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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.
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.
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.
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.
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.
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.
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.
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.
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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12. Public Health England (PHE). COVID-19: infection prevention and control guidance 2020 [updated 6 March 2020; cited 2020 8 March]. Available from: https://www.gov.uk/government/publications/wuhan-novelcoronavirus-infection-prevention-and-control/wuhan-novel-coronavirus-wn-cov-infection-prevention-andcontrol-guidance.
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.
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/.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.