Responding to community spread of COVID-19: interim guidance, 7 March 2020

-1- Responding to community spread of COVID-19 Interim guidance 7 March 2020 Background On 30 January, the World Health Organization declared the 2019 coronavirus disease (COVID-19) outbreak a public health emergency of international concern (PHEIC). As of 4 March 2020, 77 countries have reported cases of COVID-19. Several countries have demonstrated the ability to reduce or stop transmission of the COVID-19 virus. The Strategic Preparedness and Response Plan for COVID-19 aims to slow and stop transmission, prevent outbreaks and delay spread; provide optimized care for all patients, especially the seriously ill; minimize the impact of the epidemic on health systems, social services and economic activity. A comprehensive package of measures is required for countries to prepare when there are no cases, sporadic cases, clusters of cases, community transmission, or country-wide transmission. The priorities and intensity of work for each technical area will depend on which scenario a country or a sub-national area currently faces. This document provides guidance for responding to community transmission of COVID-19. This document also compiles technical guidance for government authorities, health workers, and other key stakeholders to guide response to community spread. It will be updated as new information or technical guidance become available. For countries that are already preparing or responding, this document can also serve as a checklist to identify any remaining gaps. The available guidance and trainings are grouped in ten areas: 1. National Coordination 2. Risk communication and community engagement 3. Public health measures 4. Case management and health services 5. Infection prevention and control 6. Surveillance and risk and severity assessments 7. National laboratory systems 8. Logistics, procurement and supply management 9. Maintenance of essential services 10. Research and development National coordination Summary It is critical to activate coordination mechanisms as early as possible and well before community transmission occurs widely. Existing national preparedness plans and public health incident management systems should be reviewed to include a whole-of-government and society approach. Although COVID-19 is different from influenza, building on existing Influenza Pandemic Preparedness Plans is a good starting point. Until medical countermeasures for COVID-19 are available, prevention and control strategies will rely on public health measures to reduce transmission. Recommended actions Highest priority  Enhance whole-of-society coordination mechanisms to support preparedness and response, including the health, transport, travel, trade, finance, security and other sectors. Involve public health Emergency Operations Centres and other emergency response systems early.  Sensitize the public to their active role in the response.  Engage with key partners to develop national and sub-national preparedness and response plans. Build on existing plans such as influenza pandemic preparedness plan.  Enhance hospital and community preparedness plans; ensure that space, staffing, and supplies are adequate for a surge in patient care needs. Secondary priority  Establish metrics and monitoring evaluation systems to assess effectiveness of measures. Document lessons learned to inform on-going and future preparedness and response activities.  Prepare for regulatory approval, market authorization and post-market surveillance of COVID-19 products (e.g. laboratory diagnostics, therapeutics, vaccines), when available. Resources COVID-19 strategic preparedness and response plan Outlines the strategic actions to guide national and international efforts when developing context-specific national and regional operational plans. Available in English and Russian. Public health emergency operations centre network Contains useful resources for countries activating their public health emergency operations centre. Available in English and French. Training: OpenWHO Emerging respiratory viruses, including COVID-19 Methods for detection, prevention, response and control Available in English, Arabic, Chinese, French, Portuguese, Russian, and Spanish. Responding to community spread of COVID-19: Interim guidance -2- Risk communication and community engagement Summary COVID-19 preparedness and response strategies and interventions need to be announced and explained to the public and other sectors of society ahead of time, and again whenever they change. It is essential to communicate to the public what is known, what is unknown, and what is being done to prevent and control transmission. Responsive, transparent, consistent, and nuanced messaging that acknowledges and address public perceptions is required to establish/maintain authority and trust. Systems should be developed to proactively manage the infodemic of misinformation by detecting and responding to concerns, rumours and misinformation. Recommended actions Highest priority:  Implement national risk communication and community engagement plans for COVID-19 using existing pandemic influenza or other public health communication procedures.  Use a consistent mechanism to communicate about prevention and control measures and engage with media, public health and community-based networks, local governments and NGOs, and other sectors (e.g. healthcare, education sector, business, travel, environment, animal and food/agriculture).  Promote culturally appropriate and empathetic community engagement to detect and rapidly respond to public perceptions and counter misinformation. Secondary priority  Conduct analysis of risk perceptions, high risk groups, barriers and enablers for effective public communication. Resources Risk communication and community engagement checklists Guidance to implement effective RCCE strategies, including recommended RCCE goals and actions for countries with confirmed COVID-19 cases. Available in English, Chinese, French and Russian. WHO guidance on risk communications and community engagement (RCCE) readiness and response to the 2019 novel coronavirus (nCoV 2019). Coming soon: Risk communication and community engagement strategy. Coming soon: Risk communication for health workers Coming soon: Community engagement for WHO Representatives. Training: OpenWHO Emerging respiratory viruses, including COVID-19. Module C: Risk Communication and Community Engagement. Available in English, French, Chinese, and Spanish. Public health measures Summary Public health measures can slow the transmission and spread of infectious diseases. These measures can take the form of personal protective, environmental, social distancing, and travel related interventions. Currently, there are no vaccines or specific pharmaceutical treatments available for COVID-19. Public health interventions are and will continue to be an important tool to reduce transmission and prevent spread of COVID-19. Recommended actions  Define rationale and criteria for use of social distancing measures such as cancellation of mass gatherings or school closure. Public health measures Developed for influenza, this document provides recommendations for personal protective, environmental and social distancing interventions which are useful for COVID-19 and other respiratory infections transmitted through contact and droplets. See also COVID-19 specific guidance below. Available in English. Situation Intervention Recommended in all situations. • Hand hygiene • Respiratory etiquette • Masks for symptomatic individuals. • Isolation and treatment of ill individuals. • Monitoring symptoms of healthy contacts. • Traveler health advice • Environmental cleaning Consider, based on local and/or global evaluation. • Avoid crowding (i.e. mass gatherings). • School closures and other measures. • Public transportation closures, and/or • Workplace closures and other measures. • Public health quarantine (asymptomatic contacts) and/or isolation (ill individuals). Guidance for mass gatherings in the context of COVID-19 Outlines key planning considerations for organizers of mass gatherings. Available in English and Russian. Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19). Guidance to Member States on quarantine measures for individuals in the context of containment for COVID-19. Available in English. Responding to community spread of COVID-19: Interim guidance -3- Case management and health services Summary Health care facilities should be prepared for a significant increase of COVID-19 cases while maintaining provision of essential health services. Triage systems will be needed to reduce the risk of exposing other persons or patients to COVID-19, to prioritise treatment for severe and high-risk patients and to manage demands on staff, facilities, and supplies. For many countries, the private sector will be a key partner in provision of health services. Recommended actions Highest priority:  Set up surge triage, screening areas, treatment and critical care units (including staffing, space and supplies, including oxygen) at health facilities.  Disseminate guidance to health providers for COVID-19 and severe acute respiratory infections using international and WHO standards, including for community care.  Make guidance available for home care of patients with mild COVID-19 symptoms and recommend when referral to healthcare facilities is advised if symptoms worsen.  Support comprehensive medical, nutritional, and psycho-social care for people with COVID-19.  Maintain routine and emergency health service provision for the population. Secondary priority  Update training of and refresh medical/ambulatory teams.  Participate in clinical expert networks to aid in clinical characterization of COVID-19, address challenges in clinical care, foster global collaboration. Resources Clinical management of severe acute respiratory infection when COVID-19 is suspected. Intended for clinicians caring for hospitalised adult and paediatric patients with severe acute respiratory infection when COVID-19 infection suspected. Available in English and Russian. Home care for patients with suspected novel coronavirus (COVID-19) infection presenting with mild symptoms. WHO recommendations on safe home care for patients with suspected novel coronavirus (COVID-19) infection presenting with mild symptoms. Available in English and Russian. Coming soon: Guidance on a safe and adequate blood supply for COVID-19. Coming soon: Hospital preparedness for COVID-19 Global guidance in development. Currently, PAHO and EURO guidance are available. Training: OpenWHO Critical Care Severe Acute Respiratory Infection (SARI). Module 1: Introduction to nCoV and IPC Module 2: Clinical syndromes and pathophysiology of sepsis and ARDs. Module 3: Triage Module 4: Monitoring Module 5: Diagnostics Module 6: Oxygen therapy Module 7: Antimicrobials Module 8: Sepsis Module 9: Mechanical ventilation Module 10: Sedation Module 11: Best practices to prevent complications Module 12: Liberation from mechanical ventilation Module 13: Quality in critical care Module 14: Pandemic preparedness and ethical considerations. Available in English. Infection prevention and control Summary Health care facilities should prepare for a significant increase of COVID-19 cases. Staff should be able to recognise signs and symptoms, identify known complications, and administer appropriate treatment while protecting themselves. Preventing infection in health workers and avoiding the spread of COVID-19 amongst patients is key for successful prevention and response, protects the health work force and maintains confidence in the health care system. The private sector should be included in all IPC planning and activities. Recommended actions Highest priority:  Identify and mobilize trained staff with the authority and technical expertise to implement IPC activities at vulnerable health facilities.  Implement triage, early detection, administrative, environmental and engineering controls, personal protective equipment. Provide visual alerts (educational materials in appropriate languages) for patients and families for triage of respiratory symptoms and to practice respiratory etiquette.  Define patient referral pathways and a national plan for ensuring personal protective equipment (PPE) supply management and human resource surge capacity (numbers and competence).  Implement a plan for monitoring health personnel exposed to confirmed COVID-19 cases for respiratory illness and for reporting healthcare- associated infections. Secondary priority  Monitor IPC and WASH implementation in selected health facilities and public spaces using the IPC Assessment Framework, the Hand Hygiene Self-Assessment Framework, hand hygiene compliance observation tools, and the WASH Facilities Improvement Tool. Responding to community spread of COVID-19: Interim guidance -4- Advice on the use of masks Intended for public health and IPC professionals, health care managers, health workers and community health on use of medical masks for COVD-19 in communities, at home and at health facilities. Available in English and Russian. Standard precautions in health care Aide-memoire providing checklist for infection control. Available in English and Russian. Q&A on infection prevention and control for health workers caring for patients. IPC for health workers caring for patients with suspected or confirmed COVID-19. Available in English and Russian. IPC assessment framework WHO Guidelines on Core Components of IPC programmes at the acute health facility level. Available in English. Hand hygiene self-assessment framework and compliance observation tools. Tool to help obtain a situation analysis of hand hygiene promotion and practices in a health facility. Available in English, French, and Spanish. WASH facilities improvement tool (WASH FIT) Risk-based, continuous improvement framework with tools for health facilities. Available in English, Arabic, French, Russian, and Spanish. Rational use of personal protective equipment for coronavirus disease (COVID-19). WHO recommendations for the rational use of PPE in health care and community settings, including the handling of cargo. Available in English. Coming soon: Health workers exposure risk assessment and management in the context of COVID-19 virus. Training: OpenWHO Infection prevention and control (IPC) for novel coronavirus (COVID-19). 1. IPC programmes 2. Chain of transmission 3. Hand and respiratory hygiene 4. Injection safety 5. Decontamination 6. Environmental cleaning 7. Waste management 8. Transmission based precautions Available in English. Training: OpenWHO ePROTECT respiratory infections 1. Acute Respiratory Infections (ARIs) of public health concern- Introduction Chain of transmission. 2. How to protect yourself against ARIs 3. Basic hygiene measures 4. Wearing a medical mask Available in English and French. Surveillance and risk and severity assessments Summary In the event of community transmission over large areas of the country, surveillance may need to evolve from the daily reporting of individual cases towards the less frequent (e.g., weekly) reporting of aggregated data for the purpose of monitoring disease trends. WHO will provide guidance on the reporting of aggregated data. WHO recommends a surveillance approach based on, or similar to the Global Influenza Surveillance and Response System (GISRS) that facilitates less resource-intensive monitoring. Routine surveillance will complement special studies on risk factors, severity, clinical treatments, transmission dynamics in health workers or close settings and other studies on COVID-19. Regular risk assessments at regional, national and subnational levels (including for specific settings such as e.g. small islands) should continue to guide the locally most appropriate prevention and control measures. Assessing the clinical severity of COVID-19 is required to understand excess morbidity and mortality, evaluate the impact on the health systems and plan for future needs. Countries can build on their experience with assessing disease severity of COVID-19 through influenza or other disease protocols. Recommended actions Highest priority:  Disseminate national case definitions for surveillance to the public and private health sectors and communicate changes when needed.  Implement surveillance strategies to monitor and report disease trends, disease severity and impacts on health and other systems. Secondary priority:  Continue conducting risk assessments as appropriate. Use global, regional and/or national and local risk assessments to guide actions or changes to the response strategy.  Establish mechanisms to use surveillance analysis and risk assessments to review national preparedness and response plans. Resources Coming soon: Global surveillance for monitoring community transmission of COVID-19. Training: OpenWHO Emerging respiratory viruses, including COVID-19. Module A: Introduction to emerging respiratory viruses, including COVID-19. Module B: Detecting emerging respiratory viruses, including COVID-19: Surveillance and laboratory. Available in English, Arabic, Chinese, French, Portuguese, Russian, and Spanish. Responding to community spread of COVID-19: Interim guidance -5- National laboratory systems Summary Faced with community transmission over large areas of the country, laboratories will need to prepare for a significant increase in the number of specimens to be tested for COVID-19. Clinical diagnosis may be used for suspect COVID-19 patient once transmission dynamics and clinical disease are better understood. If COVID-19-specific therapeutics are developed, then testing may again become important for clinical management. If laboratories need to rescale testing, sentinel and non- sentinel surveillance sites can be used to collect information on disease trends, impacts, and virus evolution. Countries should maintain access to a WHO-recognized international COVID-19 referral laboratory and to necessary supplies, reagents and protocols. Recommended actions Highest priority:  Prepare for an increase in the number of specimens to be tested in the laboratory.  Ensure access to reagents, supplies and laboratory protocols.  Maintain access to a WHO-recognized international COVID-19 referral laboratory. Secondary priority:  Participate in routine surveillance systems to mmonitor disease trends, impacts, and virus evolution; periodically share isolates with referral laboratories following WHO guidance. Resources WHO interim guidance for laboratory biosafety related to COVID-19. Interim guidance on laboratory biosafety, including packaging and shipping requirements for sending specimens, for stakeholders involved in COVID-19 laboratory work. Available in English and Russian. Molecular assays to diagnose COVID-19 Technical guidance about molecular assay detection protocols for COVID-19. Available in English. WHO-appointed COVID-19 referral laboratories Countries without testing capacity can send samples to WHO-appointed COVID-19 referral laboratories for testing. This link contains the WHO-recognized referral laboratories, shipping instructions, and booking form. Available in English. Training: OpenWHO Emerging respiratory viruses, including COVID-19. Module B: Detecting Emerging Respiratory Viruses, including COVID-19: Surveillance and Laboratory Available in English, Arabic, Chinese, French, Portuguese, Russian, and Spanish. Logistics, procurement and supply management Summary Logistics arrangements to support prevention and control measures for COVF-19 should be reviewed and a surge in all key areas anticipated (e.g. personnel, deployments, procurement). Recommended actions  Implement supply chain control, security, transport, management system for storage and distribution of COVID-19 Disease Commodity Package (DCP), patient kit reserves, and other essential supplies in- country.  Conduct regular review of supplies based on DCP and COVID-19 patient kit; develop a central stock reserve for case management of COVID-19. Disease commodity package Lists critical supplies, with descriptions and technical specifications per WHO guidelines for responding to an outbreak of COVID-19. Available in English and Russian. Maintenance of essential services Summary Community transmission of COVD-19 may lead to an interruption of essential services in the communities affected unless tested business continuity plans are in place. Recommended actions  Adapt and implement national cross-sectoral emergency preparedness business continuity plans, where existing, to COVID-19.  Work with UN agencies and other partners to identify and support continuation of critical functions (i.e. water and sanitation; fuel and energy; food; telecommunications/internet; finance; law and order; education; and transportation), necessary resources, essential workforce. Resources Whole-of-society pandemic readiness Provides insight on maintaining essential services during a disease outbreak. Available in English. Research and development Summary Information for countries contributing to COVID-19 research and development in the areas of diagnostics, vaccines and therapeutics. Recommended action  If national capacity exists, join international R&D blueprint efforts and WHO protocols for special studies (compassionate use, Monitored Emergency Use of Unregistered and Investigational Interventions). Responding to community spread of COVID-19: Interim guidance -6- Resources COVID-19: Research and development blueprint Website providing information on vaccines, therapeutics, diagnostics, and global coordination. Available in English. © World Health Organization 2020. All rights reserved. This is a draft. The content of this document is not final, and the text may be subject to revisions before publication. The document may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated or adapted, in part or in whole, in any form or by any means without the permission of the World Health Organization. WHO reference number: WHO/COVID-19/Community_Transmission/2020.1