Infection prevention and control for COVID-19 in healthcare settings
This document aims to provide guidance to EU/EEA healthcare facilities and healthcare providers on infection prevention and control measures during the management of suspected and confirmed cases of COVID-19 infection in healthcare settings, including long-term care facilities (LTCF). It also offers guidance on the management of specimens in laboratories in the EU/EEA.
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European Centre for Disease Prevention and Control
This is an update of the ECDC guidance from February 2020 ‘Infection prevention and control for the care of patients with 2019-nCoV in healthcare settings’ [1].
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1. European Centre for Disease Prevention and Control (ECDC). Infection prevention and control for the care of patients with 2019-nCoV in healthcare settings 2020 [updated February 2020; cited 2020 11 March]. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/nove-coronavirus-infectionprevention-control-patients-healthcare-settings.pdf.
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European Centre for Disease Prevention and Control
Additionally, older persons are at higher risk of adverse outcomes of COVID-19, including the requirement for specialised hospital care and a fatal outcome [3].
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As COVID-19 is caused by a newly identified virus, there are no therapeutics or vaccines available, and there is presumed to be no pre-existing immunity in the population [3].
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More disease background information is available online (ECDC [7], WHO [8]) and in ECDC’s Rapid Risk Assessment [3].
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3. European Centre for Disease Prevention and Control (ECDC). Rapid risk assessment: Outbreak of novel coronavirus disease 2019 (COVID-19): increased transmission globally – sixth update 2020 [cited 2020]. Available from: Url to be updated 12/03/2020.
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Russian Council
SARS-CoV-2 virus has been detected in respiratory, faecal and blood specimens [4].
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In faeces, viral RNA has been detected in up to 30% of patients from day 5 after onset and up to 4 to 5 weeks [4].
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4. World Health Organisation (WHO). Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 2020 [cited 2020 11 March]. Available from: https://www.who.int/docs/defaultsource/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf.
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New England Journal of Medicine (Massachusetts Medical Society)
Michelle L. Holshue et al. 2020
Although airborne transmission is not considered the principal transmission route, we recommend a cautious approach because of possible transmission through aerosols [5,6].
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5. Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First case of 2019 novel coronavirus in the United States. New England Journal of Medicine. 2020.
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New England Journal of Medicine (Massachusetts Medical Society)
Camilla Rothe et al. 2020
Although airborne transmission is not considered the principal transmission route, we recommend a cautious approach because of possible transmission through aerosols [5,6].
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6. Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G, Wallrauch C, et al. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. New England Journal of Medicine. 2020.
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World Health Organization
It draws on interim advice produced by WHO and national agencies, and also expert opinion [9,11,12,15,29] General infection prevention and control measures People feeling ill with respiratory symptoms should be encouraged to contact healthcare services to seek medical advice by telephone or telemedicine/online.
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9. World Health Organisation (WHO). Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. Interim Guidance Geneva2020 [cited 2020 8 March]. WHO/2019- nCoV/IPC/v2020.1:[Available from: https://www.who.int/publications-detail/infection-prevention-andcontrol-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected.
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PLoS ONE (Public Library of Science (PLoS))
Khai Tran et al. 2012
Residents in long-term care facilities (LTCF) are commonly more vulnerable to infections than the general population [10].
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These procedures have been linked to an increased risk of transmission of coronaviruses and require protection measures [10].
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10. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797-e.
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Centers for Disease Control and Prevention (CDC)
It draws on interim advice produced by WHO and national agencies, and also expert opinion [9,11,12,15,29] General infection prevention and control measures People feeling ill with respiratory symptoms should be encouraged to contact healthcare services to seek medical advice by telephone or telemedicine/online.
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11. Centers for Disease Control and Prevention (CDC). Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings 2020 [updated 21 February 2020; cited 2020 8 March]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html.
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World Health Organization
It draws on interim advice produced by WHO and national agencies, and also expert opinion [9,11,12,15,29] General infection prevention and control measures People feeling ill with respiratory symptoms should be encouraged to contact healthcare services to seek medical advice by telephone or telemedicine/online.
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If possible, a physical barrier such as glass or a plastic teller window can be used to avoid direct contact and keep the distance; in such case no PPE is necessary [15] If available, provide a surgical mask for patients with respiratory symptoms (e.g. cough) Healthcare workers performing aerosol-generating procedures (AGP), such as swabbing [16], should wear the suggested PPE set for droplet, contact and airborne transmission (gloves, goggles, gown and FFP2/FFP3 respirator) [17] If there is a shortage of FFP2/FFP3 respirators, healthcare workers performing procedures in direct contact with a suspected or confirmed case (but not at risk for generating aerosol) can consider
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While swabbing patients, healthcare personnel can use the same respirator for several patients for a maximum of 4 hours without having to remove the respirator, as long as it is not damaged or soiled, unless the manufacturer explicitly advises against this [15].
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If there is no physical separation between the front and the back of the ambulance, a surgical mask should be considered [15].
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The use of the same respirator while treating multiple patients should be considered; the maximum time a respirator can be worn is 4 hours, as long as it is not removed between patients or contraindicated by the manufacturer [15].
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If visitors keep at least 1 meter away from a patient for the duration of the visit, and PPE availability is limited, only a surgical mask may be worn [15].
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In addition, the use of heavy-duty gloves and boots should be considered [15].
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Coordinated supply chains for PPE should ensure distribution of such materials to healthcare systems in order to reduce the potential for healthcare-associated transmission to vulnerable groups and healthcare workers [15].
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The main priorities in this document for rational use are in concordance with detailed guidance published by WHO in February 2020 [15].
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Respirators can be used for up to 4 hours for multiple patients without removing them [15], unless the respirator is damaged, soiled or contaminated, for example a symptomatic suspected case coughing on them.
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If there is an insufficient stock of respirators, then staff engaged in environmental cleaning and waste management should wear a surgical mask, in addition to gloves, goggles and gown [15].
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15. World Health Organisation (WHO). Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19) 2020 [updated 27 February 2020; cited 2020 8 March]. Available from: https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf.
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World Health Organization
If possible, a physical barrier such as glass or a plastic teller window can be used to avoid direct contact and keep the distance; in such case no PPE is necessary [15] If available, provide a surgical mask for patients with respiratory symptoms (e.g. cough) Healthcare workers performing aerosol-generating procedures (AGP), such as swabbing [16], should wear the suggested PPE set for droplet, contact and airborne transmission (gloves, goggles, gown and FFP2/FFP3 respirator) [17] If there is a shortage of FFP2/FFP3 respirators, healthcare workers performing procedures in direct contact with a suspected or confirmed case (but not at risk for generating aerosol) can consider wearing a mask with the highest available filter level, such as a surgical mask, in addition to gloves, goggles and gown.
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A nasopharyngeal swab is also considered an aerosol-generating procedure (AGP), because, for example, it can induce coughing [16].
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16. World Health Organisation (WHO). Infection prevention and control of epidemic-and pandemic prone acute respiratory infections in health care. WHO guidelines 2014 [17 January 2020]. Available from: https://www.who.int/csr/bioriskreduction/infection_control/publication/en/.
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European Centre for Disease Prevention and Control
If possible, a physical barrier such as glass or a plastic teller window can be used to avoid direct contact and keep the distance; in such case no PPE is necessary [15] If available, provide a surgical mask for patients with respiratory symptoms (e.g. cough) Healthcare workers performing aerosol-generating procedures (AGP), such as swabbing [16], should wear the suggested PPE set for droplet, contact and airborne transmission (gloves, goggles, gown and FFP2/FFP3 respirator) [17] If there is a shortage of FFP2/FFP3 respirators, healthcare workers performing procedures in direct contact with a suspected or confirmed case (but not at risk for generating aerosol) can consider wearing a mask with the highest available filter level, such as a surgical mask, in addition to gloves, goggles and gown.
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REPORT Infection prevention and control for COVID-19 in healthcare settings � � � � � � � � � � � � � Healthcare workers in contact with a confirmed case, or a suspected case of COVID-19, should wear PPE for contact, droplet and airborne transmission of pathogens: FFP2 or FFP3 respirator tested for fitting, eye protection (i.e. goggles or face shield), long-sleeved water-resistant gown and gloves [17].
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Healthcare workers should strictly follow the procedures for the wearing (donning) and the safe removal (doffing) of PPE in correct sequence [17].
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Healthcare workers in contact with residents with respiratory infections should wear PPE: eye protection (i.e. goggles or face shield), long-sleeved water-resistant gown, and gloves [17].
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17. European Centre for Disease Prevention and Control (ECDC). Guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed COVID-19 2020 [cited 2020 8 March]. Available from: https://www.ecdc.europa.eu/en/publications-data/guidancewearing-and-removing-personal-protective-equipment-healthcare-settings.
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Centers for Disease Control and Prevention (CDC)
For example, identify which non-urgent outpatient visits can be re-scheduled or cancelled, and which elective urgent inpatient diagnostic and surgical procedures can be moved to the outpatient setting, re-scheduled or cancelled [19,20].
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19. Centers for Disease Control and Prevention (CDC). Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States [cited 2020 11 March]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html.
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Checklist for hospitals preparing for the reception and care of coronavirus 2019 (COVID-19) patients
European Centre for Disease Prevention and Control
For example, identify which non-urgent outpatient visits can be re-scheduled or cancelled, and which elective urgent inpatient diagnostic and surgical procedures can be moved to the outpatient setting, re-scheduled or cancelled [19,20].
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20. European Centre for Disease Prevention and Control (ECDC). Checklist for hospitals preparing for the reception and care of coronavirus 2019 (COVID-19) patients 2020 [cited 2020 11 March]. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-checklist-hospitals-preparing-receptioncare-coronavirus-patients.pdf.
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World Health Organization
Ensure access to timely virological investigations in accordance with the algorithm for laboratory diagnosis of COVID-19 (Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases [21]).
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Laboratories should adhere to the guidance provided by The European Committee for Standardisation: CWA15793 laboratory biorisk management [27] and the WHO (Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases) [21].
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21. World Health Organisation (WHO). Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases 2020 [updated 2 March 2020; cited 2020 8 March]. Available from: https://www.who.int/publications-detail/laboratory-testing-for-2019-novel-coronavirus-in-suspected-humancases-20200117.
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European Centre for Disease Prevention and Control
The number of persons in the room should be limited to a minimum during such procedures; all persons present should wear: a well-fitted FFP3 respirator, eye protection, long-sleeved impermeable protective gowns, and gloves [22].
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Additional options for infection prevention and control in LTCFs with suspected or confirmed cases of COVID-19 LTCF administrators and healthcare workers should consider implementing the following options for response and mitigation of COVID-19 – in addition to the options above – to prevent and control the COVID-19 outbreak [22]: Administrative measures � Consult with local health authorities regarding specific local measures.
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Residents should only be relocated to other facilities if clinically necessary, for example if the LTCF cannot provide an appropriate level of care [22].
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Cohorting of COVID-19 cases to designated areas of a hospital, or indeed to dedicated hospitals, should be considered, to minimise PPE stock requirements [22].
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22. European Centre for Disease Prevention and Control (ECDC). Personal protective equipment (PPE) needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus (2019-nCoV) 2020 [cited 2020 11 March]. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus-personal-protectiveequipment-needs-healthcare-settings.pdf.
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European Centre for Disease Prevention and Control
If resources are limited, testing of symptomatic people should have priority over the testing of asymptomatic patients before release from isolation [23].
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23. European Centre for Disease Prevention and Control (ECDC). Novel coronavirus (SARS-CoV-2) - Discharge criteria for confirmed COVID-19 cases – When is it safe to discharge COVID-19 cases from the hospital or end home isolation? [cited 2020 11 March]. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-Discharge-criteria.pdf.
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European Centre for Disease Prevention and Control
If there is a shortage of hospital disinfectants, decontamination may be performed with 0.1% sodium hypochlorite (dilution 1:50 if household bleach at an initial concentration of 5% is used) after cleaning with a neutral detergent, although no data are available for the effectiveness of this approach against SARS-CoV-2 [24].
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If there is a shortage of hospital disinfectants, decontamination may be performed with 0.1% sodium hypochlorite (dilution 1:50 if household bleach at an initial concentration of 5% is used) after cleaning with a neutral detergent, although no data are available on the effectiveness of this approach against SARS-CoV-2 [24].
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In the event of shortages of hospital disinfectants, decontamination may be performed using 0.1% sodium hypochlorite (dilution 1:50 if household bleach at an initial concentration of 5% is used) after cleaning with a neutral detergent, although no data are available for the effectiveness of this approach against COVID-19 [24].
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24. European Centre for Disease Prevention and Control (ECDC). Interim guidance for environmental cleaning in non-healthcare facilities exposed to SARS-CoV-2 2020 [cited 2020 March]. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/coronavirus-SARS-CoV-2-guidanceenvironmental-cleaning-non-healthcare-facilities.pdf
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Centers for Disease Control and Prevention (CDC)
Due to the possible persistence of the virus on surfaces (including bodies) for several days [28], the contact with a deceased body without using PPE should be avoided.
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28. World Health Organisation (WHO). Interim Guidance for Collection and Submission of Postmortem Specimens from Deceased Persons Under Investigation (PUI) for COVID-19, February 2020 2020 [updated 19 February 2020; cited 2020 11 March]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-postmortem-specimens.html.
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Centers for Disease Control and Prevention (CDC)
It draws on interim advice produced by WHO and national agencies, and also expert opinion [9,11,12,15,29] General infection prevention and control measures People feeling ill with respiratory symptoms should be encouraged to contact healthcare services to seek medical advice by telephone or telemedicine/online.
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Baseline options for infection prevention and control Administrative measures � Provide signs at all entrances that lists the symptoms compatible with COVID-19 (fever, cough, shortness of breath) [29], informing visitors with any of these symptoms not to enter the LTCF.
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Ensure that all people in the LTCF are aware of hand and respiratory hygiene, including cough etiquette [29].
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If possible, make alcohol-based hand rub available in every resident room, both inside and outside the room, and in all public areas [29].
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ECDC TECHNICAL REPORT Infection prevention and control for COVID-19 in healthcare settings � Ensure that soap dispensers and paper towels are available for hand washing [29].
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Check regularly that all people in the LTCF are aware of hand and respiratory hygiene, including cough etiquette [29].
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29. Centers for Disease Control and Prevention (CDC). Strategies to Prevent the Spread of COVID-19 in Long- Term Care Facilities (LTCF) 2020 [updated 1 Mach 2020; cited 2020 8 March ]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-carefacilities.html.
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World Health Organization
If no paper towels are available, use clean cloth towels and replace them when they become wet [31].
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In LTCFs with insufficient quantities of paper towels, use clean cloth towels and replace them regularly, washing them with a detergent such as household washing powder [31].
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31. World Health Organisation (WHO). Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts 2020 [updated 4 February 2020; cited 2020 8 March]. Available from: https://www.who.int/publications-detail/home-care-for-patients-withsuspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-ofcontacts.
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Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Philip W. Smith et al. 2008
If available, FFP2/3 respirators should be worn during aerosol-generating procedures, for example procedures inducing coughing or sputum [32].
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32. Smith PW, Bennett G, Bradley S, Drinka P, Lautenbach E, Marx J, et al. SHEA/APIC guideline: infection prevention and control in the long-term care facility. Infection Control & Hospital Epidemiology. 2008;29(9):785-814.
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