP3, N95)

○ Gowns

○ Goggles or safety glasses

○ Face shields

● WHO has put forward the Essential Supplies Forecasting Tool (ESFT) to help Member States manage essential supplies. It provides detailed quantifications of:

○ Equipment (PPE, diagnostics, biomedical equipment, drugs and consumables)

○ Inpatient beds (total, severe and critical)

○ Tests (for mild, suspected, severe and critical cases)

● To help healthcare facilities plan and optimize the use of PPE in response to COVID-19, CDC has developed a Personal Protective Equipment (PPE) Burn Rate Calculator.

○ CDC’s optimization strategies for PPE offer a continuum of options for use when PPE supplies are stressed, running low, or absent.

○ Contingency and then crisis capacity measures augment conventional capacity measures and are meant to be considered and implemented sequentially. Decisions to implement contingency and crisis strategies are based on these assumptions:

1. Facilities understand their current PPE inventory and supply chain.

2. Facilities understand their PPE utilization rate.

3. Facilities are in communication with local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional supplies.

4. Facilities have already implemented conventional capacity measures.

5. Facilities have provided HCP with required education and training, including having them demonstrate competency with donning and doffing, with any PPE ensemble that is used to perform job responsibilities, such as provision of patient care.

○ When using PPE optimization strategies, training on PPE use, including proper donning and doffing procedures, must be provided to HCP before they carry out patient care activities.

● Use WHO’s “My 5 Moments for Hand Hygiene” approach to know when to perform hand hygiene:

1) Before touching a patient.

2) Before any clean or aseptic procedure is performed.

3) After exposure to body fluid.

4) After touching a patient.

5) After touching a patient’s surroundings.

● Hand hygiene includes:

○ Wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol.

○ Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

○ Wash hands with soap and water when they are visibly soiled.

○ When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently.

● WHO strongly discourages the use of chlorine solutions for hand hygiene.

○ Chlorine solutions carry higher risk of hand irritation and ill health effects, including eye irritation and respiratory problems.

○ Preparing chlorine solutions requires training to reach the correct dose of 0.05%.

○ Even if stored at a cool dry place with a lid away from sunlight, chlorine solutions have to be renewed daily.

○ Simple soapy water solutions do not have any of the above-mentioned health risks and complications. The antiviral effect of soapy water is due to the oily surface membrane of the COVID virus that is dissolved by soap, killing the virus.

● WHO recommends applying standard hand hygiene practices which are:

○ Wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol.

○ Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

○ Wash hands with soap and water when they are visibly soiled.

○ When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently.

● All individuals, including family members, visitors, and healthcare workers should use contact and droplet precautions before entering the room of presumptive or confirmed COVID-19 patients, in addition to using standard precautions.

● Place COVID-19 patients in adequately ventilated single rooms.

○ For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient.

○ When single rooms are not available, patients presumptive for COVID-19 should be grouped together.

● All patients’ beds should be placed 1 - 2 meters (3 - 6 feet) apart regardless of whether they are presumptive for COVID-19.

● Where possible, a team of healthcare workers should be designated to care exclusively for presumptive or confirmed COVID-19 cases to reduce the risk of transmission.

● Appropriate personal protective equipment (PPE) should be worn.

○ If PPE is in short supply, consider strategies to maximize existing PPE.

● Use of boots, coverall, and apron is not required during routine care.

● Refrain from touching eyes, nose, or mouth with potentially contaminated gloves or bare hands.

● Use designated portable X-ray equipment or other designated diagnostic equipment.

● Avoid moving and transporting patients out of their room or area, unless medically necessary.

○ If transport is required, refer to this section to follow the recommended guidelines on how to transport patients with confirmed or suspected COVID-19.

● Routinely clean and disinfect surfaces with which the patient is in contact.

● Limit the number of healthcare workers, family members, and visitors who are in contact with suspected or confirmed COVID-19 patients.

● Maintain a record of all persons entering a patient’s room, including all staff and visitors.

● Some AGPs have been associated with an increased risk of transmission of coronaviruses (SARS-CoV-1, SARS-CoV-2 and MERS-CoV). The current WHO list of these AGPs is:

○ Tracheal intubation, non-invasive ventilation (e.g. BiPAP, CPAP), tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy, sputum induction induced by using nebulized hypertonic saline, and autopsy procedures.

● It remains unclear whether aerosols generated by nebulizer therapy or high-flow oxygen delivery are infectious, as data on this is still limited.

● Health workers performing AGPs or in settings where AGPs are performed among presumptive or confirmed COVID-19 patients (e.g. intensive care units or semi-intensive care units) should:

○ Perform procedures in an adequately ventilated room.

○ Use appropriate PPE: wear a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.

• Although initial fit testing is needed prior to the use of a particulate respirator, many countries and healthcare facilities do not have a respiratory fit testing programme. Therefore, it is critical that when health workers put on a disposable particulate respirator, they should always perform the required seal check to ensure there is no leakage.

• Note that if the wearer has a beard or other thick facial hair this may prevent a proper respirator fit. Other PPE items include eye protection (i.e. goggles or a face shield), long-sleeved gown and gloves.

• If gowns are not fluid resistant, health workers performing AGPs should use a waterproof apron if the procedure is expected to produce a large volume of fluid that might penetrate the gown.

• In the intensive care units, where AGPs are frequently performed, the health worker may choose to wear a particulate respirator throughout his or her shift, in areas of community transmission.

● Commonly performed medical procedures that are considered aerosol-generating procedures, or that create uncontrolled respiratory secretions, include:

○ Open suctioning of airways

○ Sputum induction

○ Cardiopulmonary resuscitation (CPR)

○ Endotracheal intubation and extubation

○ Non-invasive ventilation (e.g. BiPAP, CPAP)

○ Bronchoscopy

○ Manual ventilation before intubation

● It is uncertain whether aerosols generated from the following procedures are infectious:

○ Nebulizer administration

○ High flow O2 delivery

● Perform aerosol-generating procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative- pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation.

● Use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.

○ According to the CDC, if supply shortages exist, N95 or higher level respirators should be prioritized for procedures that are higher risk and generate infectious aerosols.

● Use eye protection (goggles or face shield).

● Wear a clean, non-sterile, long-sleeved gown and gloves.

○ If gowns are not fluid-resistant, healthcare workers should use a waterproof apron.

● Limit the number of persons present in the room to the absolute minimum required for the patient’s care and support.

● Clean and disinfect procedure room surfaces promptly.

● The amount of time that the air inside an examination room remains potentially infectious is not known and may depend on a number of factors including:

○ Size of the room

○ Number of air changes per hour

○ How long the patient was in the room

○ If the patient was coughing or sneezing

○ If an aerosol-generating procedure was performed

● Facilities need to consider these factors when deciding when the vacated room can be entered by someone who is not wearing personal protective equipment (PPE).

● For a patient who was not coughing or sneezing, did not undergo an aerosol-generating procedure, and occupied the room for a short period of time (e.g. a few minutes), any risk for a healthcare worker likely dissipates over a matter of minutes.

● For a patient who was coughing and remained in the room for a longer period of time or underwent an aerosol-generating procedure, the risk period is likely longer.

○ For these higher risk scenarios, it is reasonable to apply a similar time period as that used for pathogens spread by airborne route (e.g. measles, tuberculosis) and to restrict healthcare workers and patients without PPE from entering the room until enough time has passed.

● CDC provides guidance on the clearance rates under differing ventilation conditions.

● In addition to allowing sufficient time to pass, healthcare workers should clean and disinfect environmental surfaces and shared equipment before the room is used again.

● All specimens collected for laboratory investigations should be regarded as potentially infectious.

● Healthcare workers who collect, handle, or transport clinical specimens should follow standard precaution measures to minimize the possibility of exposure:

○ Ensure that healthcare workers who collect specimens use appropriate personal protective equipment (PPE).

○ Ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures.

○ Place specimen bags (secondary containers) that have a separate sealable pocket for the specimen (a plastic biohazard specimen bag) with the patient’s label on the specimen container (primary container) and a clearly written laboratory request form.

○ Ensure that laboratories in healthcare facilities adhere to appropriate biosafety practices and transport requirements.

○ Deliver all specimens by hand whenever possible. DO NOT use pneumatic-tube systems to transport specimens.

○ Document clearly each patient’s full name, date of birth and “suspected COVID-19” on the laboratory request form.

○ Notify the laboratory as soon as possible that the specimen is being transported.

● An ACS is a facility that is temporarily converted for healthcare use during a public health emergency to reduce the burden on hospitals and medical facilities.

○ Examples include schools, stadiums, hotels etc.

● CDC provides guidance on how to set up ACS facilities in a way that ensures they can support the implementation of recommended infection prevention and control practices.

○ The guidance does not address other aspects of ACS such as supplies, accessibility, and patient transportation to and from nearby health facilities.

● Depending on needs, ACS could provide three levels of care:

○ Non-acute care: low-level care for mildly to moderately symptomatic COVID-19 patients. These patients may require oxygen (less than or equal to 2L/min), but do not require extensive nursing care or assistance with activities of daily living (ADL).

○ Hospital care: mid-level care for moderately symptomatic COVID-19 patients. These patients require oxygen (more than 2L/min), nursing care, and assistance with activities of daily living.

○ Acute care: higher acuity care for COVID-19 patients. These patients require significant ventilatory support, including intensive monitoring on a ventilator.

● If ACS will be used to care for both confirmed and presumptive COVID-19 patients or for patients without COVID-19 who require care for other reasons, additional infection prevention and control considerations will apply.

○ For example, planning needs to address physical separation between the cohorts and assigning different HCP with dedicated equipment to each section.

● The ACS Toolkit is available to provide technical guidance for establishing ACS including considerations for:

○ Physical infrastructure: layout, air conditioning and heating, spacing between patients, storage areas, and floors and services.

○ Services: food services, environmental services, sanitation, laundry facilities, pharmacy access, and diagnostics.

○ Patient care: staffing, infection prevention and control supplies, personal protective equipment (PPE), and hand hygiene.

● All individuals dealing with soiled bedding, towels, and clothes from COVID-19 patients should:

○ Wear appropriate personal protective equipment (PPE), which includes heavy duty gloves, mask, eye protection (face shield/goggles), long-sleeved gown, apron (if gown is not fluid resistant), closed shoes before touching any soiled linen.

○ Place soiled linen in a clearly labelled, leak-proof container (for example, a bag or bucket) and never carry soiled linen against your body.

○ If there is any solid excrement on the linen, such as feces or vomit, scrape it off carefully with a flat, firm object and put it in the commode or designated toilet/latrine before putting linen in the designated container.

• If the latrine is not in the same room as the patient, place soiled excrement in a covered bucket to dispose of in the toilet or latrine.

○ Wash and disinfect linen: washing by machine with warm water (60-90°C or 140-194°F) and laundry detergent is recommended for cleaning and disinfection of linens.

• If use of a machine washing is not possible, linen can be soaked in hot water and soap in a large drum, using a stick to stir, avoiding splashing.

• If hot water is not available, soak linen in 0.05% chlorine for approximately 30 minutes.

● Instructions for home preparation of chlorine solutions at multiple concentrations can be found here and here.

• Finally, rinse with clean water and let linen dry fully in the sunlight.

● WHO recommends that you use the following for environmental cleaning in facilities or homes housing patients with presumptive or confirmed COVID-19:

○ 70% Ethyl alcohol to disinfect reusable dedicated equipment (for example, thermometers) between uses.

○ Sodium hypochlorite (bleach) at 0.5% (equivalent to 5000 ppm or 1-part household bleach with 5% sodium hypochlorite to 9 parts water) for disinfecting surfaces in homes or healthcare facilities.

• Instructions for home preparation of chlorine solutions at multiple concentrations can be found here and here.

● Please also refer to the guidance here on precautions using disinfectants and here for instructions on cleaning different types of surfaces.

● For more on best practices for environmental cleaning procedures and programs in healthcare facilities in resource-limited settings, see Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings.

● To date, there is no epidemiological information to suggest that you need to disinfect goods, products, or vehicles shipped from COVID-19 affected countries to prevent COVID-19 infection.

○ WHO continues to closely monitor the evolution of COVID-19, and will update the recommendations as needed.

○ Additional resources for best practices for environmental cleaning can be found in the following two documents:

• Infection prevention and control of epidemic-and pandemic prone acute respiratory infections in health care

• Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

● No. Waste produced during the health care or home care of patients with presumptive or confirmed COVID-19 should be disposed of as infectious waste.

○ Currently, there is no evidence that direct, unprotected human contact during the handling of healthcare waste has resulted in the transmission of COVID-19.

● All healthcare waste produced during patient care is considered to be infectious and should be collected safely in clearly marked lined containers and sharpsafe boxes.

○ The waste should be treated, preferably on-site, and then safely disposed of.

● Waste generated in waiting areas of healthcare facilities can be classified as non-hazardous and should be disposed in strong black bags and closed completely before collection and disposed of in strong black bags and sealed before collection and disposal in municipal waste services.

● The volume of infectious waste is expected to increase, especially through the use of PPE.

○ Therefore it is important to increase capacity to handle and treat this healthcare waste.

○ Alternative treatment technologies, such as autoclaving or high temperature burn incinerators, may need to be procured.

● For more information on disposing of infectious waste, please click here. Or visit CDC website here.

● Waste generated at home while caring for a COVID-19 patient during the recovery period should be packed in strong bags and closed completely before disposal and eventual collection by municipal waste services.

○ If such a service does not exist, waste may be buried.

● Burning is the least preferred option, as it is bad for human health and the environment .

● The following water, sanitation, and hygiene (WASH)-related actions are recommended by the WHO in healthcare settings:

○ Engage in frequent hand washing using appropriate hand hygiene techniques. This is one of the most important measures that can be used to prevent COVID-19 infection.

• Wash hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol.

• Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

• Wash hands with soap and water when they are visibly soiled.

• When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently;

○ Implement regular environmental cleaning and disinfection practices.

○ Manage feces and urine safely.

○ Safely manage healthcare waste produced by COVID-19 cases.

● WHO guidance on the safe management of drinking water and sanitation services applies to the COVID-19 outbreak.

○ Provide those with presumptive or confirmed COVID-19 with their own flush toilet or latrine.

• Where this is not possible, patients sharing the same ward should have access to toilets that are not used by patients in other wards.

○ Apply proper disinfection protocols for bedpans, surfaces and bodily fluids spills in healthcare facilities to facilitate more rapid die-off of the COVID-19 virus.

○ Manage and treat toilets and pit-latrines in healthcare facilities.

○ Ensure the safe disposal of greywater (wastewater) or water from washing reusable personal protective equipment (PPE), surfaces, and floors.

○ After attending to a dead body of a COVID-19 patient, properly decontaminate the reusable PPE, dispose of infectious waste, and practice proper hand hygiene.

○ The body of a deceased person with confirmed or suspected COVID-19 should be wrapped in cloth or fabric and transferred to the mortuary area as soon as possible.

○ Many co-benefits will be realized by safely managing water and sanitation services and applying good hygiene practices.

● Based on existing knowledge and research, there is no indication that COVID-19 can persist in drinking water. For waste water, some recent studies have found RNA fragments but not infectious virus in waste water.

● The morphology and chemical structure of this virus are similar to those of other coronaviruses a for which there are data both on their survival in the environment and on effective measures to inactivate them.

○ Existing WHO guidance on the safe management of drinking-water and sanitation services also applies to the COVID-19 pandemic.

● WHO provides detailed information on water, sanitation, hygiene, and waste management in this updated Interim Guidance.

● For more on safe healthcare waste management, see Safe management of wastes from health-care activities: A summary

● Ideally, presumptive and confirmed COVID-19 patients should be isolated in single rooms.

○ When this is not feasible (for example, when there is a limited number of single rooms), cohorting is an acceptable option.

● Patients with presumptive COVID-19 infection may actually have other respiratory illnesses, and they must be cohorted separately from patients with confirmed COVID-19 infection.

● Ensure that a range of 1 - 2 meters (3 - 6 feet) between beds is maintained at all times.

● Oxygen therapy is recommended for all severe and critical COVID-19 patients.

● Oxygen therapy is the provision of medical oxygen as a health-care intervention. Medical oxygen contains at least 82% pure oxygen, is free from any contamination, and is generated by an oil-free compressor. Only high quality, medical-grade oxygen should be given to patients.

● WHO has interim guidance on oxygen sources and distribution strategies for COVID-19 treatment centers.

● A model for setting up an isolation ward is currently under development.

● PPE specifications for healthcare workers caring for COVID-19 patients can be found in the disease commodity package.

● No. Hospitalization may not be required for patients who have mild illness (low-grade fever, cough, malaise, runny nose or sore throat) without any warning signs (shortness of breath or difficulty in breathing), increased respiratory sputum or haemoptysis, gastro-intestinal symptoms such as nausea, vomiting, and/or diarrhea, and without changes in mental status.

● Isolation is necessary to contain virus transmission.

● Some patients with initial mild clinical presentation may worsen in the second week of illness.

○ CDC recommends that the decision to monitor these patients in the inpatient or outpatient setting should be made on a case-by-case basis.

○ This decision will depend not only on the clinical presentation, but also on the patient’s ability to engage in self-monitoring, the feasibility of safe isolation at home, and the risk of transmission in the patient’s home environment.

○ Hospitalization may be required when there is concern for rapid clinical deterioration.

● All patients discharged home should be instructed to return to the hospital if they develop any worsening of illness.

● For more guidance for clinicians caring for patients with severe acute respiratory infection when COVID-19 is presumed—including hospital admission criteria—visit the WHO guidance document on this topic.

● CDC has provided guidance on how to handle face-to-face interactions with clients in the clinic and the field during the COVID-19 pandemic that address the following.

○ Activities that should receive highest priority will vary with the level of community COVID-19 transmission, characteristics of the priority populations, local capacity to implement activities, and availability of effective interventions.

○ Strategies for when the level of community transmission is none to minimal transmission:

• Plan for discontinuation of non-essential public health activities.

• Plan for implementation of flexible work (e.g. telemedicine) and sick leave policies.

• Implement triage prior to entering facilities to rapidly identify and isolate patients with respiratory illness (e.g. phone triage before arrival, triage upon arrival).

• Isolate patients with symptoms of COVID-19.

○ Within health department settings, implement physical distancing measures, practice hand hygiene, encourage the use of face masks, increase cleaning and disinfection.

• Hand hygiene is washing hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol.

• Use an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

• Wash hands with soap and water when they are visibly soiled.

• When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently.

○ Strategies for when the level of community transmission is minimal to substantial transmission:

• Discontinue non-essential public health activities.

• Encourage telework options for staff when possible.

• Encourage strict use of respiratory protection and other PPE when working in close proximity to patients.

• Encourage strict implementation of phone triage and telemedicine where possible.

• Isolate patients with symptoms of COVID-19.

• Implement physical distancing practices and place tape on floors to establish proper spacing.

○ Disease-specific priority recommendations based on the level of transmission for:

• Patients with sexually transmitted diseases (STDs)

• Patients with tuberculosis

• Patients with HIV

• Patients with hepatitis C

● The following criteria from WHO and CDC may be used to end home isolation:

○ If you did not have COVID-19 symptoms, but tested positive, you may end isolation when:

• At least 10 days have passed since the date of first positive test.

○ If you received home-based care or have been discharged from hospital for COVID-19 you may end isolation when:

• At least 10 days have passed since the date of first positive test.

• Plus at least 3 additional days without symptoms (including without fever and without respiratory symptoms).

  • • Loss of taste or smell may persist for weeks or months after recovery and should not delay the end of isolation.

• If you were severely ill with COVID-19, or have a severely compromised immune system due to health conditions or medication, you may need to stay home more than 10 days and up to 20 days after symptoms first appeared.

  • • You may require testing to determine when you can be around others.

    • Your healthcare provider will let you know if you can be around others based on the results of your testing.

● RT-PCR testing for detection of COVID-19 RNA for discontinuing isolation could be considered for persons who are severely immunocompromised, in consultation with infectious disease experts. For all others, a test-based strategy is no longer recommended except to discontinue isolation or other precautions earlier than would occur under the symptom-based strategy outlined above.

○ Accumulating evidence supports ending isolation and precautions for persons with COVID-19 using a symptom-based strategy.

○ Specifically, researchers have reported that people with mild to moderate COVID-19 remain infectious no longer than 10 days after their symptoms began, and those with more severe illness or those who are severely immunocompromised remain infectious no longer than 20 days after their symptoms began.

● Recommendations for discontinuing isolation in persons known to be infected with COVID-19 could, in some circumstances, appear to conflict with recommendations on when to discontinue quarantine for persons known to have been exposed to COVID-19.

○ CDC recommends 14 days of quarantine after exposure based on the time it takes to develop illness if infected.

○ Thus, it is possible that a person known to be infected could leave isolation earlier than a person who is quarantined because of the possibility they are infected.

○ This recommendation will prevent most, but cannot prevent all, instances of secondary spread.

○ The risk of transmission after recovery is likely substantially less than that during illness; recovered persons will not be shedding large amounts of virus by this point, if they are shedding at all.

○ Employers and local public health authorities can choose to apply more stringent criteria for certain persons where a higher threshold to prevent transmission is warranted.

● No. Current WHO recommendations do not include a requirement for exclusive use of specialized or referral hospitals to treat presumptive or confirmed COVID-19 patients.

○ Countries or local jurisdictions may choose to care for patients at such hospitals if those are deemed the most likely to be able to safely care for patients with presumptive or confirmed COVID-19 infection or for other clinical reasons (e.g., availability of advanced life support).

○ Regardless, any healthcare facility treating patients with presumptive or confirmed COVID-19 should adhere to the WHO infection prevention and control recommendations for healthcare to protect patients, staff, and visitors.

● Yes. WHO offers a toolkit for clinicians working in acute care hospitals in low- and middle-income countries. The toolkit provides guidance on how to manage adult and paediatric patients with acute respiratory infections, including COVID-19.

● There are currently no drugs, therapeutics, or antiviral drugs available and approved to prevent or treat COVID-19.

○ Several therapies are under investigation as part of the “Solidarity” clinical trial.

● Current clinical management includes infection prevention and control measures and supportive care, including oxygen therapy.and advanced organ support for respiratory failure, septic shock, and multi-organ failure

● Not all patients with COVID-19 will require medical supportive care.

● WHO Living Guidance on Corticosteroids for COVID-19 provides:

○ A strong recommendation for systemic (i.e. intravenous or oral) corticosteroid therapy for 7 to 10 days in patients with severe and critical COVID-19.

• (e.g. 6 mg of dexamethasone orally or intravenously daily or 50 mg of hydrocortisone intravenously every 8 hours)

○ Corticosteroids should be avoided unless they are indicated for another reason (e.g. COPD exacerbation or refractory septic shock).

○ A conditional recommendation NOT to use corticosteroid therapy in patients with non-severe COVID-19.

● WHO is in the process of updating treatment guidelines to include dexamethasone and other steroids.

● WHO will continue to update treatment guidelines as new research and findings become available.

● There is currently no proof that hydroxychloroquine can cure or prevent COVID-19.

○ The misuse of hydroxychloroquine can cause serious side effects and illness and even lead to death.

● When available, full personal protective equipment (PPE) should be worn including respirators (or face masks if a respirator is not available), eye protection, gloves, and gowns should be used for the care of all patients presumptive for COVID-19, including women who are pregnant.

● No. Based on limited data, forceful exhalation during the second stage of labor would not be expected to generate aerosols to the same extent as other aerosol-generating procedures.

○ Respirators should not be prioritized for the second stage of labor over procedures more likely to generate higher concentrations of infectious respiratory aerosols( such as bronchoscopy, intubation and open suctioning) if a facility is experiencing a shortage.

● When respirator supplies are restored, healthcare workers should use full PPE during the second stage of labor, including respirators (or face masks if respirators are not available), eye protection, gloves, and gowns.

● Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether a patient should be tested.

○ As part of the evaluation, clinicians are strongly encouraged to test for other causes of respiratory illness and peripartum fever.

○ Fever is the most commonly reported sign of COVID-19.

● Current data suggests that signs and symptoms of COVID-19 are expected to be similar to those for non-pregnant patients, including the presence of fever.

● Other considerations that may guide testing include the level of local community transmission.

● Healthcare workers in labor and delivery healthcare settings should follow the same infection prevention and control recommendations and wear the same personal protective equipment (PPE) as all other healthcare workers.

● No. There are no special procedures for the management of bodies of people who have died from COVID-19.

○ Authorities and medical facilities should proceed with their existing policies and regulations that guide post-mortem management of persons who die from infectious diseases.

● Health workers should do a preliminary evaluation and risk assessment before undertaking any activity related to the management of presumptive or confirmed COVID-19 fatality and follow WHO’s IPC guidance for safe management of dead bodies in the context of COVID-19.

● Health workers should:

○ Perform hand hygiene before and after handling the body. Hand hygiene includes:

• • • • • • • • • Washing hands with soap and water for 20 seconds or with an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol.

                • Using an alcohol-based hand rub (sanitizer) that is 60% ethanol, or 70% isopropanol alcohol if hands are not visibly soiled.

                • Washing hands with soap and water when they are visibly soiled.

                • When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently.

○ Use appropriate PPE based on the level of interaction with the body and risk assessment (e.g. use of eye protection and medical masks in addition to gloves and fluid-resistant gown or apron, if there is a risk of body fluids splashes while handling the body).

○ Ensure that any body fluids leaking from orifices are contained and cover the body in cloth to transfer to the mortuary area.

• Body bags are not necessary for COVID-19, although they may be used for other reasons such as excessive body fluid leakage or absence of refrigerated morgue, especially in countries with a warm climate.

• If more than 24 hours has passed since the person died, or if burial/cremation is not foreseen within the next 24–48 hours, a second body bag may be used.

• Prepare the body for transfer including removal of all lines, catheters and other tubes.

• Ensure that any body fluids leaking from orifices are contained.

• Keep both the movement and handling of the body to a minimum.

• Wrap the body in cloth and transfer it as soon as possible to the mortuary area.

• There is no need to disinfect the body before transfer to the mortuary.

• No special transport equipment or vehicle is required.

○ Do not engage in any other activity during body handling or preparation.

○ Disinfect any non-disposable equipment used during handling of the body as per WHO guidance on cleaning and disinfection in the context of COVID-19.

● Safety procedures for deceased persons infected with COVID-19 should be consistent with those used for any autopsies of people who have died from an acute respiratory illness.

○ If a person died during the infectious period of COVID-19, the lungs and other organs may still contain live virus, and additional respiratory protection is needed during aerosol-generating procedures (e.g. procedures that generate small-particle aerosols, such as the use of power saws or washing of intestines.

○ Perform autopsies in an adequately ventilated room, i.e. at least natural ventilation with at least 160L/s/patient air flow or negative pressure rooms with at least 12 air changes per hour (ACH) and controlled direction of air flow when using mechanical ventilation.

○ Only a minimum number of staff should be involved in the autopsy.

○ Appropriate PPE must be available, including a scrub suit, long sleeved fluid-resistant gown, gloves (either two pairs or one pair autopsy gloves), and face shield (preferably) or goggles, and boots. A particulate respirator (N95 mask or FFP2 or FFP3 or its equivalent) should be used in the case of aerosol-generating procedures.

○ Additional information on how to safely conduct aerosol-generating procedures is in the CDC’s Postmortem Guidance.

● WHO interim guidance is available and should be consulted by all those who tend to the bodies of persons who have died of suspected or confirmed COVID-19, including managers of healthcare facilities and mortuaries, religious and public health authorities, and families.

● Specific guidance for mortuary staff is provided in this section.

● WHO has provided international guidelines for certification and classification of COVID-19 as cause of death.

○ The guideline provides instructions for emergency ICD codes along with examples of how to certify the chain of events for death are due to COVID-19.

○ A death due to COVID-19 may not be attributed to another disease (e.g. cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19.

○ There should be no period of complete recovery from COVID-19 between illness and death.

● PAHO/WHO recommends continuing essential immunization activities wherever possible during the COVID-19 pandemic to prevent outbreaks of vaccine-preventable diseases.

● Healthcare workers should ensure that they are vaccinated against seasonal influenza themselves, as well as any other routine immunizations they might be missing.

● PAHO recommends that healthcare services that offer vaccination implement the following recommendations:

○ Offering vaccination services outside or in a well-ventilated area.

○ Keeping vaccination services separate from other health services, to help keep people who are ill and those who do not have symptoms apart.

○ Frequently disinfecting the vaccination area.

○ Limiting the number of people who accompany the patient to be vaccinated to one person.

○ Ensuring hand sanitizer or hand washing units are available for the public at the entrance of the facility.

○ Establishing exclusive vaccination sessions for at-risk groups, such as older people, pregnant women, and those with pre-existing medical conditions.

○ Scheduling immunization appointments or offering small but frequent immunization sessions to limit crowded waiting rooms.

● Considerations for establishing immunization services:

○ In circumstances where immunization services have been diminished or suspended, countries should reinstate and reinvigorate immunization services at the earliest opportunity to close immunity gaps, once reduced local transmission of the COVID-19 virus permits primary health care services to resume.

○ If resources for catch-up are limited, catch-up immunization activities should place priority on outbreak prone Vaccine Preventable Diseases such as measles, polio, diphtheria, and yellow fever.

○ Countries should implement effective communication strategies and engage with communities to allay concerns, enhance community linkages and re-establish community demand for vaccination.

● Be respectful, polite and empathetic.

● Be aware that people presumptive for or confirmed to have COVID19, and any visitors accompanying them, may be stressed or afraid.

● The most important thing you can do is to listen carefully to questions and concerns.

● Use the local language and speak slowly.

● Answer any questions and provide accurate information about COVID-19.

● You may not have an answer for every question: a lot is still unknown about COVID-19 and it is okay to admit that.

● If available, share information pamphlets or handouts with your patients.

● It is okay to touch, or comfort suspected and confirmed patients when wearing PPE.

● Gather accurate information from the patient: their name, date of birth, travel history, list of symptoms, etc.

● Explain the healthcare facility’s procedure for COVID-19, such as isolation and limited visitors, and the next steps.

● If the patient is a child, admit a family member or guardian to accompany them – the guardian should be provided and use appropriate personal protective equipment.

● Provide updates to visitors and family when possible.

● WHO provides a technical guidance package on risk communication package for healthcare facilities.

○ The package contains a series of simplified messages and reminders based on WHO's more in-depth technical guidance on infection prevention and control in healthcare facilities in the context of COVID-19: "Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected".

● See this section on stigma for additional information.

● For healthcare workers, it is normal to feel under pressure in the COVID-19 situation.

○ This is a unique and unprecedented situation for many healthcare workers, particularly if they have not been involved in similar responses.

● Stress and the feelings associated with it are not a reflection of how well you can do your job.

● Managing your mental health and psychosocial wellbeing during this time is as important as managing your physical health. Follow these tips to help manage stress:

○ Take care of yourself. Use helpful coping strategies such as ensuring sufficient rest and respite during work or between shifts, eat sufficient and healthy food, engage in physical activity, and stay in contact with family and friends.

○ Avoid using unhelpful coping strategies such as tobacco, alcohol, or other drugs. In the long term, these can worsen your mental and physical wellbeing. This is a unique and unprecedented situation for many healthcare workers, particularly if they have not been involved in similar responses.

○ Stay connected with your loved ones through digital methods.

● Some healthcare workers may unfortunately experience avoidance by their family or community due to stigma or fear.

○ This can make an already challenging situation far more difficult.

○ Turn to your colleagues, your manager, or other trusted persons for social support.

● Helping to manage the mental health and psychosocial wellbeing of patients is an important consideration during this time. The following are some tips to consider:

○ Use understandable ways to share messages with people with intellectual, cognitive, and psychosocial disabilities.

• Forms of communication that do not rely solely on written information should be utilized if you are a team leader or manager in a health facility.

○ Understand the best ways to support people with COVID-19, and know how to link them with available resources for mental health and psychosocial support.

• The stigma associated with mental health problems may cause reluctance to seek support for both COVID-19 and mental health conditions.

● Although the COVID-19 pandemic has placed an immense burden on health systems, including frontline health workers, there are things that can help mitigate the effects of violence on women, children, and older people.

● Health facilities should identify and provide information about services available locally (e.g. hotlines, shelters, rape crisis centers, counselling) for survivors, including opening hours, contact details, and whether services can be offered remotely, and establish referral linkages.

○ Maintain mental health services and those for alcohol and substance use including through online and other means as needed

○ Work across sectors to enable effective referral, including to mental health and psychosocial support and protection services

● Health providers need to be aware of the risks and health consequences of gender based violence and violence against older people.

○ Children, adolescents, women, men and older people who already live in homes with violence prior to the start of the COVID-19 pandemic will be more exposed to their abuser by stay at home measures.

○ Children, adults and older people living with disabilities or mental health issues are at a higher risk of being subjected to violence irrespective of being confined and have fewer opportunities to seek help.

○ Children, women and older people from ethnic minority or indigenous populations, LGBTQ persons, migrant and refugee populations and those living in poverty face a cumulative burden of discrimination, stigma and disadvantage and higher rates of violence in general. They may also have more challenges accessing services.

● Healthcare providers can:

○ Provide information about services available locally (e.g. helplines or hotlines, shelters, counselling services), including opening hours and contact details and establish referral linkages.

○ Help those who disclose by offering first-line support and medical treatment including listening empathetically and without judgment, inquiring about needs and concerns, validating survivors’ experiences and feelings, enhancing safety, and connecting survivors to support services.

○ Provide medical treatment for all violence-related health conditions, including immediate post-rape care for those who are subjected to sexual assault or abuse.

○ Arrange follow-up for patients who have experienced violence in case they are isolated or quarantined and remain in regular contact with them.

○ Prioritize home visits and contacts with vulnerable populations, in particularly infants and young children, older adults and people with disabilities at risk of violence, with specific attention to their safety as perpetrators of abuse are likely to be at home.

○ Explore alternative ways to reach children, women or older people depending on what is available and accessible (e.g. messenger services, telemedicine) with particular attention to reaching survivors safely while perpetrators are present and in ways that cannot be detected or traced.

○ Provide medical treatment for all violence-related health conditions, including immediate post-rape care for those who are subjected to sexual assault or abuse.

○ Arrange follow-up for patients who have experienced violence in case they are isolated or quarantined and remain in regular contact with them.

○ Prioritize home visits and contacts with vulnerable populations, in particularly infants and young children, older adults and people with disabilities at risk of violence, with specific attention to their safety as perpetrators of abuse are likely to be at home.

○ Explore alternative ways to reach children, women or older people depending on what is available and accessible (e.g. messenger services, telemedicine) with particular attention to reaching survivors safely while perpetrators are present and in ways that cannot be detected or traced.

● Facility managers can help prevent abuse in the health workplace and other institutions such as homes for children or older people:

○ Train staff to recognize signs and symptoms of abuse and how to report without compromising the safety of the person affected.

○ Rotate workers from higher-stress to lower-stress functions.

○ Partner inexperienced workers with more experienced colleagues.

○ Encourage work breaks.

○ Implement flexible schedules for workers who are directly impacted or have a family member affected by a stressful event.

○ Avoid the use of physical and chemical restraints in institutions for older people.

○ Establish mechanisms so that people living in institutions can maintain contact with family and friends while respecting local requirements for physical distance.

○ Enforce measures of accountability for any perpetrators of violence and abuse in the workplace or care institutions.

○ Ensure that residential and nursing facilities for older people are more closely monitored by relevant authorities.

● Facility managers can help to support survivors with these actions:

○ Continue to offer first line support and medical treatment for survivors of violence through the first points of contact in health facilities in line with WHO recommendations.

○ Continue to provide and arrange for post-rape care to be available 24 hours per day, seven days per week.

○ Make sure services are accessible to older adults and to those with cognitive or other disabilities.

● More information on gender based violence in the context of COVID-19 is available in this section. Additional information for policy makers is available in this section.