Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: interim guidance: updated October 2019

1 Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection Interim guidance Updated October 2019 WHO/MERS/IPC/15.1 Rev 1 Introduction The World Health Organization (WHO) has updated the interim guidance that was published on 6 May 2013 and updated in June 2015 to meet the urgent need for up-to-date information and evidence-based recommendations for the safe care of patients with probable or confirmed Middle East respiratory syndrome coronavirus (MERS-CoV) infection. The interim recommendations are informed by evidence- based guidelines WHO have published, including the Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. WHO Guidelines1 and review of current evidence on MERS- CoV infection. The recommendations have been reviewed by experts in infection prevention and control (IPC) and other technical areas (see Acknowledgements for names and affiliations). This guidance reflects current understanding of IPC related to MERS-CoV2 and uses revised case definitions3. Key changes in these guidelines include the following: -Updates on air exchanges required for patients with clinically suspected and confirmed MERS-CoV -Harmonization on wording around IPC measures throughout document (recommendations have not changed however wording is more nuanced) - PAPR use for airborne isolation is included as an alternative to particulate respirator at least as protective as a NIOSH-certified N95, EU FFP2 or equivalent -Updated guidance on duration of specific IPC measures recommended for MERS-CoV patients. This guidance is intended for health-care workers (HCWs), health-care managers, and IPC teams. Specific WHO interim guidance on Clinical Management of severe acute respiratory infection when Middle East respiratory syndrome coronavirus (MERS-CoV) infection is suspected and Management of asymptomatic persons with MERS-CoV has also been published4,5. WHO continues to monitor the situation closely for any changes that may affect this interim guidance. Should any factors change, WHO will issue a further update. Otherwise, this interim guidance document will expire 2 years after the date of publication. Links are given here to additional sources and evidence. If you have further questions, send an e-mail message to: outbreak@who.int with “MERS IPC question” in the subject line. MERS-CoV is a zoonotic virus, with evidence to date indicating that dromedary camels are the main source of infection to humans. Human-to-human transmission occurs mostly in health-care settings and, to a more limited extent, within communities, mainly in households. Close unprotected contact is needed for transmission which occurs via contact and droplet transmission. There is no evidence of sustained, human-to-human transmission to date however clusters in healthcare settings have been reported6,7 and nosocomial transmission is an important characteristic of MERS-CoV infection8,9. MERS-CoV superspreading events have also been reported in the literature10. Further studies are underway to better understand the risk factors for animal-to- human and human-to-human transmissions. The successful prevention of spread of MERS-CoV infections in health care settings depends on the existence of an effective IPC program that includes the WHO IPC Core Components11. Most transmissions occur due to lack of application of standard IPC precautions during routine care before a specific case is confirmed. The routine application of measures to prevent spread of acute respiratory infections (ARI)1 when caring for symptomatic patients is essential to reduce spread of any ARI in health-care settings. Additional precautions when caring for patients with probable or confirmed infection with MERS-CoV (see section 2.3 ) should be applied to further reduce the risk of transmission. Health-care institutions are advised to consider establishing or reinforcing existing services for the oversight of HCWs’ health to ensure a safe environment for patients and HCWs. It is crucial that HCWs are provided with training and the best locally available protection for caring for MERS-CoV- infected patients and are followed up if exposure has occurred. This guidance summarizes: • Principles of IPC strategies associated with health care • IPC precautions: - for providing care to all patients - for providing care to ARI patients, and - for providing care to patients with probable or confirmed MERS-CoV infection - for preventing and controlling transmission of MERS-CoV to caregivers of the patients in hospital settings 1. Principles of infection prevention and control strategies associated with health care IPC strategies to prevent or limit infection transmission in health-care settings include the following: early recognition and source control, administrative controls, environmental and engineering controls, and personal protective equipment (PPE)1. To be effective, IPC measures must anticipate the flow of patients (and thus the potential risks of infection spread) Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 2 from the first point of encounter until discharge from the facility. Clinical triage including early recognition and immediate placement of patients in separate areas (source control)1 is an important measure for rapid identification and appropriate isolation and care of patients with ARI including those with suspected MERS-CoV infection, as well as limiting spread of infection particularly in areas associated with higher rates of nosocomial transmission in high traffic areas such as the emergency departments, and other specific locations in the hospital such as intensive care departments and dialysis units where MERS-CoV cases have shown to spread. Identified ARI patients should be placed in an area separate from other patients, and additional IPC precautions promptly implemented as appropriate (see section 2.2). Clinical and epidemiological aspects of the cases should be evaluated as soon as possible (see WHO recommendations12) and should be complemented by laboratory evaluation to confirm diagnosis. Administrative controls. Administrative controls and policies that apply to ARI include establishment of sustainable IPC infrastructures and activities; HCW training; patients’ care givers education; clear policies on early recognition of ARIs of potential concern, access to prompt laboratory testing for identification of the etiologic agent; prevention of overcrowding especially in the Emergency department; provision of dedicated waiting areas for symptomatic patients and appropriate placement of hospitalized patients promoting an adequate patient-to-staff ratio; provision and use of regular supplies; IPC policies and procedures for all facets of healthcare provisions - with emphasis on surveillance of ARIs among HCWs and the importance of seeking medical care; and monitoring of HCW compliance, along with mechanisms for improvement as needed. Environmental and engineering controls. These include basic health-care facility infrastructures13. These controls address ensuring adequate environmental ventilation14 in all areas within a health-care facility, as well as adequate environmental cleaning. Spatial separation (social distancing) of at least 1m should be maintained between each ARI patient and others, including HCWs (when not using PPE). Both controls can help reduce the spread of many pathogens during health care15. Personal protective equipment. Rational, correct, and consistent use of available PPE and appropriate hand hygiene16 also help to reduce the spread of the pathogens. Although use of PPE is the most visible control used to prevent transmission, it is the last and weakest in the hierarchy of IPC measures and should not be relied upon as a primary prevention strategy. PPE effectiveness depends on adequate and regular supplies, adequate staff training, proper hand hygiene and in particular, appropriate human behaviour1. In the absence of effective administrative and engineering controls, PPE has limited benefit. 2. Infection prevention and control precautions In summary the following steps in Table 1 should be followed: Table 1. How to implement infection control measures in health care setting When caring for ALL patients Apply standard precautions routinely in all health-care settings for all patients. Standard precautions include: hand hygiene; use of personal protective equipment (PPE) to avoid direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin. Standard precautions also includes: prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment17. When caring for patients with cough or other respiratory symptoms (ARI) Droplet precautions prevent large droplet transmission of respiratory viruses. At triage, recognize patient with ARI, give the patient a medical mask and place the patient in separate area. Use a medical mask if working within 1-metre of the patient. Place patients in single rooms, or group together those with the same etiological diagnosis. If an etiological diagnosis is not possible, group patients with similar clinical diagnosis and based on epidemiological risk factors, with a spatial separation of at least 1 metre between individuals not wearing appropriate PPE. When providing care in close contact with a patient with respiratory symptoms (e.g. coughing or sneezing), use eye protection (face-mask or goggles), because sprays of secretions may occur. Limit patient movement within the institution and ensure that patients wear medical masks when outside their rooms for source control and to diminish potential for environmental decontamination17. Ensure that triage and waiting areas are adequately ventilated. When caring for patients with clinically suspected MERS- CoV For patients with suspected MERS-CoV infection that require hospitalization, place patient in an adequately ventilated single room away from other patient care areas. Droplet and Contact precautions prevent direct or indirect transmission from contact with contaminated surfaces or equipment (i.e. contact with contaminated oxygen tubing/interfaces). Use PPE (a disposable medical mask, eye protection, gloves and gown) when entering room and remove it when leaving. If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between each patient use. Ensure that health care workers refrain from touching their eyes, nose or mouth with potentially contaminated gloved or ungloved hands. Avoid contaminating environmental surfaces that are not directly related to patient care (e.g. door handles and light switches). Ensure adequate room ventilation. Avoid movement of patients or transport. Perform hand hygiene17. Do not place suspect patients in Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 3 the same area or room as those who are confirmed MERS-CoV cases. Limit the number of people entering the assigned area to the minimum number required for patient care. When performing an aerosol- generating procedure in patient with MERS- COV Ensure that healthcare workers performing aerosol-generating procedures (i.e. aspiration or open suctioning of respiratory tract specimens, intubation, cardiopulmonary resuscitation, bronchoscopy) use PPE, including gloves, long-sleeved gowns, eye protection, and particulate respirators (N95 or equivalent, or higher level of protection). Whenever possible, use adequately ventilated single rooms when performing aerosol-generating procedures. This means negative pressure rooms with minimum of 12 air changes per hour or 160 liters/second/patient in facilities with natural ventilation. Avoid unnecessary individuals in the room17. 2.1 Standard Precautions Standard Precautions18, a cornerstone for providing safe health care, reducing the risk of further infection and protecting HCWs, should always be applied in all health- care settings for all patients. Standard Precautions include hand hygiene and use of relevant PPE depending on risk of direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin, prevention of needle-stick or sharps injury; safe waste management; cleaning, disinfection and, where applicable, sterilization of patient-care equipment and linen, and cleaning and disinfection of the environment. Use of respiratory hygiene in anyone with respiratory symptoms should be encouraged. • Cover nose and mouth during coughing or sneezing with medical mask, cloth mask, tissue, or flexed elbow; • Followed by hand hygiene after contact with respiratory secretions. HCWs should apply WHO “My 5 moments for hand hygiene”: before touching a patient; before any clean or aseptic procedure; after body fluid exposure risk; after touching a patient; and after touching a patient’s surroundings. • Hand hygiene includes either cleansing hands with soap and water or the use of an alcohol-based hand rub (ABHR); • ABHR are preferred if hands are not visibly soiled; • Wash hands with soap and water when they are visibly soiled; • The use of PPE does not eliminate the need for hand hygiene. Hand hygiene is also necessary prior to putting on and after taking off PPE.19 The use of PPE should be guided by a risk assessment concerning anticipated contact with blood, body fluids, secretions and non-intact skin for routine patient care. When there is a risk of contamination of the face and/or body, PPE should include the use of: • Facial protection by means of either a medical mask20 and eye-visor or goggles; or a face shield; • A gown; and • Clean gloves. HCWs should avoid self-contamination from touching their eyes, nose or mouth with potentially contaminated gloved or ungloved hands. Ensure that cleaning and disinfection procedures are followed consistently and correctly. Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure. Manage laundry, food service utensils and medical waste in accordance with safe routine procedures1. 2.2. Additional infection prevention and control precautions when caring for patients with acute respiratory infection (ARI) • In addition to Standard Precautions, all individuals, including visitors and HCWs, in contact with patients with ARI should apply Droplet precautions: • Place patient in a separate area; • Use a medical mask (for specifications please see1); • Use eye protection (i.e. goggles or a face shield) when in close contact (i.e. within 1m). For practical purposes it is advisable to use medical mask upon entering the room or cubicle of the patient; • Follow WHO guidance for steps of donning and doffing PPE. Perform hand hygiene before and after contact with the patient and his or her surroundings and immediately after removal of PPE. Detailed precautions are described in published WHO guidelines1 and should be applied when providing care to patients with ARI. 2.3. Infection prevention and control precautions when caring for patients with clinically suspected or probable/confirmed MERS-CoV infection In addition to Standard Precautions, all individuals, including family members, visitors, private medical attendants and HCWs, in close contact (within 1m) or for practical purposes entering the room or cubicle of the patient with clinically suspected or probable/ confirmed MERS- CoV infection should always apply Contact and Droplet precautions • Place patients with clinically suspected or probable/ confirmed MERS-CoV infection in adequately ventilated single rooms. For naturally ventilated general ward rooms this is considered to be 60L/second per patient21; • When single rooms are not available, cohort MERS- CoV patients together; • Always place patient beds at least 1m apart; • To the extent possible, assign a specific group of skilled HCWs to exclusively care for probable or confirmed cases both for continuity of care and to Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 4 reduce opportunities for inadvertent infection control breaches that could result in unprotected exposure; • Use a medical mask (for specifications please see1,22); • Use eye protection (i.e. goggles or a face shield); • Use a clean, non-sterile, long-sleeved fluid resistant gown (if gown is not fluid resistant, wear a waterproof apron on top of the gown if splashing or spraying of potentially infectious material is anticipated); • Use gloves (some procedures may require sterile gloves); • Follow WHO guidance for steps of donning and doffing PPE. Perform hand hygiene before and after contact with the patient and his or her surroundings and immediately after removal of PPE; • Use either single use disposable equipment or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it after each patient use (e.g. ethyl alcohol 70%); • Refrain from touching their eyes, nose or mouth with potentially contaminated hands, whether gloved or ungloved; • Avoid touching and contaminating surfaces not involved with direct patient care, i.e. door knobs, light switches, mobile phones; • Avoid the movement and transport of patients out of the room or area unless medically necessary. The use of designated portable X-ray equipment and other important diagnostic equipment may make this easier. If transport is required, use routes of transport that minimize exposures to staff, other patients and visitors and apply medical mask to patient; • Notify the receiving area of the patient's diagnosis and necessary precautions as soon as possible before the patient’s arrival; • Clean and disinfect patient-contact surfaces (e.g. bed) after use23; • Ensure that HCWs who are transporting patients wear appropriate PPE as described in this section and perform hand hygiene; • Limit the number of HCWs, family members and visitors in contact with a patient with clinically suspected or probable/ confirmed MERS-CoV infection; • Family members, visitors, private medical attendants and others who come into contact with a patient should be limited to those essential for patient support and maintain contact and droplet precautions when providing this support. They should be educated on the risk of transmission and the appropriate use of the same infection control precautions to prevent infection transmission described in this section; • A record of all persons that enter the patient’s room should be kept by hospital staff; 2.4. Infection prevention and control precautions for aerosol-generating procedures for patients with clinical suspected or probable/confirmed MERS-CoV infection An aerosol-generating procedure is defined as any medical procedure that can induce the production of aerosols of various sizes, including small (≤5 µm) particles over a long distance (> 1m). Some aerosol generating procedures have been associated with increased risk of transmission of coronavirus (SARS- CoV) such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation and bronchoscopy8,20,. Increased risk of SARS-CoV transmission was also reported when performing non-invasive ventilation, tracheotomy and manual ventilation before intubation; however, these findings were identified from a limited number of very low- quality studies24,25. Though definitive evidence is lacking, non-invasive ventilation, high-flow nasal cannula, aerosolized nebulizer treatments, chest physiotherapy also have the potential to general aerosols and facilitate transmission of certain respiratory viruses. When performing these treatments, it is prudent to implement airborne precautions. Advise visitors and family members about risk of transmission. Instruct the m on PPE use and hand hygiene. Evaluate visitors for symptoms of ARI (and MERS) before visit. Limit visitors to those essential for support. Advise that anyone who is at increased risk of severe disease does not care for the ill person. Additional Airborne precautions when performing aerosol- generating procedures includes the use of: • A particulate respirator at least as protective as a NIOSH-certified N95, EU FFP2 or equivalent1,22; when putting on a disposable particulate respirator, always check the seal23; • Note that if the wearer has facial hear (beard) this can prevent a proper respirator fit26 • In some countries where available powered air-purifying respirator (PAPR) is utilized instead of a respirator27 • Eye protection (i.e. goggles or a face shield); • Clean, non-sterile, long-sleeved gown and gloves (some of these procedures require sterile gloves); • If gowns are not fluid resistant, use a waterproof apron for some procedures with expected high fluid volumes that might penetrate the gown1; • Perform procedures 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 and controlled direction of air flow when using mechanical ventilation • Limit the number of persons present in the room to the absolute minimum required for the patient’s care and support; and • Follow WHO guidance for steps of donning and doffing PPE. Perform hand hygiene before and after contact with the patient and his or her surroundings and after PPE removal. 2.5. Duration of contact and droplet precautions for MERS-CoV infection The duration of infectivity of MERS-CoV infected patients has been evaluated in several countries including the Kingdom of Saudi Arabia, United Arab Emirates and the Republic of Korea,28,29,30. From these studies, lower Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 5 respiratory tract samples are of higher diagnostic value31 and tend to be PCR positive longer compared to upper respiratory tract samples and typically, patients with more severe disease shed virus longer than laboratory confirmed cases with mild or no symptoms. Contact tracing during health care associated outbreaks have identified secondary cases who have no symptoms (i.e., are asymptomatic) but can shed virus for up to two weeks28,32. One study reported prolonged nasal virus RNA defection of more than 5 weeks in an asymptomatic HCW. Standard Precautions should always be applied at all times. Additional contact and droplet precautions should be continue until the patient is asymptomatic and has two consecutive upper respiratory tract samples (e.g. nasopharyngeal l [NP] and/or oropharyngeal [OP] swabs) taken at least 24 hours apart test negative on RT-PCR. Given that limited information is currently available on viral shedding and the potential for transmission of MERS-CoV, testing for viral shedding should assist decision-making when available. Important patient factors such as age and immune status may contribute to prolonged shedding of virus (>1 month)28 and thereby prolong the necessity for contact and droplet precautions. 2.6. Collection and handling of laboratory specimens from patients with ARIs of potential concern (including MERS-CoV) All specimens collected for laboratory investigations should be regarded as potentially infectious, and HCWs who collect or transport clinical specimens should adhere rigorously to Standard Precautions to minimize the possibility of exposure to pathogens. • Ensure that HCWs who collect specimens use appropriate PPE (eye protection, medical mask, gown, gloves). • Ensure that personnel who transport specimens are trained in safe handling practices and spill decontamination procedures. • Place specimens for transport in leak-proof specimen bags (secondary container) that have a separate sealable pocket for the specimen (i.e. a plastic biohazard specimen bag), with the patient’s label on the specimen container (primary container), and a clearly written request form. • Ensure that health-care facility laboratories adhere to appropriate biosafety practices and transport requirements according to the type of organism being handled. • Deliver all specimens by hand whenever possible. Do not use pneumatic-tube systems to transport specimens. • State the full name, date of birth of the (suspected) ARI of potential concern clearly on the accompanying request form. Notify the laboratory as soon as possible that the specimen is being transported. For further information on specimen handling in the laboratory and laboratory testing for novel coronavirus, see Laboratory biorisk management for laboratories handling human specimens suspected or confirmed to contain novel coronavirus: Interim recommendations and the Laboratory Testing for Middle East Respiratory Syndrome Coronavirus: Interim guidance. For further information on laboratory biosafety guidelines, see the WHO Laboratory Biosafety Manual, 3rd edition33. Acknowledgements This document was developed in consultation with the WHO Global Infection Prevention and Control Network and Emerging Disease Clinical Assessment and Response Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • APIC Practice Guidance Committee Review • Abdullah Assiri, Director General, Infection Control, Ministry of Health, Saudi Arabia • Michael Bell, Deputy Director of Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • John M Conly, Departments of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University of Calgary, Calgary, Canada • Niklas Danielsson, Senior expert communicable diseases, Vaccine preventable diseases, Surveillance and Response Support unit, European Centre for Disease Prevention and Control • Katherine Defalco, Nurse Consultant, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Canada • Elaine Furukawa, Director of Training, Infection Control, Ministry of Health, Saudi Arabia • Susan I. Gerber, Team Lead, Respiratory Viruses/Picornaviruses, Division of Viral Diseases/Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA • Ahmad Mohammad Hakawi, Director-General, General Directorate of Infectious Diseases Control, Ministry of Health, Saudi Arabia • Benedikt Huttner, Infection Control Program and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland • M Mushtuq Husain, Coordinator, Coordinator and Support Centre, Directorate General of Health Services and Former Principal Scientific Officer & Head, Department of Medical Social Science, Institute of Epidemiology, Disease Control & Research (IEDCR), Dhaka, Bangladesh • David Hui, Chairman, Department of Medicine & Therapeutics, Stanley Ho Professor of Respiratory Medicine, Director of Stanley Ho Center for Emerging Infectious Diseases,Director of SH Ho Sleep Apnoea Management Center, The Chinese University of Hong Kong • Souha S Kanj, Professor and Head of Infectious Diseases and Chairperson of the Infection Control and Prevention Program at the American University of Beirut Medical Center,Beirut, Lebanon • David T. Kuhar, Medical Officer, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 6 • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Anna-Pelagia Magiorakos, Senior Expert, Antimicrobial Resistance and Healthcare-Associated Infections, European Centre for Disease Prevention and Control • Shaheen Mehtar, Extraordinary Professor, Unit for Infection Prevention and Control, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa and Chair, Infection Control African Network • Ziad A Memish, Professor, College of Medicine, Alfaisal University & Prince Mohammed Bin Abdulaziz Hospital, Ministry of Health, Riyadh, Kingdom of Saudi Arabia • Nico T. Mutters, Specialist for Infection Control and Environmental Health, Specialist for Clinical Microbiology, Master of Public Health, Scientific Coordinator EUCIC • Babacar N Doye, Board Member, Infection Control African Network, Dakar, Senegal • Folasade T Ogunsola, Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Nigeria and Board member, Infection Control African Network • Fernando Otaiza O'Ryan, Head, National IPC Program, Ministry of Health, Santiago, Chile • Maria Clara Padoveze, School of Nursing, University of São Paulo, Brazil • Nick Phin, Preparedness and Response Section, Respiratory Diseases Department, HPA Colindale, London, United Kingdom • Didier Pittet, Director, Infection Control Program and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland • Natalia Pshenichnaya, Professor, Rostov State Medical University, Rostov, Russian Federation • Wing Hong Seto, Department of Community Medicine, School of Public Health, University of Hong Kong, Hong Kong, People's Republic of China • Nandini Shetty, Consultant Microbiologist, Reference Microbiology Services, Colindale, Health Protection Agency, United Kingdom • Nalini Singh, Professor of Pediatrics, Global Health, Epidemiology, The George Washington University, Washington, DC, USA • Thomas Weaver, Director, Professional Practice, APIC and the Association for Professionals in Infection Control and Epidemiology WHO Health Emergencies Programme: Janet Diaz, Devika Dixit, Amgad Elkholy, Mamun Malik, Dina Pfeifer, Maria Van Kerkhove. The reviewers were required to sign a declaration of interests, and no conflicts of interest were identified. References 1. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care - WHO Guidelines. Geneva, World Health Organization, 2014. Available at http://apps.who.int/iris/bitstream/10665/112656/1/97892 41507134_eng.pdf 2. For the latest information, please consult the WHO coronavirus web page at http://www.who.int/csr/disease/coronavirus_infections/en /. 3. Middle East respiratory syndrome Case definition for reporting to WHO: Interim case definition. Geneva, World Health Organization, 2017. Available at http://www.who.int/csr/disease/coronavirus_infections/ca se_definition/en/. 4. Clinical management of severe acute respiratory infection when Middle East respiratory syndrome coronavirus (MERS-CoV) infection is suspected: Interim guidance. Geneva, World Health Organization, 2019. Available at https://www.who.int/csr/disease/coronavirus_infections/c ase-management-ipc/en/ 5. Management of asymptomatic persons who are RT- PCR positive for Middle East respiratory syndrome coronavirus (MERS-CoV): Interim guidance. Geneva, World Health Organization, 2018. Available at https://apps.who.int/iris/bitstream/handle/10665/180973/ WHO_MERS_IPC_15.2_eng.pdf?sequence=1 6. Middle East respiratory syndrome coronavirus (MERS- CoV): Key facts. Geneva, World Health Organization, 2019. Available at https://www.who.int/en/news- room/fact-sheets/detail/middle-east-respiratory- syndrome-coronavirus-(mers-cov) 7. Hunter JC, Nguyen D, Aden B, et al. Transmission of Middle East Respiratory Syndrome Coronavirus Infections in Healthcare Settings, Abu Dhabi. Emerg Infect Dis. 2016;22(4):647–656. doi:10.3201/eid2204.151615. 8. Hui DS. Epidemic and Emerging Coronaviruses (Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome). Clin Chest Med. 2017 Mar;38(1):71-86. doi: 10.1016/j.ccm.2016.11.007. 9. Alraddadi BM, Al-Salmi HS, Jacobs-Slifka K et al. Risk Factors for Middle East Respiratory Syndrome Coronavirus Infection among Healthcare Personnel. Emerg Infect Dis. 2016 Nov;22(11):1915-1920. doi: 10.3201/eid2211.160920. 10. Korea Centers for Disease Control and Prevention. Middle East Respiratory Syndrome Coronavirus Outbreak in the Republic of Korea, 2015. Osong Public Health Res Perspect. 2015 Aug; 6(4): 269–278. 11. Core components of infection prevention and control programmes in health care. Aide-memoire. Geneva, World Health Organization, 2011. Available at http://www.who.int/csr/resources/publications/AM_core_ components_IPC/en/. 12. Interim surveillance recommendations for human infection with Middle East respiratory syndrome coronavirus. Geneva, World Health Organization, 2014. Available at http://www.who.int/csr/disease/coronavirus_infections/In terimRevisedSurveillanceRecommendations_nCoVinfect ion_14July2014.pdf Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 7 13. Essential environmental health standards in health care. Geneva, World Health Organization, 2008. Available at http://www.who.int/water_sanitation_health/hygiene/setti ngs/ehs_hc/en/index.html. 14. Natural ventilation for infection control in health-care settings. Geneva, World Health Organization, 2009. Available at http://www.who.int/water_sanitation_health/publications/ natural_ventilation/en/index.html. 15. Jefferson T, Del Mar CB, Dooley L et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews, 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD 006207.pub4/abstract;jsessionid=074644E776469A4CFB 54F28D01B82835.d03t02. 16. WHO Guidelines on hand hygiene in health care. Geneva, World Health Organization, 2009. Available at http://whqlibdoc.who.int/publications/2009/97892415979 06_eng.pdf. 17. Infection-control measures for health care of patients with acute respiratory diseases in community settings. Trainee's Guide. Geneva, World Health Organization, 2009. Available at http://www.who.int/csr/resources/publications/WHO_HS E_GAR_BDP_2009_1a/en/index.html. 18. Standard Precautions are basic precautions designed to minimize direct, unprotected exposure to potentially infected blood, body fluids or secretions applicable to all patients. See also Standard precautions in health care. Geneva, World Health Organization, 2007. Available at http://www.who.int/csr/resources/publications/EPR_AM 2_E7.pdf. 19. How to put on and take off Personal Protective Equipment (PPE). Geneva, World Health Organization 2008. Available at http://www.who.int/csr/resources/publications/putontake offPPE/en/. 20. 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:e35797. 21. Natural Ventilation for Infection Control in Health-Care Settings. Geneva, World Health Organization, 2009. Available at https://apps.who.int/iris/bitstream/handle/10665/44167/9 789241547857_eng.pdf?sequence=1: 22. How to perform a particulate respirator seal check. Geneva, World Health Organization 2008. http://www.who.int/csr/resources/publications/respirators ealcheck/en/. 23. Community case management during an influenza outbreak. A training package for community health workers. Geneva, World Health Organization, 2011. Available at http://www.who.int/influenza/resources/documents/com munity_case_management_flipbook/en/index.html. 24. Lai MY, Cheng PK, Lim WW. Survival of severe acute respiratory syndrome coronavirus. Clinical Infectious Diseases, 2005, 41(7):67–71. 25. Chan KH, Poon LL, Cheng VC et al. Detection of SARS coronavirus in patients with suspected SARS. Emerging Infectious Diseases, 2004, 10(2):294–299. 26. Laboratory biorisk management for laboratories handling human specimens suspected or confirmed to contain novel coronavirus: Interim recommendations. Geneva, World Health Organization, 2013. Available at http://www.who.int/csr/disease/coronavirus_infections/N ovelCoronavirus_InterimRecommendationsLaboratoryBi orisk_190213/en/index.html 27. Implementing the WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households. Available at http://www.stoptb.org/wg/tb_hiv/assets/documents/tbici mplementationframework1288971813.pdf 28. Kim SH, Ko JH, Park GE et al. Atypical presentations of MERS-CoV infection in immunocompromised hosts. J Infect Chemother. 2017 Nov;23(11):769-773. doi: 10.1016/j.jiac.2017.04.004. 29. Corman VM, Albarrak AM, Omrani AS, et al. Viral Shedding and Antibody Response in 37 Patients With Middle East Respiratory Syndrome Coronavirus Infection. Clin Infect Dis. 2016; 62(4):477-483. 30. Al Hosani FI, Pringle K, Al Mulla M, et al. Response to Emergence of Middle East Respiratory Syndrome Coronavirus, Abu Dhabi, United Arab Emirates, 2013- 2014. Emerg Infect Dis. 2016;22(7):1162–1168. 31. Laboratory Testing for Middle East Respiratory Syndrome Coronavirus: Interim guidance. Geneva, World Health Organization, 2018. Available at http://apps.who.int/iris/bitstream/handle/10665/259952/ WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1 32. Middle East Respiratory Syndrome Coronovirus Guidelines for Healthcare Professionals. Saudi Arabia, Ministry of Health. Version 5. April 1, 2018. Available at: https://www.moh.gov.sa/CCC/StaffRegulations/Corona/ Documents/MERS- CoV%20Guidelines%20for%20Healthcare%20Professio nals%20-%20April%202018%20-%20v5.pdf 33. WHO laboratory biosafety manual, third edition. Geneva, World Health Organization, 2004. Available at http://www.who.int/csr/resources/publications/biosafety/ WHO_CDS_CSR_LYO_2004_11/en/ Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 8 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection. Geneva, Switzerland: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev 1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

1 Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection Interim guidance Updated October 2019 WHO/MERS/IPC/15.1 Rev 1 Introduction The World Health Organization (WHO) has updated the interim guidance that was published on 6 May 2013 and updated in June 2015 to meet the urgent need for up-to-date information and evidence-based recommendations for the safe care of patients with probable or confirmed Middle East respiratory syndrome coronavirus (MERS-CoV) infection. The interim recommendations are informed by evidence- based guidelines WHO have published, including the Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. WHO Guidelines1 and review of current evidence on MERS- CoV infection. The recommendations have been reviewed by experts in infection prevention and control (IPC) and other technical areas (see Acknowledgements for names and affiliations). This guidance reflects current understanding of IPC related to MERS-CoV2 and uses revised case definitions3. Key changes in these guidelines include the following: -Updates on air exchanges required for patients with clinically suspected and confirmed MERS-CoV -Harmonization on wording around IPC measures throughout document (recommendations have not changed however wording is more nuanced) - PAPR use for airborne isolation is included as an alternative to particulate respirator at least as protective as a NIOSH-certified N95, EU FFP2 or equivalent -Updated guidance on duration of specific IPC measures recommended for MERS-CoV patients. This guidance is intended for health-care workers (HCWs), health-care managers, and IPC teams. Specific WHO interim guidance on Clinical Management of severe acute respiratory infection when Middle East respiratory syndrome coronavirus (MERS-CoV) infection is suspected and Management of asymptomatic persons with MERS-CoV has also been published4,5. WHO continues to monitor the situation closely for any changes that may affect this interim guidance. Should any factors change, WHO will issue a further update. Otherwise, this interim guidance document will expire 2 years after the date of publication. Links are given here to additional sources and evidence. If you have further questions, send an e-mail message to: outbreak@who.int with “MERS IPC question” in the subject line. MERS-CoV is a zoonotic virus, with evidence to date indicating that dromedary camels are the main source of infection to humans. Human-to-human transmission occurs mostly in health-care settings and, to a more limited extent, within communities, mainly in households. Close unprotected contact is needed for transmission which occurs via contact and droplet transmission. There is no evidence of sustained, human-to-human transmission to date however clusters in healthcare settings have been reported6,7 and nosocomial transmission is an important characteristic of MERS-CoV infection8,9. MERS-CoV superspreading events have also been reported in the literature10. Further studies are underway to better understand the risk factors for animal-to- human and human-to-human transmissions. The successful prevention of spread of MERS-CoV infections in health care settings depends on the existence of an effective IPC program that includes the WHO IPC Core Components11. Most transmissions occur due to lack of application of standard IPC precautions during routine care before a specific case is confirmed. The routine application of measures to prevent spread of acute respiratory infections (ARI)1 when caring for symptomatic patients is essential to reduce spread of any ARI in health-care settings. Additional precautions when caring for patients with probable or confirmed infection with MERS-CoV (see section 2.3 ) should be applied to further reduce the risk of transmission. Health-care institutions are advised to consider establishing or reinforcing existing services for the oversight of HCWs’ health to ensure a safe environment for patients and HCWs. It is crucial that HCWs are provided with training and the best locally available protection for caring for MERS-CoV- infected patients and are followed up if exposure has occurred. This guidance summarizes: • Principles of IPC strategies associated with health care • IPC precautions: - for providing care to all patients - for providing care to ARI patients, and - for providing care to patients with probable or confirmed MERS-CoV infection - for preventing and controlling transmission of MERS-CoV to caregivers of the patients in hospital settings 1. Principles of infection prevention and control strategies associated with health care IPC strategies to prevent or limit infection transmission in health-care settings include the following: early recognition and source control, administrative controls, environmental and engineering controls, and personal protective equipment (PPE)1. To be effective, IPC measures must anticipate the flow of patients (and thus the potential risks of infection spread) Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 2 from the first point of encounter until discharge from the facility. Clinical triage including early recognition and immediate placement of patients in separate areas (source control)1 is an important measure for rapid identification and appropriate isolation and care of patients with ARI including those with suspected MERS-CoV infection, as well as limiting spread of infection particularly in areas associated with higher rates of nosocomial transmission in high traffic areas such as the emergency departments, and other specific locations in the hospital such as intensive care departments and dialysis units where MERS-CoV cases have shown to spread. Identified ARI patients should be placed in an area separate from other patients, and additional IPC precautions promptly implemented as appropriate (see section 2.2). Clinical and epidemiological aspects of the cases should be evaluated as soon as possible (see WHO recommendations12) and should be complemented by laboratory evaluation to confirm diagnosis. Administrative controls. Administrative controls and policies that apply to ARI include establishment of sustainable IPC infrastructures and activities; HCW training; patients’ care givers education; clear policies on early recognition of ARIs of potential concern, access to prompt laboratory testing for identification of the etiologic agent; prevention of overcrowding especially in the Emergency department; provision of dedicated waiting areas for symptomatic patients and appropriate placement of hospitalized patients promoting an adequate patient-to-staff ratio; provision and use of regular supplies; IPC policies and procedures for all facets of healthcare provisions - with emphasis on surveillance of ARIs among HCWs and the importance of seeking medical care; and monitoring of HCW compliance, along with mechanisms for improvement as needed. Environmental and engineering controls. These include basic health-care facility infrastructures13. These controls address ensuring adequate environmental ventilation14 in all areas within a health-care facility, as well as adequate environmental cleaning. Spatial separation (social distancing) of at least 1m should be maintained between each ARI patient and others, including HCWs (when not using PPE). Both controls can help reduce the spread of many pathogens during health care15. Personal protective equipment. Rational, correct, and consistent use of available PPE and appropriate hand hygiene16 also help to reduce the spread of the pathogens. Although use of PPE is the most visible control used to prevent transmission, it is the last and weakest in the hierarchy of IPC measures and should not be relied upon as a primary prevention strategy. PPE effectiveness depends on adequate and regular supplies, adequate staff training, proper hand hygiene and in particular, appropriate human behaviour1. In the absence of effective administrative and engineering controls, PPE has limited benefit. 2. Infection prevention and control precautions In summary the following steps in Table 1 should be followed: Table 1. How to implement infection control measures in health care setting When caring for ALL patients Apply standard precautions routinely in all health-care settings for all patients. Standard precautions include: hand hygiene; use of personal protective equipment (PPE) to avoid direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin. Standard precautions also includes: prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment17. When caring for patients with cough or other respiratory symptoms (ARI) Droplet precautions prevent large droplet transmission of respiratory viruses. At triage, recognize patient with ARI, give the patient a medical mask and place the patient in separate area. Use a medical mask if working within 1-metre of the patient. Place patients in single rooms, or group together those with the same etiological diagnosis. If an etiological diagnosis is not possible, group patients with similar clinical diagnosis and based on epidemiological risk factors, with a spatial separation of at least 1 metre between individuals not wearing appropriate PPE. When providing care in close contact with a patient with respiratory symptoms (e.g. coughing or sneezing), use eye protection (face-mask or goggles), because sprays of secretions may occur. Limit patient movement within the institution and ensure that patients wear medical masks when outside their rooms for source control and to diminish potential for environmental decontamination17. Ensure that triage and waiting areas are adequately ventilated. When caring for patients with clinically suspected MERS- CoV For patients with suspected MERS-CoV infection that require hospitalization, place patient in an adequately ventilated single room away from other patient care areas. Droplet and Contact precautions prevent direct or indirect transmission from contact with contaminated surfaces or equipment (i.e. contact with contaminated oxygen tubing/interfaces). Use PPE (a disposable medical mask, eye protection, gloves and gown) when entering room and remove it when leaving. If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between each patient use. Ensure that health care workers refrain from touching their eyes, nose or mouth with potentially contaminated gloved or ungloved hands. Avoid contaminating environmental surfaces that are not directly related to patient care (e.g. door handles and light switches). Ensure adequate room ventilation. Avoid movement of patients or transport. Perform hand hygiene17. Do not place suspect patients in Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 3 the same area or room as those who are confirmed MERS-CoV cases. Limit the number of people entering the assigned area to the minimum number required for patient care. When performing an aerosol- generating procedure in patient with MERS- COV Ensure that healthcare workers performing aerosol-generating procedures (i.e. aspiration or open suctioning of respiratory tract specimens, intubation, cardiopulmonary resuscitation, bronchoscopy) use PPE, including gloves, long-sleeved gowns, eye protection, and particulate respirators (N95 or equivalent, or higher level of protection). Whenever possible, use adequately ventilated single rooms when performing aerosol-generating procedures. This means negative pressure rooms with minimum of 12 air changes per hour or 160 liters/second/patient in facilities with natural ventilation. Avoid unnecessary individuals in the room17. 2.1 Standard Precautions Standard Precautions18, a cornerstone for providing safe health care, reducing the risk of further infection and protecting HCWs, should always be applied in all health- care settings for all patients. Standard Precautions include hand hygiene and use of relevant PPE depending on risk of direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin, prevention of needle-stick or sharps injury; safe waste management; cleaning, disinfection and, where applicable, sterilization of patient-care equipment and linen, and cleaning and disinfection of the environment. Use of respiratory hygiene in anyone with respiratory symptoms should be encouraged. • Cover nose and mouth during coughing or sneezing with medical mask, cloth mask, tissue, or flexed elbow; • Followed by hand hygiene after contact with respiratory secretions. HCWs should apply WHO “My 5 moments for hand hygiene”: before touching a patient; before any clean or aseptic procedure; after body fluid exposure risk; after touching a patient; and after touching a patient’s surroundings. • Hand hygiene includes either cleansing hands with soap and water or the use of an alcohol-based hand rub (ABHR); • ABHR are preferred if hands are not visibly soiled; • Wash hands with soap and water when they are visibly soiled; • The use of PPE does not eliminate the need for hand hygiene. Hand hygiene is also necessary prior to putting on and after taking off PPE.19 The use of PPE should be guided by a risk assessment concerning anticipated contact with blood, body fluids, secretions and non-intact skin for routine patient care. When there is a risk of contamination of the face and/or body, PPE should include the use of: • Facial protection by means of either a medical mask20 and eye-visor or goggles; or a face shield; • A gown; and • Clean gloves. HCWs should avoid self-contamination from touching their eyes, nose or mouth with potentially contaminated gloved or ungloved hands. Ensure that cleaning and disinfection procedures are followed consistently and correctly. Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure. Manage laundry, food service utensils and medical waste in accordance with safe routine procedures1. 2.2. Additional infection prevention and control precautions when caring for patients with acute respiratory infection (ARI) • In addition to Standard Precautions, all individuals, including visitors and HCWs, in contact with patients with ARI should apply Droplet precautions: • Place patient in a separate area; • Use a medical mask (for specifications please see1); • Use eye protection (i.e. goggles or a face shield) when in close contact (i.e. within 1m). For practical purposes it is advisable to use medical mask upon entering the room or cubicle of the patient; • Follow WHO guidance for steps of donning and doffing PPE. Perform hand hygiene before and after contact with the patient and his or her surroundings and immediately after removal of PPE. Detailed precautions are described in published WHO guidelines1 and should be applied when providing care to patients with ARI. 2.3. Infection prevention and control precautions when caring for patients with clinically suspected or probable/confirmed MERS-CoV infection In addition to Standard Precautions, all individuals, including family members, visitors, private medical attendants and HCWs, in close contact (within 1m) or for practical purposes entering the room or cubicle of the patient with clinically suspected or probable/ confirmed MERS- CoV infection should always apply Contact and Droplet precautions • Place patients with clinically suspected or probable/ confirmed MERS-CoV infection in adequately ventilated single rooms. For naturally ventilated general ward rooms this is considered to be 60L/second per patient21; • When single rooms are not available, cohort MERS- CoV patients together; • Always place patient beds at least 1m apart; • To the extent possible, assign a specific group of skilled HCWs to exclusively care for probable or confirmed cases both for continuity of care and to Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 4 reduce opportunities for inadvertent infection control breaches that could result in unprotected exposure; • Use a medical mask (for specifications please see1,22); • Use eye protection (i.e. goggles or a face shield); • Use a clean, non-sterile, long-sleeved fluid resistant gown (if gown is not fluid resistant, wear a waterproof apron on top of the gown if splashing or spraying of potentially infectious material is anticipated); • Use gloves (some procedures may require sterile gloves); • Follow WHO guidance for steps of donning and doffing PPE. Perform hand hygiene before and after contact with the patient and his or her surroundings and immediately after removal of PPE; • Use either single use disposable equipment or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it after each patient use (e.g. ethyl alcohol 70%); • Refrain from touching their eyes, nose or mouth with potentially contaminated hands, whether gloved or ungloved; • Avoid touching and contaminating surfaces not involved with direct patient care, i.e. door knobs, light switches, mobile phones; • Avoid the movement and transport of patients out of the room or area unless medically necessary. The use of designated portable X-ray equipment and other important diagnostic equipment may make this easier. If transport is required, use routes of transport that minimize exposures to staff, other patients and visitors and apply medical mask to patient; • Notify the receiving area of the patient's diagnosis and necessary precautions as soon as possible before the patient’s arrival; • Clean and disinfect patient-contact surfaces (e.g. bed) after use23; • Ensure that HCWs who are transporting patients wear appropriate PPE as described in this section and perform hand hygiene; • Limit the number of HCWs, family members and visitors in contact with a patient with clinically suspected or probable/ confirmed MERS-CoV infection; • Family members, visitors, private medical attendants and others who come into contact with a patient should be limited to those essential for patient support and maintain contact and droplet precautions when providing this support. They should be educated on the risk of transmission and the appropriate use of the same infection control precautions to prevent infection transmission described in this section; • A record of all persons that enter the patient’s room should be kept by hospital staff; 2.4. Infection prevention and control precautions for aerosol-generating procedures for patients with clinical suspected or probable/confirmed MERS-CoV infection An aerosol-generating procedure is defined as any medical procedure that can induce the production of aerosols of various sizes, including small (≤5 µm) particles over a long distance (> 1m). Some aerosol generating procedures have been associated with increased risk of transmission of coronavirus (SARS- CoV) such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation and bronchoscopy8,20,. Increased risk of SARS-CoV transmission was also reported when performing non-invasive ventilation, tracheotomy and manual ventilation before intubation; however, these findings were identified from a limited number of very low- quality studies24,25. Though definitive evidence is lacking, non-invasive ventilation, high-flow nasal cannula, aerosolized nebulizer treatments, chest physiotherapy also have the potential to general aerosols and facilitate transmission of certain respiratory viruses. When performing these treatments, it is prudent to implement airborne precautions. Advise visitors and family members about risk of transmission. Instruct the m on PPE use and hand hygiene. Evaluate visitors for symptoms of ARI (and MERS) before visit. Limit visitors to those essential for support. Advise that anyone who is at increased risk of severe disease does not care for the ill person. Additional Airborne precautions when performing aerosol- generating procedures includes the use of: • A particulate respirator at least as protective as a NIOSH-certified N95, EU FFP2 or equivalent1,22; when putting on a disposable particulate respirator, always check the seal23; • Note that if the wearer has facial hear (beard) this can prevent a proper respirator fit26 • In some countries where available powered air-purifying respirator (PAPR) is utilized instead of a respirator27 • Eye protection (i.e. goggles or a face shield); • Clean, non-sterile, long-sleeved gown and gloves (some of these procedures require sterile gloves); • If gowns are not fluid resistant, use a waterproof apron for some procedures with expected high fluid volumes that might penetrate the gown1; • Perform procedures 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 and controlled direction of air flow when using mechanical ventilation • Limit the number of persons present in the room to the absolute minimum required for the patient’s care and support; and • Follow WHO guidance for steps of donning and doffing PPE. Perform hand hygiene before and after contact with the patient and his or her surroundings and after PPE removal. 2.5. Duration of contact and droplet precautions for MERS-CoV infection The duration of infectivity of MERS-CoV infected patients has been evaluated in several countries including the Kingdom of Saudi Arabia, United Arab Emirates and the Republic of Korea,28,29,30. From these studies, lower Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 5 respiratory tract samples are of higher diagnostic value31 and tend to be PCR positive longer compared to upper respiratory tract samples and typically, patients with more severe disease shed virus longer than laboratory confirmed cases with mild or no symptoms. Contact tracing during health care associated outbreaks have identified secondary cases who have no symptoms (i.e., are asymptomatic) but can shed virus for up to two weeks28,32. One study reported prolonged nasal virus RNA defection of more than 5 weeks in an asymptomatic HCW. Standard Precautions should always be applied at all times. Additional contact and droplet precautions should be continue until the patient is asymptomatic and has two consecutive upper respiratory tract samples (e.g. nasopharyngeal l [NP] and/or oropharyngeal [OP] swabs) taken at least 24 hours apart test negative on RT-PCR. Given that limited information is currently available on viral shedding and the potential for transmission of MERS-CoV, testing for viral shedding should assist decision-making when available. Important patient factors such as age and immune status may contribute to prolonged shedding of virus (>1 month)28 and thereby prolong the necessity for contact and droplet precautions. 2.6. Collection and handling of laboratory specimens from patients with ARIs of potential concern (including MERS-CoV) All specimens collected for laboratory investigations should be regarded as potentially infectious, and HCWs who collect or transport clinical specimens should adhere rigorously to Standard Precautions to minimize the possibility of exposure to pathogens. • Ensure that HCWs who collect specimens use appropriate PPE (eye protection, medical mask, gown, gloves). • Ensure that personnel who transport specimens are trained in safe handling practices and spill decontamination procedures. • Place specimens for transport in leak-proof specimen bags (secondary container) that have a separate sealable pocket for the specimen (i.e. a plastic biohazard specimen bag), with the patient’s label on the specimen container (primary container), and a clearly written request form. • Ensure that health-care facility laboratories adhere to appropriate biosafety practices and transport requirements according to the type of organism being handled. • Deliver all specimens by hand whenever possible. Do not use pneumatic-tube systems to transport specimens. • State the full name, date of birth of the (suspected) ARI of potential concern clearly on the accompanying request form. Notify the laboratory as soon as possible that the specimen is being transported. For further information on specimen handling in the laboratory and laboratory testing for novel coronavirus, see Laboratory biorisk management for laboratories handling human specimens suspected or confirmed to contain novel coronavirus: Interim recommendations and the Laboratory Testing for Middle East Respiratory Syndrome Coronavirus: Interim guidance. For further information on laboratory biosafety guidelines, see the WHO Laboratory Biosafety Manual, 3rd edition33. Acknowledgements This document was developed in consultation with the WHO Global Infection Prevention and Control Network and Emerging Disease Clinical Assessment and Response Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • APIC Practice Guidance Committee Review • Abdullah Assiri, Director General, Infection Control, Ministry of Health, Saudi Arabia • Michael Bell, Deputy Director of Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • John M Conly, Departments of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University of Calgary, Calgary, Canada • Niklas Danielsson, Senior expert communicable diseases, Vaccine preventable diseases, Surveillance and Response Support unit, European Centre for Disease Prevention and Control • Katherine Defalco, Nurse Consultant, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Canada • Elaine Furukawa, Director of Training, Infection Control, Ministry of Health, Saudi Arabia • Susan I. Gerber, Team Lead, Respiratory Viruses/Picornaviruses, Division of Viral Diseases/Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA • Ahmad Mohammad Hakawi, Director-General, General Directorate of Infectious Diseases Control, Ministry of Health, Saudi Arabia • Benedikt Huttner, Infection Control Program and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland • M Mushtuq Husain, Coordinator, Coordinator and Support Centre, Directorate General of Health Services and Former Principal Scientific Officer & Head, Department of Medical Social Science, Institute of Epidemiology, Disease Control & Research (IEDCR), Dhaka, Bangladesh • David Hui, Chairman, Department of Medicine & Therapeutics, Stanley Ho Professor of Respiratory Medicine, Director of Stanley Ho Center for Emerging Infectious Diseases,Director of SH Ho Sleep Apnoea Management Center, The Chinese University of Hong Kong • Souha S Kanj, Professor and Head of Infectious Diseases and Chairperson of the Infection Control and Prevention Program at the American University of Beirut Medical Center,Beirut, Lebanon • David T. Kuhar, Medical Officer, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 6 • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Anna-Pelagia Magiorakos, Senior Expert, Antimicrobial Resistance and Healthcare-Associated Infections, European Centre for Disease Prevention and Control • Shaheen Mehtar, Extraordinary Professor, Unit for Infection Prevention and Control, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa and Chair, Infection Control African Network • Ziad A Memish, Professor, College of Medicine, Alfaisal University & Prince Mohammed Bin Abdulaziz Hospital, Ministry of Health, Riyadh, Kingdom of Saudi Arabia • Nico T. Mutters, Specialist for Infection Control and Environmental Health, Specialist for Clinical Microbiology, Master of Public Health, Scientific Coordinator EUCIC • Babacar N Doye, Board Member, Infection Control African Network, Dakar, Senegal • Folasade T Ogunsola, Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Nigeria and Board member, Infection Control African Network • Fernando Otaiza O'Ryan, Head, National IPC Program, Ministry of Health, Santiago, Chile • Maria Clara Padoveze, School of Nursing, University of São Paulo, Brazil • Nick Phin, Preparedness and Response Section, Respiratory Diseases Department, HPA Colindale, London, United Kingdom • Didier Pittet, Director, Infection Control Program and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland • Natalia Pshenichnaya, Professor, Rostov State Medical University, Rostov, Russian Federation • Wing Hong Seto, Department of Community Medicine, School of Public Health, University of Hong Kong, Hong Kong, People's Republic of China • Nandini Shetty, Consultant Microbiologist, Reference Microbiology Services, Colindale, Health Protection Agency, United Kingdom • Nalini Singh, Professor of Pediatrics, Global Health, Epidemiology, The George Washington University, Washington, DC, USA • Thomas Weaver, Director, Professional Practice, APIC and the Association for Professionals in Infection Control and Epidemiology WHO Health Emergencies Programme: Janet Diaz, Devika Dixit, Amgad Elkholy, Mamun Malik, Dina Pfeifer, Maria Van Kerkhove. The reviewers were required to sign a declaration of interests, and no conflicts of interest were identified. References 1. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care - WHO Guidelines. Geneva, World Health Organization, 2014. Available at http://apps.who.int/iris/bitstream/10665/112656/1/97892 41507134_eng.pdf 2. For the latest information, please consult the WHO coronavirus web page at http://www.who.int/csr/disease/coronavirus_infections/en /. 3. Middle East respiratory syndrome Case definition for reporting to WHO: Interim case definition. Geneva, World Health Organization, 2017. Available at http://www.who.int/csr/disease/coronavirus_infections/ca se_definition/en/. 4. Clinical management of severe acute respiratory infection when Middle East respiratory syndrome coronavirus (MERS-CoV) infection is suspected: Interim guidance. Geneva, World Health Organization, 2019. Available at https://www.who.int/csr/disease/coronavirus_infections/c ase-management-ipc/en/ 5. Management of asymptomatic persons who are RT- PCR positive for Middle East respiratory syndrome coronavirus (MERS-CoV): Interim guidance. Geneva, World Health Organization, 2018. Available at https://apps.who.int/iris/bitstream/handle/10665/180973/ WHO_MERS_IPC_15.2_eng.pdf?sequence=1 6. Middle East respiratory syndrome coronavirus (MERS- CoV): Key facts. Geneva, World Health Organization, 2019. Available at https://www.who.int/en/news- room/fact-sheets/detail/middle-east-respiratory- syndrome-coronavirus-(mers-cov) 7. Hunter JC, Nguyen D, Aden B, et al. Transmission of Middle East Respiratory Syndrome Coronavirus Infections in Healthcare Settings, Abu Dhabi. Emerg Infect Dis. 2016;22(4):647–656. doi:10.3201/eid2204.151615. 8. Hui DS. Epidemic and Emerging Coronaviruses (Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome). Clin Chest Med. 2017 Mar;38(1):71-86. doi: 10.1016/j.ccm.2016.11.007. 9. Alraddadi BM, Al-Salmi HS, Jacobs-Slifka K et al. Risk Factors for Middle East Respiratory Syndrome Coronavirus Infection among Healthcare Personnel. Emerg Infect Dis. 2016 Nov;22(11):1915-1920. doi: 10.3201/eid2211.160920. 10. Korea Centers for Disease Control and Prevention. Middle East Respiratory Syndrome Coronavirus Outbreak in the Republic of Korea, 2015. Osong Public Health Res Perspect. 2015 Aug; 6(4): 269–278. 11. Core components of infection prevention and control programmes in health care. Aide-memoire. Geneva, World Health Organization, 2011. Available at http://www.who.int/csr/resources/publications/AM_core_ components_IPC/en/. 12. Interim surveillance recommendations for human infection with Middle East respiratory syndrome coronavirus. Geneva, World Health Organization, 2014. Available at http://www.who.int/csr/disease/coronavirus_infections/In terimRevisedSurveillanceRecommendations_nCoVinfect ion_14July2014.pdf Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 7 13. Essential environmental health standards in health care. Geneva, World Health Organization, 2008. Available at http://www.who.int/water_sanitation_health/hygiene/setti ngs/ehs_hc/en/index.html. 14. Natural ventilation for infection control in health-care settings. Geneva, World Health Organization, 2009. Available at http://www.who.int/water_sanitation_health/publications/ natural_ventilation/en/index.html. 15. Jefferson T, Del Mar CB, Dooley L et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews, 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD 006207.pub4/abstract;jsessionid=074644E776469A4CFB 54F28D01B82835.d03t02. 16. WHO Guidelines on hand hygiene in health care. Geneva, World Health Organization, 2009. Available at http://whqlibdoc.who.int/publications/2009/97892415979 06_eng.pdf. 17. Infection-control measures for health care of patients with acute respiratory diseases in community settings. Trainee's Guide. Geneva, World Health Organization, 2009. Available at http://www.who.int/csr/resources/publications/WHO_HS E_GAR_BDP_2009_1a/en/index.html. 18. Standard Precautions are basic precautions designed to minimize direct, unprotected exposure to potentially infected blood, body fluids or secretions applicable to all patients. See also Standard precautions in health care. Geneva, World Health Organization, 2007. Available at http://www.who.int/csr/resources/publications/EPR_AM 2_E7.pdf. 19. How to put on and take off Personal Protective Equipment (PPE). Geneva, World Health Organization 2008. Available at http://www.who.int/csr/resources/publications/putontake offPPE/en/. 20. 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:e35797. 21. Natural Ventilation for Infection Control in Health-Care Settings. Geneva, World Health Organization, 2009. Available at https://apps.who.int/iris/bitstream/handle/10665/44167/9 789241547857_eng.pdf?sequence=1: 22. How to perform a particulate respirator seal check. Geneva, World Health Organization 2008. http://www.who.int/csr/resources/publications/respirators ealcheck/en/. 23. Community case management during an influenza outbreak. A training package for community health workers. Geneva, World Health Organization, 2011. Available at http://www.who.int/influenza/resources/documents/com munity_case_management_flipbook/en/index.html. 24. Lai MY, Cheng PK, Lim WW. Survival of severe acute respiratory syndrome coronavirus. Clinical Infectious Diseases, 2005, 41(7):67–71. 25. Chan KH, Poon LL, Cheng VC et al. Detection of SARS coronavirus in patients with suspected SARS. Emerging Infectious Diseases, 2004, 10(2):294–299. 26. Laboratory biorisk management for laboratories handling human specimens suspected or confirmed to contain novel coronavirus: Interim recommendations. Geneva, World Health Organization, 2013. Available at http://www.who.int/csr/disease/coronavirus_infections/N ovelCoronavirus_InterimRecommendationsLaboratoryBi orisk_190213/en/index.html 27. Implementing the WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households. Available at http://www.stoptb.org/wg/tb_hiv/assets/documents/tbici mplementationframework1288971813.pdf 28. Kim SH, Ko JH, Park GE et al. Atypical presentations of MERS-CoV infection in immunocompromised hosts. J Infect Chemother. 2017 Nov;23(11):769-773. doi: 10.1016/j.jiac.2017.04.004. 29. Corman VM, Albarrak AM, Omrani AS, et al. Viral Shedding and Antibody Response in 37 Patients With Middle East Respiratory Syndrome Coronavirus Infection. Clin Infect Dis. 2016; 62(4):477-483. 30. Al Hosani FI, Pringle K, Al Mulla M, et al. Response to Emergence of Middle East Respiratory Syndrome Coronavirus, Abu Dhabi, United Arab Emirates, 2013- 2014. Emerg Infect Dis. 2016;22(7):1162–1168. 31. Laboratory Testing for Middle East Respiratory Syndrome Coronavirus: Interim guidance. Geneva, World Health Organization, 2018. Available at http://apps.who.int/iris/bitstream/handle/10665/259952/ WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1 32. Middle East Respiratory Syndrome Coronovirus Guidelines for Healthcare Professionals. Saudi Arabia, Ministry of Health. Version 5. April 1, 2018. Available at: https://www.moh.gov.sa/CCC/StaffRegulations/Corona/ Documents/MERS- CoV%20Guidelines%20for%20Healthcare%20Professio nals%20-%20April%202018%20-%20v5.pdf 33. WHO laboratory biosafety manual, third edition. Geneva, World Health Organization, 2004. Available at http://www.who.int/csr/resources/publications/biosafety/ WHO_CDS_CSR_LYO_2004_11/en/ Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: Interim guidance 8 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection. Geneva, Switzerland: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev 1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

1       الوقايــة مــن العــدوى ومكافحتهــا أثنــاء الرعايــة الصــحية لحــالات الإصــابة المحتملــة أو المؤكــدة بعــدوى فيــروس كورونــا المســبب لمتلازمــة الشــرق الأوسط التنفسية إرشادات مبدئية ٥١٠٢ يونيو/ حزيران ٤تحديث 1.51/CPI/SREM/OHW المعلومات الأساسية التـــي نشـــرتها فـــي المبدئي ـــةحـــدَّثت منظمـــة الصـــحة العالمي ـــة الإرشـــادات ، مــــن أجــــل تلبيــــة الحاجــــة العاجلــــة إلــــى أحــــدث ٣١٠٢مــــايو / أيــــار ٦ المأمونـة للمرضـى المعلومات والتوصيات المسنَّدة بالبيِّنات بشأن الرعايـة المصابين بحالات العدوى المحتملة أو المؤكـدة بفيـروس كورونـا المسـبب بالمبـادئ المبدئيـةوتسترشد التوصيات . لمتلازمة الشرق الأوسط التنفسية الوقايـة مـن التوجيهية المسنَّدة بالبيِّنات التي نشرتها المنظمة بما في ذلـك التــي قــد تســبب أوبئــة وجــوائح العــدوى بــأمراض الجهــاز التنفســي الحــادة المبــــادئ التوجيهيــــة لمنظمــــة . فــــي مجــــال الرعايــــة الصــــحيةومكافحتهــــا واســـتعراض البيِّنـــات الحاليـــة بشـــأن العـــدوى بفيـــروس ١الصـــحة العالميـــة وقـــــد خضـــــعت . كورونـــــا المســـــبب لمتلازمـــــة الشـــــرق الأوســـــط التنفســـــية وى الخبـــــراء فـــــي الوقايـــــة مـــــن العـــــد ِقَبـــــلالتوصـــــيات للاســـــتعراض مـــــن للاطـــلاع " شـــكر وتقـــدير"نظـــر ا)ومكافحتهـــا والمجـــالات التقنيـــة الأخـــرى (.على أسماء الخبراء والمؤسسات التي يتبعونها فيمــــا يتعلــــق ٢وتجســــد هــــذه الإرشــــادات فهمنــــا الحــــالي لفيــــروس كورونــــا ٣.بالوقايـــة مـــن العـــدوى ومكافحتهـــا وتســـتخدم تعـــاريف الحـــالات المنقحـــة وتســــتهدف الإرشــــادات العــــاملين فــــي مجــــال الرعاي ــــة الصــــحية ومــــديري وقــد . الرعايــة الصــحية والأفرقــة المعنيــة بالوقايــة مــن العــدوى ومكافحتهــا ُنشــــرت كــــذلك إرشــــادات المنظمــــة الخاصــــة بالتــــدبير العلاجــــي الســــريري وتواصــل منظمــة الصــحة العالميــة رصــد الأوضــاع عــن كثــب ٤.تحديــدا ً وفــي . المبدئيــةات قــد تــؤثر علــى هــذه الإرشــادات للكشــف عــن أي تغيــر حــال تغيــر أي عامــل مــن العوامــل ســوف تصــدر المنظمــة تحــديثًا آخــر شــهرًا ٢١وٕالا فســوف تنتهــي صــلاحية هــذه الإرشــادات بعــد . للمعلومــات ويشــــار هنــــا إلــــى الــــروابط المؤديــــة إلــــى المزيــــد مــــن . مــــن تــــاريخ النشــــر تســاؤلات أخــرى، ُيرجــى إرســال بريــد وٕاذا كــان لــديكم . والبيِّنــات المصــادر ســؤال "مــع كتابــة ohw@kaerbtuotni.: إلكترونــي إلــى العنــوان التــالي " حــول الوقايــة مــن العــدوى بمتلازمــة الشــرق الأوســط التنفســية ومكافحتهــا .في موضوع الرسالة التنفســية هــو فيــروس فيــروس كورونــا المســبب لمتلازمــة الشــرق الأوســط حيــواني، وتشــير البيِّنــات المتاحــة حتــى الآن إلــى أن الإبــل هــي مصــدر ويحـدث انتقـال العـدوى بـين البشـر فـي معظمـه . انتقال العدوى إلى البشر فــي أمــاكن الرعايــة الصــحية، كمــا تحــدث فــي نطــاق أضــيق بكثيــر داخــل ولا توجــد . المجتمعــات المدنيــة وفــي المقــام الأول داخــل الأســر المعيشــية وتلـــزم . بيِّنـــات واضـــحة تـــدل علـــى تواصـــل انتقـــال الفيـــروس بـــين البشـــر المخالطـــة عـــن كثـــب كـــي يحـــدث انتقـــال الفيـــروس وهنـــاك طـــرق مختلفـــة ويلـزم إجـراء المزيـد مـن الدراسـات . محتملة لانتقاله مثل الرذاذ والملامسـة للوصول إلى فهم أفضـل لعوامـل خطـر انتقـال الفيـروس مـن الحيـوان إلـى .البشر وانتقاله بين البشر ويتوقف نجاح الوقاية من انتشار حالات العدوى بفيروس كورونا المرتبط عناصر الأساسية لبرامج الوقايةبالرعاية الصحية، على التنفيذ الكامل لل وتحــدث معظــم حــالات انتقــال العــدوى فــي غيــاب ٥.العــدوى ومكافحتهــامــن الاحتياطـات الخاصـة بالوقايـة مـن العـدوى ومكافحتهـا قبـل الاشـتباه فـي حالـة محددة أو التأكد منها؛ ولذا فإن التطبيق الروتيني للتدابير الرامية إلـى الوقايـة عنـد رعايـة المرضـى المصـابين ١من انتشـار أمـراض الجهـاز التنفسـي الحـادة اض، ُيعد ضروريًا من أجل الحد من انتشـار هـذه الأمـراض فـي أمـاكن بالأعر وينبغـــي اتخـــاذ احتياطـــات إضـــافية عنـــد رعايـــة المرضـــى . الرعايـــة الصـــحية انظـر الفـرع )المصابين بحالات العدوى المحتملة أو المؤكدة بفيـروس كورونـا . من أجل مواصلة الحد من مخـاطر انتقـال الفيـروس( من هذا المطبوع ٤-٢ توصـى مؤسسـات الرعايـة الصـحية بـالنظر فـي تعزيـز خدمـة الإشـراف علـى و لضــــمان تهيئــــة بيئــــة مأمونــــة فــــي مجــــال الرعايــــة الصــــحيةصــــحة العــــاملين ومن الأهميـة بمكـان تـوفير أفضـل سـبل الحمايـة المتاحـة . للمرضى والعاملين الـــذين يتولـــون رعايـــة المرضـــى فـــي مجـــال الرعايـــة الصـــحيةمحليـــًا للعـــاملين .ابين بفيروس كورونا، ومتابعتهم في حالة تعرضهم للعدوىالمص :وتلخص هذه الإرشادات ما يلي المبـــــادئ الخاصـــــة باســـــتراتيجيات الوقاي ـــــة مـــــن العـــــدوى المرتبطـــــة  بالرعاية الصحية ومكافحتها :والاحتياطات الخاصة بالوقاية من العدوى ومكافحتها  تقديم الرعاية إلى جميع المرضىل ‐ إلى المرضى المصابين بأمراض الجهاز التنفسـي لتقديم الرعاية ‐ الحادة لتق ــــــديم الرعاي ــــــة إل ــــــى المرضــــــى المصــــــابين بحــــــالات العــــــدوى ‐ .المحتملة أو المؤكدة بفيروس كورونا المبــادئ الخاصــة باســتراتيجيات الوقايــة مــن العــدوى المرتبطــة -١ بالرعاية الصحية ومكافحتها تتطلـب الوقايــة مـن انتقــال العــدوى فـي أمــاكن الرعايــة الصـحية أو الحــد منهــا وقــد ". الضــوابط"تطبيــق الإجــراءات والبروتوكــولات التــي ُيشــار إليهــا بمســمى ُنظِّمت هذه الضوابط في تسلسل هرمي وفقًا لفعاليتهـا فـي الوقايـة مـن العـدوى ضــــوابط البيئيــــة الضــــوابط الإداريــــة، وال: ومكافحتهــــا، وهــــي تشــــمل مــــا يلــــي .والهندسية، ومعدات الحماية الشخصية ُتعطــى هــذه الضــوابط الأولويــة الأولــى فــي اســتراتيجيات .الضــوابط الإداريــة وهــــــي تـــــوفر البنيــــــة التحتيـــــة للسياســــــات . الوقايـــــة مـــــن العــــــدوى ومكافحتهـــــا والإجـــراءات الراميـــة إلـــى الوقايـــة مـــن انتقـــال العـــدوى أثنـــاء الرعايـــة الصـــحية ولكـــي تكــون تـــدابير الوقايـــة مـــن العـــدوى . المبكـــر عنهـــا ومكافحتهـــاوالكشــف والتنبـــــؤ بالتـــــالي )ومكافحتهـــــا فعالـــــة، يجـــــب التنبـــــؤ بمـــــدى تـــــدفق المرضـــــى .بدءًا من اللقاء الأول وحتى الخروج من المرفق( بالمخاطر المحتملة مبدئيةإرشادات : الأوسط التنفسيةالوقاية من العدوى ومكافحتها أثناء الرعاية الصحية لحالات الإصابة المحتملة أو المؤكدة بعدوى فيروس كورونا المسبب لمتلازمة الشرق 2 وُتعـــد التجــــارب الســــريرية تــــدبيرًا مهمــــًا مـــن هــــذه التــــدابير وُتســــتخدم فــــي التحديـــد الســـريع للمرضـــى المصـــابين بـــأمراض الجهـــاز التنفســـي الحـــادة ورعايتهم على النحو الملائم، بما في ذلك المرضى المشتبه في إصابتهم وينبغـي وضـع المرضـى الـذين تحـددت إصـابتهم . بعـدوى فيـروس كورونـا بــــأمراض الجهــــاز التنفســــي الحــــادة فــــي مكــــان منفصــــل عــــن المرضــــى اطـات إضـافية للوقايـة مـن العـدوى ومكافحتهـا علـى الآخـرين، وتنفيـذ احتي وينبغــــي تقيـــــيم الجوانــــب الســـــريرية (. ٢-٢انظـــــر الفــــرع )وجــــه الســــرعة انظـر توصـيات منظمـة الصـحة )والوبائية للحالات في أسرع وقت ممكن .وينبغي أن ُتكمَّل بتقييم مختبري( ٦العالمية وتشـمل الضـوابط والسياسـات الإداريـة الأخـرى التـي تنطبـق علـى أمـراض الجهاز التنفسي الحادة، وضع البنية التحتية والأنشـطة المسـتدامة للوقايـة ؛ فــي مجــال الرعايــة الصــحيةمــن العــدوى ومكافحتهــا؛ وتوعيــة العــاملين ومنــع الازدحــام فــي أمــاكن الانتظــار؛ وتــوفير أمــاكن مخصصــة لانتظــار ى ووضــــــع المرضــــــى المحتجــــــزين فــــــي المستشــــــفى فــــــي عنــــــابر المرضــــــ مخصصــة؛ وتنظــيم خــدمات الرعايــة الصــحية لتــوفير الإمــدادات الكافيــة واسـتخدامها؛ ووضـع السياسـات والإجـراءات بشـأن جميـع جوانـب الصـحة المهني ـــة مـــع تأكي ـــد ترصـــد أمـــراض الجهـــاز التنفســـي الحـــادة فـــي أوســـاط أهميــة التمــاس الرعايــة الصــحية؛ و فــي مجــال الرعايــة الصــحيةالعــاملين ، فضـــًلا عـــن فـــي مجـــال الرعايـــة الصـــحيةورصــد مـــدى امتثـــال العـــاملين .وضع الآليات اللازمة للتحسين حسب الاقتضاء تتضــــمن هــــذه الضــــوابط البنــــى التحتيــــة .الضــــوابط البيئي ــــة والهندســــية وُتعنــــى هــــذه الضــــوابط بضــــمان . ٧الأساســــية لمرافــــق الرعايــــة الصــــحية فــــي جميــــع الأمــــاكن داخــــل مرافــــق الرعايــــة الصــــحية، ٨كافيــــةالتهويــــة ال وينبغـي الفصـل بمسـافة متـر واحـد علـى . والتنظيف الكـافي لهـذه الأمـاكن مصـاب بأحـد أمـراض الجهـاز للمـريض الالأقـل بـين الأمـاكن المخصصـة فــي مجــال التنفســي الحــادة والأشــخاص الآخــرين، بمــا فــي ذلــك العــاملين ونــــون غيــــر مســــتخدمين لمعــــدات الحمايــــة عنــــدما يك) الرعايــــة الصــــحية ومن شأن هـذين الضـابطين أن يحـدا مـن انتشـار العديـد مـن (. الشخصية ٩.الممرضات أثناء الرعاية الصحية يسـاعد الاسـتخدام الرشـيد والمسـتمر لمعـدات .معدات الحماية الشخصـية أيضـا ًعلـى النحـو الملائـم ٠١الحماية الشخصية المتاحـة وتنظيـف اليـدين وُيعـد اسـتخدام معـدات الحمايـة الشخصـية . على الحد من انتشار العـدوى الضابط الأكثر وضوحًا للعيان من بـين الضـوابط المسـتخدمة فـي الوقايـة ل الهرمـي سـمن العدوى، ومع ذلك فهو آخر الضوابط وأضـعفها فـي التسل لتــــــدابير الوقايــــــة مــــــن العــــــدوى ومكافحتهــــــا، وينبغــــــي ألا ُيعتمــــــد عليــــــه وفــــي غي ــــاب الضــــوابط الإداري ــــة والهندســــية . يجية أولي ــــة للوقاي ــــةكاســــترات .الفعالة، لا تعود معدات الحماية الشخصية إلا بفائدة محدودة احتياطات الوقاية من العدوى ومكافحتها -٢ الاحتياطات القياسية ١-٢ حجــر الأســاس فــي تــوفير الرعايــة الصــحية ١١ُتعــد الاحتياطــات القياســية في مجال المأمونة، والحد من مخاطر استمرار العدوى، وحماية العاملين ، وينبغـــي أن ُتطبـــق دومـــًا فـــي أمـــاكن الرعايـــة الصـــحية الرعايـــة الصـــحية وتشــمل الاحتياطــات القياســية نظافــة اليــدين واســتخدام . لجميــع المرضــى وفقـًا لمخـاطر الملامسـة المباشـرة لـدم معدات الحماية الشخصية الملائمة ( بمــا فــي ذلــك الإفــرازات التنفســية)المــريض أو ســوائل جســمه أو إفرازاتــه الوقايـة : وتشـمل الاحتياطـات القياسـية أيضـًا مـا يلـي. والجلـد غيـر السـليم مـــن الإصـــابات الناجمـــة عـــن الإبـــر والأدوات الحـــادة؛ والإدارة المأمونـــة هيـــر؛ وحيثمـــا ينطبـــق ذلـــك، تعقـــيم المعـــدات للنفايـــات؛ والتنظيـــف؛ والتط المستخدمة في رعاية المرضـى والمفروشـات، وتنظيـف الأمـاكن المحيطـة وينبغــــي التشــــجيع علــــى اتخــــاذ إجــــراءات النظافــــة الخاصــــة . وتطهيرهــــا .بالتنفس مع الأشخاص المصابين بأعراض تنفسية الخمـس وقـاتالأ"أن يطبقوا نهـج في مجال الرعاية الصحيةوينبغي للعاملين تنظيـف قبل لمس المريض؛ وقبل أي إجـراء ": ينبغي فيها تنظيف اليدين التي ؛ وبعد التعرض لمخاطر سوائل الجسم؛ وبعد لمـس المـريض؛ وبعـد أو تطهير .لمس ما يحيط بالمريض بما في ذلك الأغراض أو الأسطح الملوثة وتشــمل نظافــة اليــدين غســل اليــدين بالصــابون والمــاء أو اســتخدام  .اليدين لفركمحلول كحولي .غسل اليدين بالصابون والماء عندما يظهر عليهما الاتساخ  . لا ُيغنــي اســتخدام معــدات الحمايــة الشخصــية عــن نظافــة اليــدين  كمــا ُتعــد نظافــة اليــدين ضــرورية عنــد وضــع هــذه المعــدات وكــذلك ٢١.وبصفة خاصة عند خلعها الشخصــــية بتقيــــيم للمخــــاطر وينبغــــي أن يسترشــــد اســــتخدام معــــدات الحمايــــة المتعلقــة بتوقــع ملامســة الــدم وســوائل الجســم والإفــرازات والجلــد غيــر الســليم أو / وعنـــد احتمـــال تلـــوث الوجـــه و. أثنـــاء تقـــديم الرعايـــة الروتينيـــة للمـــريض :الجسم، ينبغي أن تشمل معدات الحماية الشخصية استخدام ما يلي عينــين أو نظــارة؛ أو وقنــاع لل ٣١حمايــة الوجــه بواســطة قنــاع طبــي  درع الوجه؛ معطف؛  .قفازين نظيفين  الامتنـــاع عـــن لمـــس العينـــين فـــي مجـــال الرعايـــة الصـــحيةوينبغـــي للعـــاملين .أو اليدين العاريتين التي يحتمل تلوثهما ينوالأنف والفم بالقفاز . ضــمان اتبــاع إجــراءات التنظيــف والتطهيــر باســتمرار وعلــى النحــو الســليمو الأسطح المحيطة بالماء والصـابون واسـتخدام المطهـرات الشـائع ُيعد تنظيف و غسـل الملابـس وتـدبير. ، إجـراًء فعـاًلا وكافيـا ً(مثـل الهيبوكلورايـت)استخدامها .وأدوات تقديم الطعام والنفايات الطبية وفقًا للإجراءات الروتينية المأمونة عنــد رعايــة الاحتياطــات الإضــافية للوقايــة مــن العــدوى ومكافحتهــا ٢-٢ المرضى المصابين بأمراض الجهاز التنفسي الحادة فضـًلا عـن الاحتياطـات القياسـية، ينبغـي لجميـع الأفـراد المخـالطين للمرضــى المصــابين بــأمراض الجهــاز التنفســـي الحــادة، بمــا فـــي ذلــك الزائــرون، اتبـــاع :يلي ما أي علـــى )مخالطــة المـــريض عــن كثــب داســتخدام قنــاع طبـــي عنــ  وعنـــد الـــدخول إلـــى غرفـــة المـــريض أو ( واحـــد تقريبـــا ًمســـافة متـــر ؛مقصورته ه وبعـــده، وفـــور خلـــع حيطـــتنظيـــف اليـــدين قبـــل لمـــس المـــريض وم  .القناع الطبي التـــي نشـــرتها منظمـــة ١وتـــرد الاحتياطـــات المفصـــلة فـــي المبـــادئ التوجيهيـــة الصـــحة العالميـــة وينبغـــي تطبيقهـــا عنـــد تقـــديم الرعايـــة للمرضـــى المصـــابين .بأمراض الجهاز التنفسي الحادة أثنــــاء تنفيــــذاحتياطــــات الوقايــــة مــــن العــــدوى ومكافحتهــــا ٣-٢ الإجراءات التي يتولد عنها الرذاذ ُتعرَّف الإجـراءات التـي يتولـد عنهـا الـرذاذ بأنهـا أي إجـراء طبـي قـد ينـتج عنـه التـــي يقـــل )ال ـــرذاذ مـــن مختلـــف الأحجـــام، بمـــا فـــي ذلـــك الجزيئـــات الصـــغيرة وتشير البيِّنات الحالية التي صدر أفضـلها عـن (. ميكرومترات ٥حجمها عن ، الوخيمــة الحــادةمتلازمــة التنفســية لدراســات تتنــاول فيــروس كورونــا المســبب ل وفضـًلا ٤١.إلى وجود علاقة متسـقة بـين انتقـال الممرضـات وتنبيـب الُرغـامى عن ذلك، فقد أفاد عدد من الدراسات بزيـادة مخـاطر العـدوى بفيـروس كورونـا المرتبطـــــة بالبضـــــع الُرغـــــامي التنفســـــية الحـــــادة الوخيمـــــةمتلازمـــــة لالمســـــبب ل ولكن التوصل إلى هذه . ل التنبيبوالتهوية غير الباضعة والتهوية اليدوية قب مبدئيةإرشادات : الأوسط التنفسيةالوقاية من العدوى ومكافحتها أثناء الرعاية الصحية لحالات الإصابة المحتملة أو المؤكدة بعدوى فيروس كورونا المسبب لمتلازمة الشرق 3 النتــائج جــاء عــن طريــق عــدد قليــل مــن الدراســات ذات الجــودة المتدنيــة ولـــم . للغايـــة، مـــا يجعـــل مـــن الصـــعب تفســـيرها وتطبيقهـــا تطبيقـــًا عمليـــا ً ُتكتشف أي إجراءات ُأخـرى تـرتبط ارتباطـًا ذا شـأن بزيـادة مخـاطر انتقـال .أمراض الجهاز التنفسي الحادة ي اتخاذ احتياطات إضافية عند تنفيذ إجراءات يتولد عنها الرذاذ قـد وينبغ .ترتبط بزيادة مخاطر انتقال العدوى، ولاسيما تنبيب الُرغامى وتشــمل الاحتياطـــات الإضـــافية عنـــد تنفيـــذ إجـــراءات يتولـــد عنهـــا الـــرذاذ، :يلي ما وفــــي حــــال ٥١اســــتخدام أقنعــــة مانعــــة لاستنشــــاق الجســــيمات،  وضـع قنـاع ُيسـتعمل مـرة واحـدة ينبغـي دومـًا التحقـق مـن مـدى ٦١إحكامه؛ ؛(للوجه واق ٍأي نظارة أو )استخدام واق للعينين  أكمـام طويلـة، وقفـازين ذيغيـر معقـم نظيـف استخدام معطـف  ؛(تتطلب بعض هذه الإجراءات استخدام قفازات معقمة) جـــراءات التـــي مقاومـــة للســـوائل فـــي بعـــض الإ مريلـــةاســـتخدام  يتوقــع أن ُتســفر عــن قــدر كبيــر مــن الســوائل التــي قــد تنفــذ مــن خلال المعطف؛ تنفيــذ هــذه الإجــراءات فــي غرفــة جيــدة التهويــة؛ أي يتغيــر فيهــا  مــــرة فــــي الســــاعة فــــي المرافــــق حيــــث ٢١إلــــى ٦الهــــواء مــــن الغـرف مـزودة بتهويـة ميكانيكيـة، أو يتغيـر فيهـا الهـواء بمقـدار يــــة لكــــل مــــريض فــــي المرافــــق ذات التهويــــة لتــــر فــــي الثان ٠٦ ٨الطبيعية؛ الحد من عدد الأشـخاص الموجـودين فـي الغرفـة إلـى أدنـى حـد  ممكــــن ليقتصــــر علــــى الأشــــخاص اللازمــــين لرعايــــة المــــريض ودعمه؛ ، وبعــد اتنظيــف اليــدين قبــل ملامســة المــريض ومحيطــه وبعــده  .خلع معدات الحماية الشخصية العــدوى ومكافحتهــا عنــد رعايــة المرضــى احتياطــات الوقايــة مــن ٤-٢ المصــابين بالعــدوى المحتملــة أو المؤكــدة بفيــروس كورونــا المســبب لمتلازمة الشرق الأوسط التنفسية وضع المرضى المصابين بالعـدوى المحتملـة أو المؤكـدة بفيـروس كورونـا المسبب لمتلازمة الشرق الأوسط التنفسـية فـي غـرف فرديـة جيـدة التهويـة مـــزودة بالاحتياطـــات الخاصـــة بالعـــدوى المنقول ـــة ب ـــالهواء؛ وٕان أو غـــرف أمكن اختيار أماكن الغرف المستخدمة في التمريض الوقـائي فـي منـاطق وعنــدما لا تتــوافر . منفصــلة تمامــًا عــن منــاطق رعايــة المرضــى الآخــرين الغرف الفردية، يوضع المرضى المؤكـدة إصـابتهم بالعـدوى معـًا وُيعزلـون ة وٕان تعـذر ذلـك، توضـع أسـرَّ . محتملـة إصـابتهم بالعـدوىعـن المرضـى ال .المرضى بحيث تفصل بينها مسافة متر واحد على الأقل وأفـراد الأسـر والـزوار فـي مجـال الرعايـة الصـحيةالحد من عـدد العـاملين الذين يخالطون المريض المصاب بالعدوى المحتملة أو المؤكـدة بفيـروس .كورونا الحــــالات المحتملــــة أو المؤكــــدة التــــي وبقــــدر الإمكــــان، إســــناد  ينبغـــي رعايتهـــا إلـــى مجموعـــة محـــددة مـــن العـــاملين الصـــحيين المهــرة حصــرًا، مــن أجــل اســتمرارية الرعايــة والحــد مــن فــرص حـــدوث ثغـــرات فـــي مكافحـــة العـــدوى نتيجـــة للســـهو ُتســـفر عـــن .التعرض بغير حماية وينبغــــي أن يقتصــــر أفــــراد الأســــرة وال ــــزوار الــــذين ُيســــمح لهــــم  بمخالطـــة المـــريض علـــى الأفـــراد الـــذين ُيعـــد وجـــودهم ضـــروريًا لدعم المريض، وينبغي أن يتلقـوا التـدريب علـى مخـاطر انتقـال احتياطـــات مكافحـــة العـــدوى نفســـها التـــي أن يتخـــذواالمـــرض و الـــذين يتولـــون فـــي مجـــال الرعايـــة الصـــحيةيتخـــذها العـــاملون أهميـــة خاصـــة فـــي ويكتســـي هـــذا الأمـــر . الرعايـــة الروتينيـــةتقـــديم الأمــــاكن التــــي يتــــولى فيهــــا أفــــراد الأســــرة عــــادة رعايــــة المرضــــى .المحتجزين في المستشفى وفضًلا عن الاحتياطات القياسية، ينبغـي لجميـع الأفـراد، بمـا فـي ذلـك الـزوار ، عنـــد مخالطـــة المرضـــى المصـــابين فـــي مجـــال الرعايـــة الصـــحيةوالعـــاملين س كورونـا عـن كثـب أو عنـد دخـولهم إلـى بالعدوى المحتملة أو المؤكدة بفيـرو :غرف المرضى أو مهاجعهم، أن يتبعوا ما يلي ٤١استخدام قناع طبي؛  ؛(للوجه واق ٍأي نظارة أو )استخدام واق للعينين  أكمام طويلة؛ ذيغير معقم نظيف استخدام معطف  وقـــد تتطلـــب بعـــض الإجـــراءات اســـتخدام قفـــازات )اســـتخدام قفـــازين  ؛(معقمة خلـع وبعـد، االيـدين قبـل ملامسـة المـريض ومحيطـه وبعـدهتنظيـف  .معدات الحماية الشخصية مثــل )وٕان أمكـن، اسـتخدام معـدات ُتسـتعمل مـرة واحـدة أو معـدات مخصصـة وٕاذا لـــــزم اســـــتخدام (. الســـــماعات، وجهـــــاز قيـــــاس الضـــــغط ومـــــوازين الحـــــرارة . مـريضالمرضى للمعدات نفسها، ينبغي تنظيفها وتعقيمهـا بعـد اسـتخدام كـل الامتنـــاع عـــن لمـــس العينـــين فـــي مجـــال الرعايـــة الصـــحيةوينبغـــي للعـــاملين .أو اليدين العاريتين التي يحتمل تلوثهما ينوالأنف والفم بالقفاز وفضـــًلا عـــن ذلـــك، ينبغـــي اتبـــاع مـــا يلـــي مـــع المرضـــى المصـــابين بحـــالات :العدوى المحتملة أو المؤكدة بفيروس كورونا قلــه خــارج غرفــة أو منطقــة التمــريض تجنــب تحريــك المــريض أو ن  ومـن شـأن اسـتخدام معـدات . الوقائي إلا فـي حالـة الضـرورة الطبيـة الأشــعة الســينية وغيرهــا مــن معــدات التشــخيص المهمــة المحمولــة وٕاذا لــزم نقــل المــريض، ينبغــي . المخصصــة، أن يســهل هــذا الأمــر اسـتخدام مسـارات النقـل التـي تقلــل مـن تعـرض العـاملين والمرضــى .أدنى قدرلآخرين والزوار للعدوى إلى ا إخطار منطقة الاستقبال بتشخيص المريض وبالاحتياطات اللازمة  .في أسرع وقت ممكن قبل وصول المريض وتطهيرهــا ( مثــل الســرير)تنظيــف الأســطح التــي يلامســها المــريض  ٧١.بعد استعمالها الــذين يتولــون فــي مجــال الرعايــة الصــحيةالتأكــد مــن أن العــاملين  نقل المرضى يلبسون معدات الحماية الشخصية الملائمة وينظفـون .أيديهم بعد ذلك مـدة اسـتمرار احتياطـات التمـريض الوقـائي الخاصـة بعـدوى فيـروس ٥-٢ كورونا المسبب لمتلازمة الشرق الأوسط التنفسية زمــة لا ُتعــرف المــدة التــي تســتمر خلالهــا قــدرة فيــروس كورون ــا المســبب لمتلا وفـــي حـــين أنـــه ينبغـــي دومـــًا اتخـــاذ . الشـــرق الأوســـط التنفســـية علـــى العـــدوى الاحتياطــات القياســية، ينبغــي اتخــاذ احتياطــات التمــريض الوقــائي الإضــافية ســاعة بعــد ٤٢واســتمرارها لمــدة ١٢خـلال فتــرة المــرض المصــحوب بـأعراض الفيروســي ونظــرًا لقلــة المعلومــات المتاحــة حاليــًا عــن الطــرح . زوال الأعــراض واحتمــال انتقــال فيــروس كورونــا، ينبغــي الاســتعانة باختبــار الطــرح الفيروســي وينبغــــي أيضــــًا النظــــر فــــي . فــــي صــــنع القــــرار عنــــدما يتــــاح ذلــــك بســــهولة مثــــــل الســــــن والحالــــــة المناعيــــــة والأدويــــــة )المعلومــــــات الخاصــــــة بــــــالمريض للفيــروس فــي الحــالات التــي ُيخشــى فيهــا اســتمرار طــرح المــريض ( المســتعملة .لفترة ممتدة قرشلا ةمزلاتمل ببسملا انوروك سوريف ىودعب ةدكؤملا وأ ةلمتحملا ةباصلإا تلااحل ةيحصلا ةياعرلا ءانثأ اهتحفاكمو ىودعلا نم ةياقولاةيسفنتلا طسولأا : تاداشرإةيئدبم 4 ٢-٦ عـــمج نـــم ًاـــ قلق ببـــسُت دـــ ق يـــ تلا ةـــ يربتخملا تاـــ نيعلا ةـــ لوانمو ةداحلا يسفنتلا زاهجلا ضارمأب نيباصملا ىضرملا نأ رابتعا يغبنيلك دـق يرـبتخملا يرـحتلا لـجأ نـم عـمجُت يـتلا تانيعلا تاــنيعلا ذــخأ نوــلوتي نيذــلا نييحــصلا نيلماــعلل يــغبنيو ،ىودــعلا ببــست نأ اـهلقن وأ ةيريرـسلااوـمزتلي ىـندأ ىـلإ دـحلل ةيـسايقلا تاـطايتحلااب ةـقدب ُملل مهضرعت لامتحا نم ردقتاضرم.  نيلماــــعلا نأ نــــم دــــكأتلاةيحــــصلا ةــــياعرلا لاــــجم يــــف ــــلا نيذ ةيـــصخشلا ةـــ يامحلا تادـــعم نومدختـــسي تاـــ نيعلا ذـــخأ نوـــ لوتي ةمئلاملا.  ىـلع نوبردـم تانيعلا لقن نولوتي نيذلا نيلماعلا نأ نم دكأتلا نـع جتاـنلا ثوـلتلا ةـلازإ تاءارـجٕاو ةـنومأملا ةـلوانملا تاسرامم تانيعلا برست.  ةــعناملا تاــنيعلا ساــيكأ يــف اــهلقن يــغبني يــتلا تاــنيعلا عــضو برــــستلل)لا تاــــيواحلاةــــيوناث( قــــلغي لــــصفنم بــــيجب ةدوزــــملا ةـــــنيعلا عـــــضول ماـــــكحإب) صـــــصخملا يكيتـــــسلابلا سيـــــكلا يأ ةـيجولويبلا ةروـطخلا تاذ تانيعلل( مـسا لـمحي قـصلم عـضوو ، ةـنيعلا ةـيواح ىـلع ضيرـملا)ةـيلولأا ةـيواحلا( جذوـمن قاـفرٕاو ، حضاو طخب بوتكملا بلطلا.  ةياعرلا قفرم تاربتخم نأ نم دكأتلا تاـسراممب مزتلت ةيحصلا تاـنئاكلا عوـنل ًاـقفو لـقنلا طورـشو ةـمئلاملا ةـيجولويبلا ةملاـسلا اهلوانت يرجي يتلا.  نـــكمأ اـــملك دـــيلاب تاـــنيعلا عـــيمج ميلـــست . مـــظُن مادختـــسا مدـــع تانيعلا لقن يف ةيئاوهلا بيبانلأا.  مــسا رــكذللاتــعا لا داــحلا يــسفنتلا زاــهج)هــيف هبتــشملا ( يذــلا ـــشب فواـــخم دـــجوت بـــلطلا جذوـــمن يـــف حـــضاو وـــحن ىـــلع ،هنأ قفرملا . و ةـنيعلا نأـب نكمم تقو عرسأ يف ربتخملا راطخٕا يـف قيرطلا. صـــــحفلاو رـــــبتخملا يـــــف تاـــــنيعلا ةـــــلوانم نـــــع تاـــــمولعملا نـــــم دـــــيزملل رظنا ،دجتسملا انوروك سوريف نع فشكلل يربتخملا: Laboratory biorisk management for laboratories handling human specimens suspected or confirmed to contain novel coronavirus: Interim recommendations22 and the Laboratory testing for Middle East respiratory syndrome coronavirus - Interim recommendations (revised) 23 و نأـشب ةـيهيجوتلا ئداـبملا نـع تاـمولعملا نم ديزملل ةـيجولويبلا ةملاـسلا رظنا ،تاربتخملا يف: WHO Laboratory Biosafety Manual, 3rd edition.24 ريدقتو ركش ىودـــعلا نـــم ةـــ ياقولل ةـــيملاعلا ةكبـــشلا عـــم رواـــشتلاب ةـــ قيثولا هذـــه تدـــعُأ نيرخآ نييلود ءاربخو ةيملاعلا ةحصلا ةمظنمل ةعباتلا اهتحفاكمو . مدـقتتو ةــيلمع ىــلع نيمئاــقلا مهؤامــسأ ةــيلاتلا صاخــشلأا ىــلإ ركــشلاب ةــمظنملا ضارعتسلاا)ةيزيلكنلإا فرحلأا بيترتل ًاقفو:(  Abdulla Assiri, Director General, Infection Control, Ministry of Health, Saudi Arabia  Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom  John M Conly, Departments of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University of Calgary, Calgary, Canada  Niklas Danielsson, Senior expert communicable diseases, Vaccine preventable diseases, Surveillance and Response Support unit, European Centre for Disease Prevention and Control  Katherine Defalco, Nurse Consultant, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Canada  Elaine Furukawa, Director of Training, Infection Control, Ministry of Health, Saudi Arabia  Susan I. Gerber, Team Lead, Respiratory Viruses/Picornaviruses, Division of Viral Diseases/Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA  Benedikt Huttner, Infection Control Program and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland  M Mushtuq Husain, Principal Scientific Officer & Head, Department of Medical Social Science, Institute of Epidemiology, Disease Control & Research (IEDCR), Dhaka, Bangladesh  David T. Kuhar, Medical Officer, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA  Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC)  Anna-Pelagia Magiorakos, Senior Expert, Antimicrobial Resistance and Healthcare-Associated Infections, European Centre for Disease Prevention and Control  Shaheen Mehtar, Extraordinary Professor, Unit for Infection Prevention and Control, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa and Chair, Infection Control African Network  Ziad A Memish, Deputy Minister for Public Health, Ministry of Health, Riyadh, Saudi Arabia  Babacar NDoye, Board Member, Infection Control African Network, Dakar, Senegal  Folasade T Ogunsola, Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Nigeria and Secretary, Infection Control African Network  Fernando Otaiza O'Ryan, Head, National IPC Program, Ministry of Health, Santiago, Chile  Maria Clara Padoveze, School of Nursing, University of São Paulo, Brazil  Nick Phin, Preparedness and Response Section, Respiratory Diseases Department, HPA Colindale, London, United Kingdom  Didier Pittet, Director, Infection Control Program and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland  Natalia Pshenichnaya, Professor, Rostov State Medical University, Rostov, Russian Federation  Wing Hong Seto Department of Community Medicine, School of Public Health, University of Hong Kong, Hong Kong, People's Republic of China  Nandini Shetty, Consultant Microbiologist, Reference Microbiology Services, Colindale, Health Protection Agency, United Kingdom  Nalini Singh, Professor of Pediatrics, Global Health, Epidemiology, The George Washington University, Washington, DC, USA  Thomas Weaver, Director, Professional Practice, APIC and the Association for Professionals in Infection Control and Epidemiology مـلو ،حلاـصملا نلاـعإ ىـلع عـيقوتلا ضارعتـسلاا ىـلع نيمئاـقلا ىلإ بلُط دقو براضت يأ ددحتي حلاصملا يف. قرشلا ةمزلاتمل ببسملا انوروك سوريف ىودعب ةدكؤملا وأ ةلمتحملا ةباصلإا تلااحل ةيحصلا ةياعرلا ءانثأ اهتحفاكمو ىودعلا نم ةياقولاةيسفنتلا طسولأا : تاداشرإةيئدبم 5 عجارملا 1. Infection prevention and control of epidemic- and pandemic- prone acute respiratory infections in health care - WHO Guidelines. Geneva, World Health Organization, 2014. Available at http://apps.who.int/iris/bitstream/10665/112656/1/97892415 07134_eng.pdf 2. For the latest information, please consult the WHO coronavirus web page at http://www.who.int/csr/disease/coronavirus_infections/en/. 3. The WHO case definitions for reporting are available at http://www.who.int/csr/disease/coronavirus_infections/case_ definition/en/. 4. Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do. Geneva, World Health Organization, 2013. Available at http://www.who.int/csr/disease/coronavirus_infections/Interi mGuidance_ClinicalManagement_NovelCoronavirus_11Feb 13u.pdf. 5. Core components of infection prevention and control programmes in health care. Aide-memoire. Geneva, World Health Organization, 2011. Available at http://www.who.int/csr/resources/publications/AM_core_com ponents_IPC/en/. 6. Interim surveillance recommendations for human infection with Middle East respiratory syndrome coronavirus. Geneva, World Health Organization, 2014. Available at http://www.who.int/csr/disease/coronavirus_infections/Interi mRevisedSurveillanceRecommendations_nCoVinfection_14 July2014.pdf 7. Essential environmental health standards in health care. Geneva, World Health Organization, 2008. Available at http://www.who.int/water_sanitation_health/hygiene/settings /ehs_hc/en/index.html. 8. Natural ventilation for infection control in health-care settings. Geneva, World Health Organization, 2009. Available at http://www.who.int/water_sanitation_health/publications/nat ural_ventilation/en/index.html. 9. Jefferson T, Del Mar CB, Dooley L et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews, 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006 207.pub4/abstract;jsessionid=074644E776469A4CFB54F28 D01B82835.d03t02. 10. WHO Guidelines on hand hygiene in health care. Geneva, World Health Organization, 2009. Available at http://whqlibdoc.who.int/publications/2009/9789241597906_ eng.pdf. 11. Standard Precautions are basic precautions designed to minimize direct, unprotected exposure to potentially infected blood, body fluids or secretions applicable to all patients. See also Standard precautions in health care. Geneva, World Health Organization, 2007. Available at http://www.who.int/csr/resources/publications/EPR_AM2_E7 .pdf. 12. A visual aid on how to put on and take off PPE is available at http://www.who.int/csr/resources/publications/putontakeoffP PE/en/. 13. In this document, the term "medical mask" refers to disposable surgical or procedure masks. 14. 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:e35797. Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjo urnal.pone.0035797. 15. Examples of acceptable, disposable particulate respirators in use in various parts of the world include: Australia/New Zealand: P2 (94%), P3 (99.95%); China: II (95%), I (99%); European Union: CE-certified filtering face-piece class 2 (FFP2) (95%), class 3 (FFP3) (99.7%); Japan: 2nd class (95%), 3rd class (99.9%); Republic of Korea: 1st class (94%), special (99.95%); United States: NIOSH-certified N95 (95%), N99 (99%), N100 (99.7%). 16. A visual aid on how to perform a particulate respirator seal check is available at http://www.who.int/csr/resources/publications/respiratorsealc heck/en/. 17. Lai MY, Cheng PK, Lim WW. Survival of severe acute respiratory syndrome coronavirus. Clinical Infectious Diseases, 2005, 41(7):67–71. 18. Community case management during an influenza outbreak. A training package for community health workers. Geneva, World Health Organization, 2011. Available at http://www.who.int/influenza/resources/documents/communit y_case_management_flipbook/en/index.html. 19. Infection-control measures for health care of patients with acute respiratory diseases in community settings. Trainer's Guide. Geneva, World Health Organization, 2009. Available at http://www.who.int/csr/resources/publications/WHO_HSE_G AR_BDP_2009_1/en/index.html. 20. Infection-control measures for health care of patients with acute respiratory diseases in community settings. Trainee's Guide. Geneva, World Health Organization, 2009. Available at http://www.who.int/csr/resources/publications/WHO_HSE_G AR_BDP_2009_1a/en/index.html. 21. In studies conducted in Hong Kong SAR, China, no SARS- CoV was cultured from the clinical specimens from infected patients once they were asymptomatic (see Chan KH, Poon LL, Cheng VC et al. Detection of SARS coronavirus in patients with suspected SARS. Emerging Infectious Diseases, 2004, 10(2):294–299). 22. Laboratory biorisk management for laboratories handling human specimens suspected or confirmed to contain novel coronavirus: Interim recommendations. Geneva, World Health Organization, 2013. Available at http://www.who.int/csr/disease/coronavirus_infections/Novel Coronavirus_InterimRecommendationsLaboratoryBiorisk_19 0213/en/index.html. 23. Laboratory testing for Middle East respiratory syndrome coronavirus - Interim recommendations, Geneva, World Health Organization, 2014. Available at http://www.who.int/csr/disease/coronavirus_infections/WHO_i nterim_recommendations_lab_detection_MERSCoV_092014 .pdf?ua=1. 24. WHO laboratory biosafety manual, third edition. Geneva, World Health Organization, 2004. Available at http://www.who.int/csr/resources/publications/biosafety/WHO _CDS_CSR_LYO_2004_11/en/. مبدئيةإرشادات : الأوسط التنفسيةالوقاية من العدوى ومكافحتها أثناء الرعاية الصحية لحالات الإصابة المحتملة أو المؤكدة بعدوى فيروس كورونا المسبب لمتلازمة الشرق 6 ٥١٠٢منظمة الصحة العالمية © أو شـراؤها مـن قسـم )tni.ohw.www( يمكن الحصول على مطبوعات منظمة الصحة العالمية من على موقع المنظمة الإلكترونـي. جميع الحقوق محفوظة ؛ فـاكس +١٤ ٢٢ ١٩٧ ٤٦٢٣ :هـاتف رقـم) dnalreztiwS ,72 aveneG 1121 ,aippA eunevA 02 الطباعـة والنشـر، منظمـة الصـحة العالميـة .( )tni.ohw@sredrokoob:البريد الإلكتروني +١٤ ٢٢ ١٩٧ ٧٥٨٤ :رقم لنشـر إلـى قسـم الطباعـة وا –لأغـراض البيـع أو التوزيـع غيـر التجـاري –وينبغي إرسال طلبات الحصول على إذن باستنسـاخ مطبوعـات المنظمـة أو ترجمتهـا )lmth.xedni/ne/mrof_thgirypoc/gnisnecil/tuoba/tni.ohw.www(.ي عبر موقع المنظمة الإلكترون المطبوع، وطريقة عرض المواد الواردة فيه، لا تعبر ضمنًا عن أي رأي كـان مـن جانـب منظمـة الصـحة العالميـة بشـأن الوضـع التسميات المستعملة في هذا و وتشـكل الخطـوط المنقوطـة والخطـوط المتقطعـة . القانوني لأي بلد، أو أرض، أو مدينة، أو منطقة، أو لسلطات أي منها، أو بشأن تحديد حدودها أو تخومهـا .خطوطًا حدودية تقريبية قد لا يوجد بعد اتفاق كامل بشأنهاعلى الخرائط لميـة، كما أن ذكر شركات محددة أو منتجات جهات صانعة معينة لا يعني أن هذه الشركات والمنتجات معتمدة أو موصى بهـا مـن قبـل منظمـة الصـحة العا حـالات الخطـأ والسـهو فـإن أسـماء المنتجـات المسـجلة الملكيـة ُتمّيـز بـذكر الأحـرف وباسـتثناء . تفضـيًلا لهـا علـى سـواها ممـا يماثلهـا فـي الطـابع ولـم يـرد ذكـره .(في النص الإنكليزي)الكبيرة الاستهلالية من أسمائها ع دون أي ومـع ذلـك فـإن المـواد المنشـورة تُـوز . وقد اتخذت منظمة الصحة العالمية كل الاحتياطـات المعقولـة للتحقـق مـن المعلومـات الـواردة فـي هـذا المطبـوع والمنظمـة ليسـت مسـؤولة بـأي . والقـارئ هـو المسـؤول عـن تفسـير واسـتعمال المـواد المنشـورة. ضـمان مـن أي نـوع سـواء أكـان بشـكل صـريح أم بشـكل ضـمني .حال عن الأضرار التي قد تترتب على استعمالها

1 Профилактика инфекций и борьба с ними во время оказания медицинской помощи при вероятных или подтвержденных случаях инфицирования коронавирусом ближневосточного респираторного синдрома (БВРС-КоВ) Временное руководство Обновлено 4 июня 2015 г. WHO/MERS/IPC/15.1 История вопроса ВОЗ выпускает обновленный вариант временного руководства, опубликованного 6 мая 2013 г., для удовлетворения неотложной необходимости в обновленной информации и основанных на фактических данных рекомендациях в отношении безопасной помощи пациентам с вероятной или подтвержденной инфекцией коронавирусом ближневосточного респираторного синдрома (БВРС-КоВ). Информация для временных рекомендаций взята из основанных на фактических данных и опубликованных ВОЗ руководящих принципах, включая публикацию «Профилактика инфекций и борьба с острыми респираторными инфекциями, способными вызывать эпидемии и пандемии, при оказании медико-санитарной помощи. Руководящие принципы ВОЗ»1, а также из обзора имеющейся в настоящее время фактической информации об инфекции БВРС-КоВ. Рекомендации были рассмотрены экспертами по профилактике инфекций и борьбе с ними (ПБИ) и экспертами из других областей (фамилии и места работы см. в разделе «Выражение признательности»). Данное руководство отражает нынешний уровень понимания БВРС-КоВ2 в связи с ПБИ и использует пересмотренные определения случаев заболевания3. Это руководство предназначено для медико-санитарных работников (МСР), руководителе й медико-санитарной помощи и бригад по ПБИ. Было также опубликовано специальное руководство ВОЗ по клиническому ведению4. ВОЗ продолжает внимательно следить за ситуацией для выявления любых изменений, которые могут повлиять на это временное руководство. При изменении любого фактора ВОЗ выпустит следующее обновление. В противном случае срок действия данного временного руководства истечет через 12 месяцев после даты публикации. Здесь же приведены ссылки на дополнительные источники и фактическую информацию. В случае возникновения у вас дополнительных вопросов, направляйте их по электронной почте по адресу: outbreak@who.int ,указав в строке темы “MERS IPC question”. БВРС-КоВ является зоонозным вирусом с подтвержденными на сегодня данными о том, что источником заражения людей являются одногорбые верблюды. Передача от человека человеку происходит, главным образом, в медицинских учреждениях и – в гораздо меньшей степени – в общинах, в основном между членами домашнего хозяйства. Отсутствуют четкие свидетельства устойчивой передачи от человека человеку. Для передачи необходим тесный контакт, но возможны также другие виды передачи, такие как капельная и контактная передача. Необходимы дальнейшие исследования, чтобы лучше понять факторы риска передачи от животного человеку и от человека человеку. Успешная профилактика амплификации инфекции БВРС-КоВ в связи с оказанием медицинской помощи зависит от полного осуществления основных компонентов программ по ПБИ5. Большинство случаев передачи происходят при отсутствии базисных мер предосторожности для ПБИ и до возникновения подозрительного или подтвержденного случая; следовательно, регулярное применение мер для предотвращения распространения острых респираторных инфекций (ОРИ)1 при оказании помощи симптоматическим больным является важным для сокращения распространения любой ОРИ в медико- санитарных учреждениях. Дополнительные меры предосторожности при уходе за пациентами с вероятной или подтвержденной инфекцией БВРС-КоВ (см. раздел 2.4 настоящей публикации) должны применяться для дальнейшего сокращения риска передачи. Медико- санитарным учреждениям рекомендуется рассмотреть вопрос об усилении службы контроля за здоровьем медико-санитарных работников (МСР) в целях обеспечения безопасных условий для пациентов и МСР. Важно, чтобы для МСР была обеспечена наилучшая имеющаяся на месте защита для оказания помощи пациентам, инфицированным БВРС-КоВ, и чтобы были приняты меры на случай их заражения. В настоящем руководстве кратко излагаются:  Принципы стратегий ПБИ в связи с оказанием медицинской помощи  Меры предосторожности ПБИ для: - оказания помощи всем пациентам - оказания помощи пациентам с ОРИ, и - оказания помощи пациентам с вероятной или подтвержденной инфекцией БВРС-КоВ. Профилактика инфекций и борьба с ними во время оказания медицинской помощи при вероятных или подтвержденных случаях инфицирования коронавирусом ближневосточного респираторного синдрома (БВРС-КоВ): Временное руководство 2 1. Принципы стратегий профилактики инфекций и борьбы с ними в связи с оказанием медицинской помощи Профилактика или ограничение передачи инфекции в учреждениях медико-санитарной помощи требует применения процедур и протоколов, упоминаемых как «меры борьбы». Они представлены в иерархическом порядке в соответствии с их эффективностью в отношении ПБИ и включают следующие: административные меры, меры, связанные с окружающей средой и техникой, и индивидуальные средства защиты (ИСЗ). Административные меры. Они являются первым приоритетом стратегий по ПБИ. Они обеспечивают инфраструктуру политики и процедур для предотвращения, раннего выявления и борьбы с передачей инфекций во время оказания медицинской помощи. Чтобы меры ПБИ были эффективными, они должны распространяться на весь цикл пребывания пациентов (и учитывать возникающие в результате потенциальные риски), от места поступления до выписки из медицинского учреждения. Клиническая сортировка пациентов является одной из важных административных мер и используется для быстрого выявления и оказания помощи пациентам с ОРИ, в том числе с подозреваемой инфекцией БВРС- КоВ. Пациенты с установленной ОРИ должны помещаться в зону, отделенную от других пациентов, и должны быть быстро приняты дополнительные меры предосторожности, связанные с ПБИ (см. раздел 2.2). Клинические и эпидемиологические аспекты случаев должны оцениваться как можно скорее (см. рекомендации ВОЗ 6) и дополняться лабораторной оценкой. Другие административные меры борьбы и политика, которые применяются к ОРИ, включают создание устойчивых инфраструктур и мероприятий для ПБИ; просвещение МСР; предотвращение скопления людей в зонах ожидания; предоставление специально выделенных зон ожидания для больных и размещения госпитализированных пациентов; организацию медико- санитарных услуг для адекватного предоставления и использования предметов снабжения; политику и процедуры для всех аспектов профессиональной гигиены с акцентом на контроль ОРИ среди МСР и важность обращения за медицинской помощью; и мониторинг за соблюдением мер МСР, наряду с созданием механизмов для улучшения в соответствии с необходимостью. Меры, связанные с окружающей средой и техникой. Они включают базисную инфраструктуру медико- санитарного учреждения7. Эти меры направлены на обеспечение адекватной вентиляции среды8 во всех зонах медико-санитарного учреждения, а также адекватную чистку окружающей среды. Между каждым пациентом с ОРИ и другими людьми, включая МСР, должно соблюдаться пространственное разделение в 1 метр. Эти меры борьбы могут помочь сократить распространение многих возбудителей инфекций во время оказания медицинской помощи9. Индивидуальные средства защиты. Рациональное и последовательное использование ИСЗ и надлежащая гигиена рук10 также помогают уменьшить распространение инфекции. Хотя использование ИСЗ является наиболее видимой мерой, применяемой для профилактики передачи, она является последней и самой слабой в иерархии мер ПБИ и не должна признаваться в качестве основной стратегии профилактики. В отсутствие административных мер и мер, касающихся технических средств, ИСЗ имеют ограниченные преимущества. 2. Меры предосторожности для профилактики инфекций и борьбы с ними 2.1 Стандартные меры предосторожности Стандартные меры предосторожности11 являются фундаментальным элементом обеспечения безопасной медицинской помощи, сокращая риск дальнейшей инфекции и защищая МСР, и должны применяться во всех медико-санитарных учреждениях для всех пациентов. Стандартные меры предосторожности включают гигиену рук и использование соответствующих ИСЗ в зависимости от риска прямого контакта с кровью, жидкостями, выделениями организма пациента (включая респираторные выделения) и с поврежденной кожей. Стандартные меры предосторожности также включают: предотвращение травм от острых и колющих инструментов; безопасное удаление отходов; чистку, дезинфекцию и, в случае необходимости, стерилизацию оборудования и белья, использованного при оказания помощи пациенту; а также чистку и дезинфекцию окружающей среды. Следует также поощрять респираторную гигиену при оказании помощи пациентам с респираторными симптомами. МСР должны применять «Пять правил гигиены рук», которые рекомендуют дезинфицировать руки: до прикосновения к пациенту; до применения любой чистки или асептической процедуры; после риска воздействия жидкости организма; после прикосновению к пациенту; и после соприкосновения со средой, окружающей пациента, включая зараженные предметы или поверхности.  Гигиена рук включает либо мытье рук водой с мылом, либо использование содержащего спирт антисептика для рук.  Мытье рук водой с мылом, если на них видна грязь.  Использование ИСЗ не исключает необходимости гигиены рук. Гигиена рук также необходима при надевании и особенно снимании ИСЗ.12 Использование ИСЗ должно определяться оценкой риска в отношении предполагаемого контакта с кровью, жидкостями организма, выделениями и поврежденной кожей при оказании рутинной помощи пациенту. Если существует риск заражения лица и/или тела, ИСЗ должны включать использование :  средств защиты лица с помощью либо медицинской маски13 и козырька или очков для защиты глаз; или лицевого щитка;  халата; и  чистых перчаток. Профилактика инфекций и борьба с ними во время оказания медицинской помощи при вероятных или подтвержденных случаях инфицирования коронавирусом ближневосточного респираторного синдрома (БВРС-КоВ): Временное руководство 3 МСР должны избегать прикосновения к своим глазам, носу или рту, возможно, контаминированными перчатками или голыми руками. Следует обеспечить последовательное и правильное применение процедур чистки и дезинфекции. Чистка окружающих поверхностей водой и моющими средствами и применение обычных дезинфицирующих средств (таких как гипохлориты) является эффективной и достаточной процедурой. Обращаться с прачечными, посудой для общественного питания и медицинскими отходами следует в соответствии с регулярными процедурами обеспечения безопасности. 2.2. Дополнительные меры предосторожности для профилактики инфекций и борьбы с ними при оказании помощи пациентам с острой респираторной инфекцией (ОРИ) В дополнение к Стандартным мерам предосторожности все люди, включая посетителей и МСР, вступающие в контакт с пациентами с ОРИ, должны:  использовать медицинские маски при тесном контакте (приблизительно менее 1 м) и прежде чем войти в палату или кабинку пациента;  выполнять гигиену рук до и после прикосновения к пациенту и окружающей его среде, а также сразу же после снятия медицинской маски. Подробные меры предосторожности описаны в Руководящих принципах ВОЗ1 и должны применяться при оказании помощи пациентам с ОРИ. 2.3. Меры предосторожности для профилактики инфекций и борьбы с ними при процедурах, сопровождающихся образованием аэрозолей Процедура, сопровождающаяся образованием аэрозолей, - это любая медицинская процедура, которая может вызвать образование аэрозолей различных размеров, включая очень мелкие (< 5 µm) частицы. Имеющиеся в настоящее время фактические данные, лучшие из которых поступают из исследований коронавируса тяжелого острого респираторного синдрома (ТОРС- КоВ), свидетельствуют о систематической связи между передачей патогена и интубацией трахеи.14 Кроме того, небольшое число исследований сообщило о повышенном риске инфекции ТОРС-КоВ в связи с трахеотомией, неинвазивной вентиляцией и мануальной вентиляцией до интубации. Однако, поскольку эти результаты были обнаружены лишь в небольшом числе исследований весьма низкого качества, интерпретировать и практически использовать эти результаты довольно трудно. Не было обнаружено никакой значительной связи других процедур с повышенным риском передачи ОРИ. Дополнительные меры предосторожности следует соблюдать при выполнении процедур с образованием аэрозолей, которые могут быть связаны с повышенным риском передачи инфекции, особенно интубации трахеи. Дополнительные меры предосторожности при выполнении процедур с образованием аэрозолей включают:  использование противоаэрозольного респиратора15; при надевании одноразового респиратора этого типа всегда проверяйте герметичность прилегания16;  использование средств защиты глаз (например, очков или лицевых щитков);  использование чистого нестерильного халата с длинными рукавами и перчаток (некоторые из таких процедур требуют использования стерильных перчаток);  использование устойчивого к проникновению жидкостей передника для некоторых процедур с предполагаемым большим объемом жидкости, которая может проникнуть в халат;  выполнение процедур в адекватно вентилируемом помещении; то есть не менее чем с 6-12 воздухообменами в час в учреждениях с механической вентиляцией помещений и не менее чем 60 литрами в секунду на пациента в учреждениях с естественной вентиляцией8;  ограничение количества людей, присутствующих в помещении до абсолютного минимума, необходимого для оказания помощи и поддержки пациенту; и  выполнение гигиены рук до и после контакта с пациентом и окружающей его средой, а также после снятия ИСЗ. 2.4. Меры предосторожности для профилактики инфекций и борьбы с ними при оказании помощи пациентам с вероятной или подтвержденной инфекцией БВРС-КоВ Помещайте пациентов с вероятной или подтвержденной инфекцией БВРС- КоВ в адекватно вентилируемые отдельные палаты или палаты с защитой от воздушно- капельных инфекций; по возможности, расположите отдельные помещения, используемые для защищенного ухода, в зоне, которая четко отделена от других зон оказания помощи пациентам. Если отдельные помещения отсутствуют, поместите пациентов с подтвержденной инфекцией вместе и отделите их от пациентов с вероятной инфекцией. Если это невозможно, расположите кровати пациентов на расстоянии по крайней мере одного метра друг от друга. Ограничьте количество МСР, членов семей и посетителей, контактирующих с пациентом, имеющим вероятную или подтвержденную инфекцию БВРС-КоВ.  В той степени, в какой это возможно, для оказания помощи вероятным или подтвержденным случаям назначьте исключительно специальную группу квалифицированных МСР как для непрерывности оказания помощи, так и для уменьшения возможностей случайного нарушения мер борьбы, которое может привести к незащищенному воздействию.  Членов семей и посетителей, которые могут вступать в контакт с пациентом, следует ограничить только теми, кто оказывает важную для пациента поддержку, и их следует обучить предотвращению риска передачи и применению тех же мер предосторожности, какие применяют МСР, оказывающие регулярную медицинскую помощь. Это особенно важно в местах, где уход за госпитализированными больными осуществляют члены семей. В дополнение к Стандартным мерам предосторожности все люди, включая посетителей и МСР, вступающие в Профилактика инфекций и борьба с ними во время оказания медицинской помощи при вероятных или подтвержденных случаях инфицирования коронавирусом ближневосточного респираторного синдрома (БВРС-КоВ): Временное руководство 4 тесный контакт (в пределах одного метра) или заходящие в палату или бокс пациентов с вероятной или подтвержденной инфекцией БВРС-КоВ, всегда должны:  использовать медицинскую маску14;  использовать защиту глаз (то есть очки или лицевой щиток);  использовать чистый нестерильный халат с длинными рукавами;  использовать перчатки (некоторые процедуры могут потребовать стерильных перчаток);  выполнять гигиену рук до и после контакта с пациентом и окружающей его средой, а также немедленно после снятия ИСЗ. По возможности, используйте либо одноразовые средства, либо специальное оборудование (например, стетоскопы, манжеты для измерения кровяного давления и термометры). Если необходимо использовать оборудование для нескольких пациентов, чистите и дезинфицируйте его после каждого пациента. МСР следует воздерживаться от прикосновения к своим глазам, носу и рту потенциально контаминированными перчатками или голыми руками. Кроме того, в отношении пациентов с вероятной или подтвержденной инфекцией БВРС-КоВ:  Избегайте перемещения и транспортировки пациентов за пределы защищенного помещения или защищенной зоны без медицинской необходимости. Этому может содействовать использование мобильного рентгенологического и другого важного диагностического оборудования. Если требуется транспортировка, используйте маршруты, которые сводят к минимуму воздействие на персонал, других пациентов и посетителей.  Уведомьте приемное отделение о диагнозе пациента и необходимых мерах предосторожности как можно скорее до прибытия пациента.  Проведите чистку и дезинфекцию поверхностей, с которыми контактировал пациент (например, кровати), после использования17.  Обеспечьте, чтобы МСР, транспортирующие пациентов, носили надлежащие ИСЗ и после использования применяли надлежащие меры ПБИ. 2.5. Длительность применения барьерных мер предосторожности при инфекции БВРС-КоВ Продолжительность инфективности инфекции БВРС- КоВ неизвестна. Если Стандартные меры предосторожности следует применять всегда, то дополнительные барьерные меры должны применяться во время симптоматического протекания болезни21 и продолжаться в течение 24 часов после прекращения симптомов. Учитывая, что в настоящее время имеется мало информации о выделении вируса и потенциале для передачи БВРС-КоВ, тестирование на выделение вируса должно помочь в принятии решения, если такое тестирование легкодоступно. Информацию о пациенте (например, возраст, иммунный статус и лекарственное лечение) также следует рассматривать в ситуациях, когда существует обеспокоенность по поводу того, что пациент может выделять вирус в течение длительного времени. 2.6. Получение лабораторных образцов от пациентов с ОРИ, вызывающих беспокойство, и обращение с такими образцами Все образцы, полученные для лабораторного исследования, следует считать потенциально инфекционными, и МСР, которые собирают или транспортируют клинические образцы, должны строго соблюдать Стандартные меры предосторожности для сведения к минимуму возможности воздействия возбудителей болезни.  Обеспечьте, чтобы МСР, которые берут образцы, использовали надлежащие ИСЗ.  Обеспечьте, чтобы персонал, который транспортирует образцы, был обучен практике безопасного обращения и процедурам деконтаминации пролившегося вещества .  Поместите образцы для транспортировки в герметичный пакет для образцов (вторичный контейнер), имеющий отдельное запечатываемое отделение для образцов (например, пластиковый пакет биобезопасности для образцов) с этикеткой пациента на контейнере с образцом (первичном контейнере) и с четко заполненным формуляром запроса.  Убедитесь, что лаборатории медико-санитарного учреждения соблюдают надлежащую практику биологической безопасности и транспортные требования в соответствии с видом отправляемого микроорганизма.  Доставляйте все образцы вручную каждый раз, когда это возможно. Не используйте пневматические системы доставки для транспортировки образцов.  На сопровождающем формуляре запроса четко укажите наименование (подозреваемой) ОРИ, вызывающей обеспокоенность. Как можно скорее уведомьте лабораторию о том, что образец транспортируется. Для получения дальнейшей информации об обращении с образцами в лаборатории и при лабораторном тестировании на новый коронавирус см. «Преодоление биологического лабораторного риска для лабораторий, работающих с образцами, взятыми у людей и подозреваемыми на наличие нового коронавируса или с подтвержденным наличием нового коронавируса: Временные рекомендации»22 и «Лабораторное тестирование на коронавирус ближневосточного респираторного синдрома – Временные рекомендации (пересмотренные). 23 Для получения дальнейшей информации о принципах обеспечения биологической безопасности лабораторий см. Руководство ВОЗ по биологической безопасности, 3-е издание.24 Профилактика инфекций и борьба с ними во время оказания медицинской помощи при вероятных или подтвержденных случаях инфицирования коронавирусом ближневосточного респираторного синдрома (БВРС-КоВ): Временное руководство 5 Выражение признательности Настоящий документ был подготовлен в консультации с сотрудниками Глобальной сети ВОЗ по профилактике инфекций и борьбе с ними и с другими международными экспертами. ВОЗ выражает признательность следующим лицам за рассмотрение этого документа (в алфавитном порядке):  Abdulla Assiri, Генеральный директор, Борьба с инфекциями, Министерство здравоохранения, Саудовская Аравия  Barry Cookson, Факультет инфекций и иммунитета, Университетский колледж, Лондон, Соединенное Королевство  John M Conly, Департаменты медицины, микробиологии, иммунологии и инфекционных болезней, Институт Кэлвина, Фиби и Джоан Синдер по хроническим болезням, Факультет медицины, Университет Калгари, Калгари, Канада  Niklas Danielsson, старший эксперт по инфекционным болезням, Болезни, предупреждаемые вакцинацией, подразделение по эпиднадзору и ответным мерам, Европейский центр профилактики болезней и борьбы с ними  Katherine Defalco, консультант по сестринскому делу, Центр по инфекционным болезням и инфекционному контролю, Агентство общественного здравоохранения Канады, Оттава, Канада  Elaine Furukawa, Директор по подготовке, Инфекционный контроль, Министерство здравоохранения, Саудовская Аравия  Susan I. Gerber, руководитель группы, Респираторные вирусы/пикорнавирусы, Отдел вирусных болезней/отделение эпидемиологии, Центры борьбы с болезнями и профилактики болезней, Атланта, Джорджия, США  Benedikt Huttner, Программа борьбы с инфекциями и Сотрудничающий центр ВОЗ по безопасности пациентов, Больницы и медицинский факультет Женевского университета, Женева, Швейцария  M Mushtuq Husain, Старший научный сотрудник и руководитель Департамента медико-социальных наук, Институт эпидемиологии, борьбы с болезнями и научных исследований (IEDCR), Дакка, Бангладеш  David T. Kuhar, Медицинский сотрудник, Отдел усиления качества медицинской помощи, Центры борьбы с болезнями и профилактики болезней, Атланта, Джорджия, США  Moi Lin Ling, Директор, Департамент инфекционного контроля, Центральная больница Сингапура, и Президент Общества инфекционного контроля стран Азии и Тихого океана (APSIC)  Anna-Pelagia Magiorakos, Старший эксперт, Устойчивость к противомикробным препаратам и инфекции, связанные с оказанием медицинской помощи, Европейский центр профилактики болезней и борьбы с ними  Shaheen Mehtar, экстраординарный профессор, Отделение профилактики инфекций и борьбы с ними, Факультет медицины и медико-санитарных дисциплин, Стелленбосский университет, Тайгерберг , и Заведующей кафедрой, Африканская сеть борьбы с инфекциями  Ziad A Memish, Заместитель министра по общественному здравоохранению, Министерство здравоохранения, Эр-Рияд, Саудовская Аравия  Babacar NDoye, Член Совета, Африканская сеть борьбы с инфекциями, Дакар, Сенегал  Folasade T Ogunsola, Кафедра медицинской микробиологии и паразитологии, Медицинский колледж, Лагосский университет, Нигерия, и Секретарь Африканской сети борьбы с инфекциями  Fernando Otaiza O'Ryan, Руководитель, Национальная программа ПБИ, Министерство здравоохранения, Сантьяго, Чили  Maria Clara Padoveze, Школа сестринского дела, Университет Сан-Пауло, Бразилия  Nick Phin, Отдел обеспечения готовности и ответных мер, Департамент респираторных болезней, АОЗ Колиндейл, Лондон, Соединенное Королевство  Didier Pittet, Директор, Программа борьбы с инфекциями и Сотрудничающий центр ВОЗ по безопасности пациентов, Больницы и медицинский факультет Женевского университета, Женева, Швейцария  Наталья Пшеничная, Профессор, Ростовский государственный медицинский университет, Ростов, Российская Федерация  Wing Hong Seto, Департамент коммунальной медицины, Школа общественного здравоохранения, Гонконгский университет, Гонконг, Китайская Народная Республика  Nandini Shetty, Консультант-микробиолог, Референс- службы по микробиологии, Колиндейл, Агентство по охране здоровья, Соединенное Королевство  Nalini Singh, Профессор педиатрии, Глобальное здравоохранение, Эпидемиология, Университет Джорджа Вашингтона, Вашингтон, ОК, США  Thomas Weaver, Директор, Профессиональная практика, АСИКЭ и Ассоциация профессиональных работников по инфекционному контролю и эпидемиологии Всем принимавшим участие в рассмотрении было предложено подписать декларацию интересов, и никаких конфликтов интересов обнаружено не было. Ссылки 1. «Infection prevention and control of epidemic- and pandemic- prone acute respiratory infections in health care - WHO Guidelines. Geneva, World Health Organization, 2014. Имеется по адресу: http://apps.who.int/iris/bitstream/10665/112656/1 /9789241507134_eng.pdf 2. Для получения самой последней информации просьба проконсультироваться на веб-странице ВОЗ, посвященной коронавирусу: http://www.who.int/csr/disease/coronavirus_infections/en/. 3. Определения случая заболевания для сообщения в ВОЗ имеются по адресу: http://www.who.int/csr/disease/coronavirus _infections/case_definition/en/. 4. Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do. Geneva, World Health Organization, 2013. Имеется по адресу: http://www.who.int/csr/disease/coronavirus_infections /InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf. Профилактика инфекций и борьба с ними во время оказания медицинской помощи при вероятных или подтвержденных случаях инфицирования коронавирусом ближневосточного респираторного синдрома (БВРС-КоВ): Временное руководство 6 5. Core components of infection prevention and control programmes in health care. Aide-memoire. Geneva, World Health Organization, 2011. Имеется по адресу: http://www.who.int/csr/resources/publications/AM_core_components_IPC/en/. 6. Interim surveillance recommendations for human infection with Middle East respiratory syndrome coronavirus. Geneva, World Health Organization, 2014. Имеется по адресу: http://www.who.int /csr/disease/coronavirus_infections/InterimRevisedSurveillanceRecommendatio ns_nCoVinfection_14July2014.pdf 7. Essential environmental health standards in health care. Geneva, World Health Organization, 2008. Имеется по адресу: http://www.who.int/water_sanitation_health/hygiene/settings/ehs_hc/en/index.ht ml. 8. Natural ventilation for infection control in health-care settings. Geneva, World Health Organization, 2009. Имеется по адресу: http://www.who.int/water_sanitation_health/publications/natural_ventilation/en/i ndex.html. 9. Jefferson T, Del Mar CB, Dooley L et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews, 2011, 7:CD006207. Имеется по адресу: http://onlinelibrary.wiley.com/doi/10.1002/14651858 .CD006207.pub4/abstract;jsessionid=074644E776469A4CFB54F28D01B8283 5.d03t02. 10. WHO Guidelines on hand hygiene in health care. Geneva, World Health Organization, 2009. Имеется по адресу: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. 11. Standard Precautions are basic precautions designed to minimize direct, unprotected exposure to potentially infected blood, body fluids or secretions applicable to all patients. See also Standard precautions in health care. Geneva, World Health Organization, 2007. Имеется по адресу: http://www.who .int/csr/resources/publications/EPR_AM2_E7.pdf. 12. Видеоматериал о том, как надевать и снимать ИСЗ, имеется по адресу: http://www.who.int/csr/resources/publications/putontakeoffPPE /en/. 13. В настоящем документе термин «медицинская маска» относится к одноразовым хирургическим и процедурным маскам. 14. 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:e35797. Имеется по адресу: http://www .plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0035797. 15. Примеры приемлемых одноразовых респираторов частиц, используемых в различных частях мира, включают: Австралия/Новая Зеландия : P2 (94%), P3 (99,95%); Китай: II (95%), I (99%); Европейский союз: сертифицированные, как отвечающие европейским нормам, фильтрующие лицевые респираторы класса 2 (FFP2) (95%), класса 3 (FFP3) (99,7%); Япония: 2-ой класс (95%), 3-й класс (99,9%); Республика Корея: 1-й класс (94%), специальные (99,95%); Соединенные Штаты: сертифицированные НИОТПГ - N95 (95%), N99 (99%), N100 (99,7%). 16. Видеоматериал о том, как проверять герметичность респиратора частиц, имеется по адресу: http://www.who.int/csr /resources/publications/respiratorsealcheck/en/. 17. Lai MY, Cheng PK, Lim WW. Survival of severe acute respiratory syndrome coronavirus. Clinical Infectious Diseases, 2005, 41(7):67–71. 18. Community case management during an influenza outbreak. A training package for community health workers. Geneva, World Health Organization, 2011. Имеется по адресу: http://www.who.int /influenza/resources/documents/community_case_management_flipbook/en/in dex.html. 19. Infection-control measures for health care of patients with acute respiratory diseases in community settings. Trainer's Guide. Geneva, World Health Organization, 2009. Имеется по адресу:http://www.who.int/csr/resources/publications/WHO_HSE_GAR_BDP _2009_1/en/index.html. 20. Infection-control measures for health care of patients with acute respiratory diseases in community settings. Trainee's Guide. Geneva, World Health Organization, 2009. Имеется по адресу: http://www.who.int/csr/resources/publications/WHO_HSE_GAR_BDP _2009_1a/en/index.html. 21. In studies conducted in Hong Kong SAR, China, no SARS- CoV was cultured from the clinical specimens from infected patients once they were asymptomatic (see Chan KH, Poon LL, Cheng VC et al. Detection of SARS coronavirus in patients with suspected SARS. Emerging Infectious Diseases, 2004, 10(2):294–299). 22. Laboratory biorisk management for laboratories handling human specimens suspected or confirmed to contain novel coronavirus: Interim recommendations. Geneva, World Health Organization, 2013. Имеется по адресу: http://www.who.int/csr /disease/coronavirus_infections/NovelCoronavirus_InterimRecommendationsLa boratoryBiorisk_190213/en/index.html. 23. Laboratory testing for Middle East respiratory syndrome coronavirus - Interim recommendations, Geneva, World Health Organization, 2014. Имеется по адресу: http://www.who.int/csr /disease/coronavirus_infections/WHO_interim_recommendations_lab_detection _MERSCoV_092014.pdf?ua=1. 24. WHO laboratory biosafety manual, third edition. Geneva, World Health Organization, 2004. Имеется по адресу: http://www.who.int/csr/resources/publications/biosafety/WHO_CDS_CSR_LYO _2004_11/en/. © Всемирная организация здравоохранения, 2015 г. Все права защищены. Публикации Всемирной организации здравоохранения имеются на веб-сайте ВОЗ (www.who.int) или могут быть приобретены в Отделе прессы ВОЗ, Всемирная организация здравоохранения, 20 Avenue Appia, 1211 Geneva 27, Switzerland (тел.: +41 22 791 3264; факс: +41 22 791 4857; эл. почта: bookorders@who.int). Запросы на получение разрешения на воспроизведение или перевод публикаций ВОЗ - как для продажи, так и для некоммерческого распространения - следует направлять в Отдел прессы ВОЗ через веб-сайт ВОЗ (http://www.who.int/about/licensing/copyright_form/en/index.html). Обозначения, используемые в настоящей публикации, и приводимые в ней материалы не отражают какого-либо мнения Всемирной организации здравоохранения относительно юридического статуса какой-либо страны, территории, города или района или их органов власти, либо относительно делимитации их границ. Пунктирные линии на географических картах обозначают приблизительные границы, в отношении которых пока еще может быть не достигнуто полное согласие. Упоминание конкретных компаний или продукции некоторых изготовителей не означает, что Всемирная организация здравоохранения поддерживает или рекомендует их, отдавая им предпочтение по сравнению с другими компаниями или продуктами аналогичного характера, не упомянутыми в тексте. За исключением случаев, когда имеют место ошибки и пропуски, названия патентованных продуктов выделяются начальными прописными буквами. Всемирная организация здравоохранения приняла все разумные меры предосторожности для проверки информации, содержащейся в настоящей публикации. Тем не менее, опубликованные материалы распространяются без какой-либо четко выраженной или подразумеваемой гарантии. Ответственность за интерпретацию и использование материалов ложится на пользователей. Всемирная организация здравоохранения ни в коем случае не несет ответственности за ущерб, возникший в результате использования этих материалов.

1 中东呼吸综合征冠状病毒感染可能或确诊病 例治疗期间的感染预防和控制 临时指导文件 2015年 6月 4日更新 WHO/MERS/IPC/15.1 背景 世卫组织更新了 2013年 5月 6日发布的临时指导文 件，以满足安全护理可能或确诊中东呼吸综合征冠状病 毒感染患者所迫切需要的最新信息和循证建议。本文件 的临时建议参考了世卫组织业已出版的循证指南，包括 《卫生保健中对易流行和大流行的急性呼吸道感染的感 染预防和控制世卫组织指南》1，并审查了当前有关中东 呼吸综合征冠状病毒感染的证据。建议已经感染预防和 控制及其它技术领域专家（相关专家姓名和单位见致谢 部分）审阅。 本指导文件反映目前与感染预防和控制有关的对中 东呼吸综合征冠状病毒的理解 2，并使用经修订的病例 定义 3。本指导文件针对医务工作者、卫生保健管理人 员和感染预防和控制团队。有关临床管理的世卫组织指 导文件也已发布 4。世卫组织继续密切监测可能影响本 临时指导文件的形势变化。如任何因素发生变化，世卫 组织将发布更新。否则，本临时指导文件将在发布之日 起 12 个月后失效。此处提供更多资源和证据的链接。 如有进一步问题，请发电子邮件至 outbreak@who.int ，标 题请注明“MERS IPC question”。 中东呼吸综合征冠状病毒是一种人畜共患病毒，迄 今已有证据显示骆驼是人类感染的来源。人际间传播大 部分发生在卫生保健环境下，在更有限地程度上发生在 社区，主要是家庭内部。并无持续人际间传播的明确证 据。传播需要密切接触，也可能存在液滴和接触传播等 不同模式。需要开展进一步研究，以便更好地了解从动 物到人和人际间传播的危险因素。 成功防止与卫生保健有关的中东呼吸综合征冠状病 毒感染的增加有赖于全面实施感染预防和控制规划的核 心内容 5。大部分传播发生在没有采取基本的感染预防 和控制措施的情况下和出现具体的疑似或确诊病例之 前；因此，在护理有症状患者时常规实施预防急性呼吸 道感染的措施 1对于减少卫生保健环境下的急性呼吸道 感染传播必不可少。护理可能或确诊的中东呼吸综合征 冠状病毒感染者（见本文第 2.4 节）时，应采取更多防 护措施，以进一步降低传播风险。建议卫生保健机构考 虑加强对医务工作者健康的监测，以便确保患者和医务 工作者享有安全的环境。重要的是，要向护理中东呼吸 综合冠状病毒感染患者的医务工作者提供当地可获得的 最佳保护；如发生暴露，则需采取后续措施。 本指导文件总结如下内容：  与卫生保健有关的感染预防和控制策略的原则  感染预防和控制防护措施： - 护理所有患者时 - 护理急性呼吸道感染患者时 - 护理可能或确诊中东呼吸综合征冠状病毒 感染患者时。 1. 与卫生保健有关的感染预防和控制策 略的原则 预防或限制卫生保健环境下的感染传播需要实施各 种名为“控制”的程序和方案。这些措施按照感染预防 和控制的有效性分级，包括如下内容：行政控制、环境 和工程控制以及个体防护装备。 行政控制。这些是感染预防和控制策略的首要任 务。它们提供在卫生保健过程中预防、及早发现并控制 感染传播的基本政策和程序架构。要产生效果，感染预 防和控制措施就必须能够预见患者（及潜在风险）从第 一次接触到离开医院的流线。 临床分诊是一项重要措施，用于快速发现急性呼吸 道感染患者（包括疑似中东呼吸综合征冠状病毒感染 者）并为其提供适当护理。应将发现的急性呼吸道感染 患者安排在与其他患者分开的区域，并立刻实施更多感 染预防和控制措施（见第 2.2 节）。应尽快评估相关病 例的临床和流行病学情况（见世卫组织建议 6），并进 行实验室评估。 其它适用于急性呼吸道感染的行政控制措施和政策 包括：建立可持续的感染预防和控制基础设施和活动； 教育医务工作者；防止等候区过于拥挤；为患病者提供 专门的等候区及为住院患者提供专门区域；对卫生保健 服务进行组织以便充分提供并使用相关物资；针对职业 卫生的所有方面确定政策和程序，其中强调监测医务工 作者的急性呼吸道感染和就医的重要性；监督医务工作 者遵守规定并建立必要的改进机制。 环境和工程控制。包括基本卫生保健机构的基础设 施 7。这些控制措施是要确保卫生保健设施内所有区域 中东呼吸综合征冠状病毒感染可能或确诊病例治疗期间的感染预防和控制：临时指导文件 2 都得到充分的环境通风 8，并进行充分环境清洁。每位 急性呼吸道感染患者和其它人（包括未穿戴个体防护装 备的医务工作者）之间应确保至少 1 米的空间距离。这 两类控制措施都有助于减少卫生保健过程中的多种病原 体传播 9。 个体防护装备。合理使用、坚持使用可获得的个体 防护装备并按正确方法洗手 10也有助于减少传播。 虽然 使用个体防护装备是预防传播的最显眼控制措施，但它 其实是分级感染预防和控制措施中的最后和最弱手段， 不能将其作为主要预防策略。如果没有有效的行政和工 程控制，个体防护装备的好处有限。 2. 感染预防和控制防护措施 2.1 标准防护措施 标准防护措施 11是提供安全卫生保健、减少进一步 感染风险和保护医务工作者的基石，应在所有卫生保健 环境下针对所有病人实施。标准防护措施包括洗手和在 有直接接触患者血液、体液、分泌物（包括呼吸道分泌 物）和不完整皮肤风险时使用相关个体防护装备。标准 防护措施还包括：防止针刺或锐器损伤；安全废物管 理；患者护理设备和被服的清洁、消毒和酌情进行灭菌 操作以及环境的清扫和消毒。应鼓励任何有呼吸道症状 者均养成呼吸卫生习惯。 医务工作者应实施“手卫生的五个时刻”：接触患 者前；进行清洁或无菌操作前；体液暴露后；接触患者 后；接触患者周围环境（包括被污染的物体或表面） 后。  手卫生包括用肥皂和水洗手或者使用醇基擦手 剂。  手部有明显污垢时用肥皂和水洗手。  使用个体防护装备并不意味着不用进行手卫生 程序。穿戴、特别是脱摘个体防护装备时也需 要进行手卫生程序 12。 是否使用个体防护装备应根据对常规患者护理中预 期接触血液、体液、分泌物和不完整皮肤的风险分析进 行。存在污染面部和/或身体风险时，使用个体防护装备 应包括：  通过戴医用口罩 13和护目镜或者防护面罩保护 面部；  大褂；和  干净手套。 医务工作者应避免用可能被污染的戴手套或不戴手 套的手接触自己的眼睛、鼻子或嘴。 确保坚持随后正确进行清洁和消毒程序。用水和洗 涤剂清洁环境表面并使用常用的消毒剂（如次氯酸盐） 的程序就是有效、充分的。根据安全的常规程序管理被 服、食品服务用具和医疗废物。 2.2. 护理急性呼吸道感染患者时的额外感染预防和控制 防护措施 除标准防护措施外，所有接触急性呼吸道感染患者 的访客和医务工作者均应：  密切接触（约 1米距离内）及进入患者房间或 隔间时佩戴医用口罩；  接触患者或其周围环境前后以及摘下医用口罩 后进行手卫生程序。 已发布的世卫组织指南 1描述了详细的防护措施， 应在护理急性呼吸道感染患者时实施。 2.3. 针对产生气溶胶的操作的感染预防和控制防护措施 产生气溶胶的操作是指能够引起产生包括微小颗粒 物（<5 µm）在内的各种大小的气溶胶的任何医疗操作 程序。目前最佳证据来自对严重急性呼吸综合征冠状病 毒的研究。证据前后一贯地显示，病原体传播和气管插 管术之间存在关联 14。此外，一些研究报告，严重急性 呼吸综合征冠状病毒感染风险增加与气管切开术、无创 通气和插管前手控通气有关。但是，由于这些发现仅来 自少量质量非常低的研究，对其解读和实际应用均很困 难。还没有发现有其它操作与急性呼吸道感染传播风险 增加显著相关。 进行产生气溶胶的操作时应采取额外防护措施，这 些操作困难与感染传播风险增加有关，特别是气管插管 术。 进行产生气溶胶的操作时采取的额外防护措施包 括：  使用防颗粒物呼吸器 15；戴上一次性防颗粒物 呼吸器时，总是检查密封是否良好 16；  使用眼部保护（即护目镜或防护面罩）；  使用清洁、非无菌、长袖大褂和手套（其中一 些操作要求使用无菌手套）；  进行预计会产生可能渗入大褂的高液量操作时 使用防水围裙；  操作时使用通风良好的单间，即 每小时至少换 气 6-12次的机械通风房间，或者自然通风实现 至少 60升/秒/位患者的设施 8；  将房间内人员数量限制在提供患者护理和支持 所必需的绝对最低数量；并且  接触患者及其周围环境之前和之后以及脱摘个 体防护装备后进行手卫生程序。 中东呼吸综合征冠状病毒感染可能或确诊病例治疗期间的感染预防和控制：临时指导文件 3 2.4. 护理可能或确诊中东呼吸综合征冠状病毒感染者时 的感染预防和控制防护措施 将可能或确诊中东呼吸综合征冠状病毒感染患者安 排在通风良好的单间或“防空气传播”病房；如有可 能，将隔离用单间病房安排在与其它患者护理区域明确 分开的区域。如没有单间可用，则将确诊患者安排在一 起，并与可能患者分开。如果做不到这一点，则保证病 床之间有至少 1米的距离。 限制与可能或确诊中东呼吸综合征冠状病毒感染患 者接触的医务工作者、家人和访客的数量。  尽可能做出安排，由专门一组熟练的医务工作 者治疗可能或确诊病例，这样既确保治疗的连 续性，又可以减少意外违反感染控制规定造成 未受保护的暴露的情况。  可能接触患者的家人和访客应限制在支持患者 所必需的人员，并接受有关传播风险和采取与 提供常规治疗的医务工作者一样的感染控制措 施的培训。这对那些住院病人往往由家人照顾 的环境尤其重要。 除标准防护措施外，所有个人，包括访客和医务工 作者，在密切接触（1 米以内）可能或确诊中东呼吸综 合征冠状病毒感染患者或进入其房间或隔间时，应总 是：  佩戴医用口罩 14；  保护眼部（即戴护目镜或防护面罩）；  穿清洁、非无菌的长袖大褂；  戴手套（有些操作可能需要使用无菌手套）；  接触患者及其周围环境前后以及脱摘个体防护 装备后立即进行手卫生程序。 如有可能，使用一次性设备或专用设备（例如听诊 器、血压袖带和体温计）。如需要患者共用设备，则每 位患者用后均需清洁消毒。医务工作者应避免用可能污 染的戴手套或不戴手套的手接触自己的眼睛、鼻子或 嘴。 此外，对于可能或确诊中东呼吸综合征冠状病毒感 染患者：  除非治疗需要，否则应避免将患者移动或运送 出隔离病房或隔离区。使用专门的便携式 X光 设备和其它重要诊断设备可以便利工作。如需 移动，应使用令工作人员、其它患者和访客暴 露最少的路线。  在患者抵达前尽快将患者的诊断结果和必要的 防护措施通知接收区。  使用后清洁消毒患者接触物体的表面（如床）17。  确保运送患者的医务工作者穿戴适当的个体防 护装备并在完成运送后进行手卫生程序。 2.5. 中东呼吸综合征冠状病毒感染隔离防护措施的持续 时间 中东呼吸综合征冠状病毒感染的传染性持续时间尚 不得而知。在总是采取标准防护措施的同时，在症状 21 持续期间以及症状后 24 小时内还应采取额外的隔离防 护措施。考虑到目前有关病毒脱落和中东呼吸综合征冠 状病毒传播可能性的信息还很少，如方便开展，病毒脱 落试验有助于做出决定。如果担心患者排出病毒的时间 更长，也应考虑患者信息（例如年龄、免疫状态和用药 情况）。 2.6. 采集和处理来自可能令人关切的急性呼吸道感染患 者的实验室标本 所有为实验室调查目的收集的标本均应视作具有潜 在传染性，采集或运送临床标本的医务工作者应严格坚 持标准防护措施，以降低接触病原体的可能性。  确保采集标本的医务工作者使用适当的个体防 护装备。  确保运送标本的人员受过安全处置和溢出后去 污的培训。  将要运送的标本放入防泄漏标本袋（二次容 器），该标本袋应有单独可密封的口袋用于放 标本（即塑料生物危害标本袋），患者标签在 标本容器（主容器）上，此外还应有填写清楚 的检验申请单。  确保卫生保健设施实验室根据处理的生物类型 遵守适当的生物安全规定和运送要求。  尽可能派人手运送所有标本。不要使用气动输 送管系统运送标本。  在相应的检验申请单上清楚写明（疑似）可能 令人关切的急性呼吸道感染者姓名。尽快通知 实验室即将运送标本。 如需有关实验室处理标本和实验室检测新型冠状病 毒的进一步信息，见《实验室处理怀疑或确认含有新型 冠状病毒的人类标本的实验室生物风险管理：临时建 议》22和《实验室检测中东呼吸综合征冠状病毒：临时 建议（修订）》23。如需有关实验室生物安全指南的进 一步信息，见世卫组织《实验室生物安全手册》（第三 版）24。 中东呼吸综合征冠状病毒感染可能或确诊病例治疗期间的感染预防和控制：临时指导文件 4 致谢 本文件经与世卫组织全球感染预防和控制网络及其 他国际专家磋商拟定。世卫组织感谢如下专家（按英文 字母顺序）审阅文件：  沙特阿拉伯卫生部感染控制司司长 Abdulla Assiri  英国伦敦大学学院感染和免疫系 Barry Cookson  加拿大卡尔加里大学医学院加尔文、菲比和 琼·辛德慢性病研究所医学、微生物学、免疫 学和传染病科 John M Conly  欧洲疾病预防控制中心监测与响应支持处传染 性疾病和疫苗可预防疾病高级专家 Niklas Danielsson  加拿大渥太华加拿大公共卫生署传染病和感染 控制中心护理顾问 Katherine Defalco  沙特阿拉伯卫生部感染控制司培训处处长 Elaine Furukawa  美国亚特兰大美国疾病控制预防中心病毒病/流 行病学处呼吸道病毒/小核糖核酸病毒组组长 Susan I. Gerber  瑞士日内瓦日内瓦大学医院和医学院感染控制 规划和世卫组织患者安全合作中心 Benedikt Huttner,  孟加拉达卡流行病学、疾病控制与研究所医学 社会科学室首席科学官、负责人M Mushtuq Husain  美国亚特兰大美国疾病控制预防中心卫生保健 质量促进处医学官 David T. Kuhar  新加坡总医院感染预防科主任、亚太地区感染 控制学会会长Moi Lin Ling  欧洲疾病预防控制中心抗微生物药物耐药性与 卫生保健相关感染问题高级专家 Anna-Pelagia Magiorakos  南非泰格堡斯坦陵布什大学医学和卫生科学院 感染预防和控制系特聘教授、非洲感染控制网 络主席 Shaheen Mehtar  沙特阿拉伯卫生部负责公共卫生事务的副部长 Ziad A Memish  塞内加尔达喀尔非洲感染控制网络理事会成员 Babacar NDoye  尼日利亚拉各斯大学医学院医学微生物学和寄 生虫学系、非洲感染控制网络秘书 Folasade T Ogunsola  智利卫生部国家感染预防和控制规划负责人 Fernando Otaiza O'Ryan  巴西圣保罗大学护理学院Maria Clara Padoveze  英国伦敦克林代尔健康保护局呼吸道疾病处防 范与应对科 Nick Phin  瑞士日内瓦日内瓦大学医院和医学院感染控制 规划和世卫组织患者安全合作中心主任 Didier Pittet  俄罗斯罗斯托夫国立医科大学教授 Natalia Pshenichnaya  中国香港特别行政区香港大学公共卫生学院社 区医学部Wing Hong Seto  英国健康保护局克林代尔参考微生物学服务顾 问微生物学家 Nandini Shetty  美国华盛顿特区乔治·华盛顿大学儿科学、全球 卫生和流行病学教授 Nalini Singh  感染控制和流行病学专业学会专业实践部主任 Thomas Weaver 审阅人员被要求填写利益申报表。未发现存在利益 冲突。 参考文献 1. Infection prevention and control of epidemic- and pandemic- prone acute respiratory infections in health care - WHO Guidelines. Geneva, World Health Organization, 2014. Available at http://apps.who.int/iris/bitstream/10665/112656/1/9789241507134_eng.pdf 2. For the latest information, please consult the WHO coronavirus web page at http://www.who.int/csr/disease/coronavirus_infections/en/. 3. The WHO case definitions for reporting are available at http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/. 4. Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do. Geneva, World Health Organization, 2013. Available at http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_Clinical Management_NovelCoronavirus_11Feb13u.pdf. 5. Core components of infection prevention and control programmes in health care. Aide-memoire. Geneva, World Health Organization, 2011. Available at http://www.who.int/csr/resources/publications/AM_core_components_IPC/en/. 6. Interim surveillance recommendations for human infection with Middle East respiratory syndrome coronavirus. Geneva, World Health Organization, 2014. Available at http://www.who.int/csr/disease/coronavirus_infections/InterimRevisedSurveillan ceRecommendations_nCoVinfection_14July2014.pdf 7. Essential environmental health standards in health care. Geneva, World Health Organization, 2008. Available at http://www.who.int/water_sanitation_health/hygiene/settings/ehs_hc/en/index.ht ml. 8. Natural ventilation for infection control in health-care settings. Geneva, World Health Organization, 2009. Available at http://www.who.int/water_sanitation_health/publications/natural_ventilation/en/i ndex.html. 9. Jefferson T, Del Mar CB, Dooley L et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews, 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006207.pub4/abstract;js essionid=074644E776469A4CFB54F28D01B82835.d03t02. 10. WHO Guidelines on hand hygiene in health care. Geneva, World Health Organization, 2009. Available at http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. 11. Standard Precautions are basic precautions designed to minimize direct, unprotected exposure to potentially infected blood, body fluids or secretions applicable to all patients. See also Standard precautions in health care. Geneva, World 中东呼吸综合征冠状病毒感染可能或确诊病例治疗期间的感染预防和控制：临时指导文件 5 Health Organization, 2007. Available at http://www.who.int/csr/resources/publications/EPR_AM2_E7.pdf. 12. A visual aid on how to put on and take off PPE is available at http://www.who.int/csr/resources/publications/putontakeoffPPE/en/. 13. In this document, the term "medical mask" refers to disposable surgical or procedure masks. 14. 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:e35797. Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.00357 97. 15. Examples of acceptable, disposable particulate respirators in use in various parts of the world include: Australia/New Zealand: P2 (94%), P3 (99.95%); China: II (95%), I (99%); European Union: CE-certified filtering face-piece class 2 (FFP2) (95%), class 3 (FFP3) (99.7%); Japan: 2nd class (95%), 3rd class (99.9%); Republic of Korea: 1st class (94%), special (99.95%); United States: NIOSH-certified N95 (95%), N99 (99%), N100 (99.7%). 16. A visual aid on how to perform a particulate respirator seal check is available at http://www.who.int/csr/resources/publications/respiratorsealcheck/en/. 17. Lai MY, Cheng PK, Lim WW. Survival of severe acute respiratory syndrome coronavirus. Clinical Infectious Diseases, 2005, 41(7):67–71. 18. Community case management during an influenza outbreak. A training package for community health workers. Geneva, World Health Organization, 2011. Available at http://www.who.int/influenza/resources/documents/community_case_managem ent_flipbook/en/index.html. 19. Infection-control measures for health care of patients with acute respiratory diseases in community settings. Trainer's Guide. Geneva, World Health Organization, 2009. Available at http://www.who.int/csr/resources/publications/WHO_HSE_GAR_BDP_2009_1/ en/index.html. 20. Infection-control measures for health care of patients with acute respiratory diseases in community settings. Trainee's Guide. Geneva, World Health Organization, 2009. Available at http://www.who.int/csr/resources/publications/WHO_HSE_GAR_BDP_2009_1a /en/index.html. 21. In studies conducted in Hong Kong SAR, China, no SARS- CoV was cultured from the clinical specimens from infected patients once they were asymptomatic (see Chan KH, Poon LL, Cheng VC et al. Detection of SARS coronavirus in patients with suspected SARS. Emerging Infectious Diseases, 2004, 10(2):294–299). 22. Laboratory biorisk management for laboratories handling human specimens suspected or confirmed to contain novel coronavirus: Interim recommendations. Geneva, World Health Organization, 2013. Available at http://www.who.int/csr/disease/coronavirus_infections/NovelCoronavirus_Interi mRecommendationsLaboratoryBiorisk_190213/en/index.html. 23. Laboratory testing for Middle East respiratory syndrome coronavirus - Interim recommendations, Geneva, World Health Organization, 2014. Available at http://www.who.int/csr/disease/coronavirus_infections/WHO_interim_recommen dations_lab_detection_MERSCoV_092014.pdf?ua=1. 24. WHO laboratory biosafety manual, third edition. Geneva, World Health Organization, 2004. Available at http://www.who.int/csr/resources/publications/biosafety/WHO_CDS_CSR_LYO _2004_11/en/. © 世界卫生组织 2015年 版权所有。世界卫生组织的出版物可从世卫组织网站（www.who.int）获得，或向世卫组织出版处购买（地址：WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27）（电话 1： +41 22 791 3264；传真：+41 22 791 4857；电子邮件：bookorders@who.int）。 要获得复制或翻译世界卫 生组织出版物的许可-无论是为了出售或非商业性分发，应通过世卫组织网站 （www.who.int/about/licensing/copyright_form/en/index.html）向世界卫生组织出版处提出申请。 本出版物采用的名称和陈述的材料并不代表世界卫生组织对任何国家、领地、城巿或地区或其当局的合法地位，或关于边界或分界线的规定有任何意 见。地图上的虛线表示可能尚未完全达成一致的大致边界线。 凡提及某些公司或某些制造商的产品时，并不意味着它们已为世界卫生组织所认可或推荐，或比其它未提及的同类公司或产品更好。除差错和疏忽外， 凡专利产品名称均冠以大写字母，以示区别。 世界卫生组织已采取一切合理的预防措施来核实本出版物中包含的信息。但是， 已出版材料的分发无任何明确或含蓄的保证。解释和使用材料的责任 取决于读者。世界卫生组织对于因使用这些材料造成的损失不承担责任。