1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
1 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected Interim guidance 25 January 2020 Introduction This is the first edition of guidance on infection prevention and control (IPC) strategies for use when infection with a novel coronavirus (2019-nCoV) is suspected. It has been adapted from WHO’s Infection prevention and control during health care for probable or confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection,1 based on current knowledge of the situation in China and other countries where cases were identified and experiences with severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.2 WHO will update these recommendations as new information becomes available. This guidance is intended for healthcare workers (HCWs), healthcare managers and IPC teams at the facility level but it is also relevant for the national and district/provincial level. Full guidelines are available from WHO.2 Principles of IPC strategies associated with health care for suspected nCoV infection To achieve the highest level of effectiveness in the response to an 2019-nCoV outbreak using the strategies and practices recommended in this document, an IPC programme with a dedicated and trained team or at least an IPC focal point should be in place and supported by the national and facility senior management.3 In countries where IPC is limited or inexistent, it is critical to start by ensuring that at least minimum requirements for IPC are in place as soon as possible, both at the national and facility level, and to gradually progress to the full achievement of all requirements of the IPC core components according to local priority plans.4 IPC strategies to prevent or limit transmission in healthcare settings include the following: 1. ensuring triage, early recognition, and source control (isolating patients with suspected nCoV infection); 2. applying standard precautions for all patients; 3. implementing empiric additional precautions (droplet and contact and, whenever applicable, airborne precautions) for suspected cases of nCoV infection; 4. implementing administrative controls; 5. using environmental and engineering controls. 1. Ensuring triage, early recognition, and source control Clinical triage includes a system for assessing all patients at admission allowing early recognition of possible 2019-nCoV infection and immediate isolation of patients with suspected nCoV infection in an area separate from other patients (source control). To facilitate the early identification of cases of suspected nCoV infection, healthcare facilities should: • encourage HCWs to have a high level of clinical suspicion; • establish a well-equipped triage station at the entrance of health care facility, supported by trained staff; • institute the use of screening questionnaires according to the updated case definition (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov) and • post signs in public areas reminding symptomatic patients to alert HCWs. The promotion of hand hygiene and respiratory hygiene are essential preventive measures. 2. Applying standard precautions for all patients Standard precautions include hand and respiratory hygiene, the use of appropriate personal protective equipment (PPE) according to risk assessment, injection safety practices, safe waste management, proper linens, environmental cleaning and sterilization of patient-care equipment. Ensure that the following respiratory hygiene measures are used: • ensure that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing; • offer a medical mask to patients with suspected 2019-nCoV infection while they are in waiting/public areas or in cohorting rooms; • perform hand hygiene after contact with respiratory secretions. HCWs should apply the WHO’s My 5 Moments for Hand Hygiene approach before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings.5 • hand hygiene includes either cleansing hands with an alcohol-based hand rub (ABHR) or with soap and water; • alcohol-based hand rubs are preferred if hands are not visibly soiled; • wash hands with soap and water when they are visibly soiled. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 2 The rational, correct, and consistent use of PPE also helps to reduce the spread of pathogens. The use of PPE effectiveness strongly depends on adequate and regular supplies, adequate staff training, appropriate hand hygiene and specifically appropriate human behaviour. 2,5,6 It is important to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Thoroughly cleaning environmental surfaces with water and detergent and applying commonly used hospital- level disinfectants (such as sodium hypochlorite) are effective and sufficient procedures.7 Medical devices and equipment, laundry, food service utensils and medical waste should be managed in accordance with safe routine procedures.2,8 3. Implementing empiric additional precautions 3.1 Contact and droplet precautions • in addition to using standard precautions, all individuals, including family members, visitors and HCWs, should use contact and droplet precautions before entering the room where suspected or confirmed nCoV patients are admitted; • patients should be placed in adequately ventilated single rooms. For general ward rooms with natural ventilation, adequate ventilation is considered to be 60 L/s per patient;9 • when single rooms are not available, patients suspected of being infected with nCoV should be grouped together; • all patients’ beds should be placed at least 1 m apart regardless of whether they are suspected to have nCov infection; • where possible, a team of HCWs should be designated to care exclusively for suspected or confirmed cases to reduce the risk of transmission; • HCWs should use a medical mask a (for specifications, please see references 2); • HCWs should wear eye protection (googles) or facial protection (face shield) to avoid contamination of mucous membranes; • HCWs should wear a clean, non-sterile, long- sleeved gown; • HCWs should also use gloves; • the use of boots, coverall and apron is not required during routine care; • after patient care, appropriate doffing and disposal of all PPE's and hand hygiene should be carried out.5,6 Also, a new set of PPE's is needed, when care is given to a different patient; • equipment should be either single-use and disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it between use for each individual patient (e.g., by using ethyl alcohol 70%);8 a Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps2 • HCWs should refrain from touching eyes, nose or mouth with potentially contaminated gloved or bare hands; • avoid moving and transporting patients out of their room or area unless medically necessary. Use designated portable X-ray equipment and/or other designated diagnostic equipment. If transport is required, use predetermined transport routes to minimize exposure for staff, other patients and visitors, and have the patient using a medical mask; • ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE as described in this section; • notify the area receiving the patient of any necessary precautions as early as possible before the patient’s arrival; • routinely clean and disinfect surfaces which the patient is in contact; • limit the number of HCWs, family members and visitors who are in contact with a suspected and confirmed 2019-nCoV patient; • maintain a record of all persons entering the patient’s room, including all staff and visitors. 3.2 Airborne precautions for aerosol-generating procedures Some aerosol-generating procedures have been associated with an increased risk of transmission of coronaviruses (SARS-CoV and MERS-CoV), such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.10,11 Ensure that HCWs performing aerosol-generating procedures: • perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least 160 L/s per patient or in negative pressure rooms with at least 12 air changes per hour and controlled direction of air flow when using mechanical ventilation;9 • use a particulate respirator at least as protective as a US National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent.2,12 When HCWs put on a disposable particulate respirator, they must always perform the seal check.12 Note that if the wearer has facial hair (i.e., a beard) it may prevent a proper respirator fit;12 • use eye protection (i.e., goggles or a face shield); • wear a clean, non-sterile, long-sleeved gown and gloves. If gowns are not fluid resistant, HCWs should use a waterproof apron for procedures expected to have high volumes of fluid that might penetrate the gown;2 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 3 • limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 4. Implementing administrative controls Administrative controls2 and policies for the prevention and control of transmission of 2019-nCoV infections within the healthcare setting include, but may not be limited to: establishing sustainable IPC infrastructures and activities; educating patients’ caregivers; developing policies on the early recognition of acute respiratory infection potentially caused by 2019-nCoV; ensuring access to prompt laboratory testing for identification of the etiologic agent; preventing overcrowding, especially in the emergency department; providing dedicated waiting areas for symptomatic patients; appropriately isolating hospitalized patients; ensuring adequate supplies of PPE; ensure the adherence of IPC policies and procedures for all facets of health care. 4.1. Administrative measures related to healthcare workers • provision of adequate training for HCWs; • ensuring an adequate patient-to-staff ratio; • establishing a surveillance process for acute respiratory infections potentially caused by nCoV among HCWs; • ensuring that HCWs and the public understand the importance of promptly seeking medical care; • monitoring HCW compliance with standard precautions and providing mechanisms for improvement as needed. 5. Using environmental and engineering controls These controls address the basic infrastructure of the health care facility.13 These controls aim to ensure there is adequate ventilation9 in all areas in the healthcare facility, as well as adequate environmental cleaning. Additionally, spatial separation of at least 1 meter should be maintained between all patients. Both spatial separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare setting.14 Ensure that cleaning and disinfection procedures are followed consistently and correctly.8 Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure.7 Manage laundry, food service utensils and medical waste in accordance with safe routine procedures. Duration of contact and droplet precautions for patients with nCoV infection Standard precautions should be applied at all times. Additional contact and droplet precautions should continue until the patient is asymptomatic. More comprehensive information about the mode of 2019-nCoV infection transmission is required to define the duration of additional precautions. Collecting and handling laboratory specimens from patients with suspected 2019-nCoV infection All specimens collected for laboratory investigations should be regarded as potentially infectious. HCWs who collect, handle or transport any clinical specimens should adhere rigorously to the following standard precaution measures and biosafety practices to minimize the possibility of exposure to pathogens.15,16,17 • ensure that HCWs who collect specimens use appropriate PPE (i.e., eye protection, a medical mask, a long-sleeved gown, gloves). If the specimen is collected with an aerosol-generating procedure, personnel should wear a particulate respirator at least as protective as a NIOSH-certified N95, an EU standard FFP2, or the equivalent; • ensure that all personnel who transport specimens are trained in safe handling practices and spill decontamination procedures;7 • place specimens for transport in leak-proof specimen bags (i.e., secondary containers) 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 (i.e., the primary container), and a clearly written laboratory request form; • ensure that laboratories in health care facilities 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; • document clearly each patient’s full name, date of birth and suspected nCoV of potential concern on the laboratory request form. Notify the laboratory as soon as possible that the specimen is being transported. Recommendation for outpatient care The basic principles of IPC and standard precautions should be applied in all health care facilities, including outpatient care and primary care. For 2019-nCoV infection, the following measures should be adopted: • triage and early recognition; • emphasis on hand hygiene, respiratory hygiene and medical masks to be used by patients with respiratory symptoms; • appropriate use of contact and droplet precautions for all suspected cases; • prioritization of care of symptomatic patients; • when symptomatic patients are required to wait, ensure they have a separate waiting area; • educate patients and families about the early recognition of symptoms, basic precautions to be used and which health care facility they should refer to. Acknowledgements Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 4 The original version of the MERS-CoV IPC guidance1 was developed in consultation with WHO’s Global Infection Prevention and Control Network and Emerging Diseases Clinical Assessment and Response Network, and other international experts. WHO thanks those who were involved in developing and updating the IPC documents for MERS- CoV. This document was developed in consultation with the WHO Global Infection Prevention and Control Network and other international experts. WHO thanks the following individuals for providing review (in alphabetical order): • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove References 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 8. 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How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance 5 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al- Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019- nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). 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. ISBN 978-92-4-000091-9 (electronic version) ISBN 978-92-4-000092-6 (print version) © World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC- SA 3.0 IGO licence.
-1- 怀疑发生新型冠状病毒感染时医疗机构的感染 预防和控制 临时指导文件 2020年 1月 25日 引言 本文是怀疑发生新型冠状病毒感染时使用的感染预 防和控制策略指导文件第一版，系在世卫组织《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》1基础上根据目前对中国和其他发现病例 国家情况的了解及严重急性呼吸综合征冠状病毒和中东 呼吸综合征冠状病毒经验改编 2。 世卫组织将在获得新信息时更新这些建议。 本指导文件针对设施一级医护人员、管理人员及感 染预防和控制团队，但对国家和省市级也有意义。完整 的指南可从世卫组织获得 2。 与疑似新型冠状病毒感染治疗有关的感 染预防控制策略的原则 要通过采用本文件推荐的策略和做法最有效地应对 2019 新型冠状病毒疫情，应设立感染预防和控制规划， 配备训练有素的全职团队并得到国家和设施高级管理层 的支持 3。在感染预防控制措施有限或不存在的国家， 关键是先确保在国家和设施层面都尽快满足感染预防控 制的最低要求，并根据本地确定的重点和工作计划逐步 全面满足所有感染预防控制要求 4。 预防或限制医疗机构内传播的感染预防控制策略包 括： 1. 落实分诊、早期识别和源头控制（隔离疑似感染新 型冠状病毒的患者）； 2. 针对所有患者采取标准预防措施； 3. 对疑似新型冠状病毒感染病例实施经验性的额外预 防措施（飞沫和接触，酌情采取空气传播预防措 施）； 4. 实施行政控制； 5. 实施环境和工程控制。 1. 落实分诊、早期识别和源头控制 临床分诊包括建立制度对所有患者在入院时进行评 估，以便及早识别可能的 2019新型冠状病毒感染，并立 即隔离疑似感染者，将其安排在与其他患者分开的区域 （源头控制）。为促进及早发现疑似新型冠状病毒感染 病例，医疗机构应： • 鼓励医护人员保持高度临床怀疑态度； • 在入口处设置设备完善的分诊台并安排训练有 素的工作人员； • 根据最新的病例定义使用筛查问卷（https:// www.who.int/publications-detail/global-surveill ance- for-human-infection-with-novel-coronavirus- （2019-ncov））； • 并在公共场所张贴标志，提醒有症状患者告知 医护人员）。 最基本预防措施是促进手卫生和呼吸卫生。 2. 针对所有患者采取标准预防措施 标准预防措施包括手卫生和呼吸卫生、根据风险评 估结果使用合适的个体防护装备、注射安全措施、安全 废物管理、被服洗消、环境清洁和患者护理设备的消 毒。 确保采取以下呼吸卫生措施： • 确保所有患者在咳嗽或打喷嚏时用纸巾或肘部 掩住口鼻； • 在候诊/公共场所或集合室向疑似 2019 新型冠 状病毒感染患者提供医用口罩； • 接触呼吸道分泌物后采取手卫生措施。 医护人员应根据世卫组织《手卫生的五个时刻》在 以下五个时刻采取手卫生措施：接触患者前；进行任何 清洁或无菌操作前；体液暴露后；触碰到患者后；触碰 患者周围环境后 5。 怀疑发生新型冠状病毒感染时医疗机构的感染预防和控制：临时指导文件 -2- • 手卫生措施包括用含酒精成分的免洗洗手液或 肥皂和水清洁双手； • 如果手部没有明显污垢，最好使用含酒精成分 的免洗洗手液； • 手部有明显污垢时用肥皂和水清洗双手。 合理、正确、一贯地使用个体防护装备也有助于减 少病原体传播。使用个体防护装备的有效性在很大程度 上取决于充足和经常的物资供应、充分的人员培训和恰 当的手卫生措施，特别是人的行为要恰当 2,5,6。 确保前后一贯地正确遵守环境清洁和消毒程序十分 重要。使用水和清洁剂彻底清洁环境表面并使用医院常 用消毒剂（例如次氯酸钠）的做法有效且充分 7。应根 据常规安全程序管理医疗器械和设备、被服、餐食服务 用具和医疗废物 2,8。 3. 实施经验性的额外预防措施 3.1 针对接触和飞沫的防护 • 除采取标准预防措施外，所有人（包括患者家 人、探访者和医护人员）在进入疑似或确诊新 型冠状病毒患者的病房前均应采取针对接触和 飞沫的预防措施； • 患者应安置在通风良好的单人病房。对于自然 通风的普通病房，每位患者的通风量应达到 60 升/秒 9； • 如果没有单人病房可用，怀疑感染新型冠状病 毒的患者应该安排在一起； • 所有患者的病床之间应该至少相距 1 米，不管 他们是疑似还是确诊感染新型冠状病毒； • 在可能的情况下，应指定一组医护人员专门照 顾疑似或确诊病例，以减少传播风险； • 医护人员应使用医用口罩 a（有关规格请参阅 参考文献 2）： • 医护人员应佩戴眼睛保护（护目镜）或面部保 护（防护面罩）设备，以避免粘膜污染； • 医护人员应穿着清洁、无菌的长袖袍服； • 医护人员应戴手套； • 在日常护理期间，无须使用靴子、连体工作服 及围裙； a 医用口罩指平面或有褶皱的外科或操作用口罩（有些是杯型），用系带固定至头部。 • 在护理完患者后，应正确脱下所有个体防护装 备并采取手卫生措施 5,6。此外，护理不同患者 时，需要一套新的个体防护装备； • 设备应为一次性，即用即弃或者专用（例如听 诊器、血压袖带和体温计）。如果设备需要多 位患者共用，两次使用之间须进行清洗和消毒 （例如使用 70%的乙醇）8； • 医护人员应避免用可能被污染的手套或裸手触 摸眼睛、鼻子或口部； • 除非医学上有需要，否则应避免移动和运送患 者离开病房或病区。使用指定的便携式 x 光机 和/或其他指定的诊断设备。如果需要运送患者， 应采用事先确定的运送路线并让患者戴上医用 口罩，以尽量减少工作人员、其他患者和探访 者的暴露； • 确保运送患者的医护人员根据本部分内容采取 手卫生措施并穿着适当的个体防护装备； • 在患者抵达前尽早通知接收患者的病区采取任 何必要的预防措施； • 定期清洁和消毒患者接触的表面； • 限制与 2019新型冠状病毒疑似和确诊患者有接 触的医护人员、家属和探访者的数量； • 记录所有进入病房的人员，包括所有工作人员 和探访者。 3.2 针对产生气溶胶的操作的空气传播预防措施 一些产生气溶胶的操作会增加传播冠状病毒 （严重急性呼吸综合征冠状病毒和中东呼吸综合征 冠状病毒）的风险，例如气管插管、无创通气、气 管切开术、心肺复苏、插管前人工通气和支气管镜 检查 10,11。 确保进行产生气溶胶的操作的医护人员： • 在充分通风的房间里操作，即每个患者的空气 流量至少为 160升/秒的自然通风房间或每小时 至少换气 12次且使用机械通风时可以控制空气 流动方向的负压房间 9； • 使用防颗粒物呼吸器，其防护程度至少应达到 美国国家职业安全卫生研究所认证的 N95、欧 盟 FFP2标准或同等标准 2,12。使用一次性防颗 怀疑发生新型冠状病毒感染时医疗机构的感染预防和控制：临时指导文件 -3- 粒物呼吸器时，必须检查密封是否良好 12。注 意，如果佩戴者有胡须，可能造成呼吸器不能 正确贴合 12； • 保护眼睛（即使用护目镜或防护面罩）； • 穿着干净、无菌的长袖袍服和手套。如果长袍 不耐液体，在进行预计会产生大量液体并可能 渗透进袍服的操作时，医护人员应使用防水围 裙 2； • 将房间里的人数限制在患者护理和支持所需的 绝对最低限度。 4. 实施行政控制 医疗机构内预防和控制 2019新型冠状病毒感染传播 的行政控制措施 2和政策包括但不仅限于以下：建立可 持续的感染预防控制基础设施和开展活动；教育患者的 护理人员；制定促进及早识别可能由 2019新型冠状病毒 造成的急性呼吸道感染的政策；确保及时进行实验室检 测以查明病原体；防止过度拥挤，特别是在急诊部；为 有症状的患者提供专门的等候区；适当隔离住院患者； 确保个体防护设备的充足供应；确保医疗机构各方面工 作遵守感染预防控制政策和程序。 4.1. 与医护人员有关的行政措施 • 为医护人员提供足够培训； • 确保充足的医护人员和患者配比； • 在医护人员中建立针对可能由新型冠状病毒引 起的急性呼吸道感染的监测程序； • 确保医护人员和公众了解及时就医的重要性； • 监测医护人员遵守标准预防措施的情况，并酌 情建立改进机制。 5. 实施环境和工程控制 这些控制措施针对医疗机构的基本基础设施 13。其 目的是确保医疗机构内各区域都有足够的通风 9和充分 环境清洁。 此外，所有患者之间应保持至少 1 米的空间距离。 空间分隔和充分通风有助于减少许多病原体在医疗机构 内的传播 14。 确保前后一贯地正确遵守环境清洁和消毒程序 8。 使用水和清洁剂彻底清洁环境表面并使用医院常用消毒 剂（例如次氯酸钠）的做法有效且充分 7。应根据常规 安全程序管理被服洗消、餐食服务用具和医疗废物。 针对新型冠状病毒感染患者的接触和飞 沫预防措施的持续时间 任何时候都应该实施标准预防措施。额外的接触及 飞沫预防措施应持续到患者不再出现症状。要明确额外 预防措施的持续时间，还需要更全面地了解 2019新型冠 状病毒感染的传播模式。 采集和处理疑似 2019新型冠状病毒感染 患者的实验室标本 所有为实验室调查目的采集的样本均应视作具有潜 在传染性。采集、处理或运送任何临床标本的医护人员 应严格遵守以下标准预防措施和生物安全措施，以尽量 减少接触病原体的可能性 15, 16, 17。 • 确保采集标本的医护人员使用适当的个体防护装备 （即护眼、医用口罩、长袖袍服和手套）。如果采 取产生气溶胶的操作采集标本，工作人员应佩戴防 颗粒物呼吸器，其防护程度至少应达到美国国家职 业安全卫生研究所认证的N95、欧盟 FFP2标准或同 等标准； • 确保所有运送标本的工作人员都接受过安全处置和 溢出后去污程序的培训 7； • 把标本放入防漏样本袋（即二次容器）内运送，该 标本袋应有单独可密封的口袋用于放标本（即防生 物危害塑料标本袋），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； • 确保医疗机构的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患者的全名、出生 日期和怀疑感染的新型冠状病毒。尽快通知实验室 即将运送标本。 门诊护理建议 感染预防控制的基本原则和标准预防措施应适用于 所有医疗机构，包括门诊和初级卫生保健机构。针对 2019新型冠状病毒感染应采取以下措施： 怀疑发生新型冠状病毒感染时医疗机构的感染预防和控制：临时指导文件 -4- • 分诊和早期识别； • 强调有呼吸道症状的患者的手卫生、呼吸卫生及医 用口罩的使用； • 对所有疑似病例均适当采取针对接触和飞沫的预防 措施； • 优先诊治有症状的患者； • 当有症状的患者需要等候时，确保他们有一个单独 的等候区； • 教育患者和家属及早识别症状并采取基本预防措施， 告知他们应向哪些医疗机构求诊。 致谢 《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》1指导文件的最初版本是与 世卫组织全球感染预防和控制网络、新发疾病临床评估 和应对网络以及其他国际专家协商制定的。世卫组织感 谢那些参与编制和更新中东呼吸综合征冠状病毒感染预 防和控制文件的人。 本文件是在与世卫组织全球感染预防和控制网络及 其他国际专家协商后编写的。世卫组织感谢下列个人审 阅（以英文字母表为序）： • 沙特阿拉伯卫生部感染控制司司长Abdullah M Assiri • 美国亚特兰大疾病控制与预防中心保健质量促进部 副主任Michael Bell • 国际严重急性呼吸感染和新发感染疾病联盟全球支 持中心网络发展主任、英国英格兰传染病事务顾问 和公共卫生事务名誉顾问 Gail Carson • 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 • 英国伦敦大学学院感染和免疫系 Barry Cookson • 塞内加尔达喀尔感染控制网理事会成员 Babacar N Doye • 加拿大公共卫生署传染病预防和控制中心卫生保健 相关感染及感染预防和控制部经理 Kathleen Dunn • 全球疫情警报和反应网络指导委员会 Dale Fisher • 美国亚特兰大疾病控制与预防中心保健质量促进部 流行病学家 Fernanda Lessa • 新加坡总医院感染控制科主任、亚太感染控制协会 会长Moi Lin Ling • 智利卫生部国家感染预防控制规划负责人 Fernando Otaiza O’Rayan • 欧洲疾病预防和控制中心监测和响应支持部 Diamantis Plachouras • 中国香港特别行政区香港大学公共卫生学院社区医 学系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 世卫组织： Benedetta Allegranzi、April Baller、 Ana Paula Coutinho、 Janet Diaz、 Christine Francis、 Maria Clara Padoveze 、 Joao Paulo de Toledo 、 Maria Van Kerkhove 参考文献 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. Geneva: World Health Organization; 2019 (WHO/MERS/IPC/15.1 Rev. 1; https://apps.who.int/iris/handle/10665/174652, accessed 17 January 2020). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, accessed 17 January 2020). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (Available at: https://www.who.int/gpsc/ipc- components-guidelines/en/, accessed 20 January 2020. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (Available at: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, accessed 20 January 2020. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, accessed 17 January 2020). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/putonta keoffPPE/en/, accessed 17 January 2020). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) 怀疑发生新型冠状病毒感染时医疗机构的感染预防和控制：临时指导文件 -5- 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (Available at: https://www.who.int/infection- prevention/publications/decontamination/en/, accessed 20 January 2020) 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44167, accessed 17 January 2020). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, accessed 17 January 2020). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/disease/coronavirus_infections/ en/. 13. Adams J, Bartram J, Chartier Y, editors. Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43767, accessed 17 January 2020). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.C D006207.pub4/abstract;jsessionid=074644E776469A4 CFB54F28D01B82835.d03t02. accessed 17 January 2020). 15. Laboratory testing for 2019 novel coronavirus (2019-nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus accessed 20 January 2020) 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/25995 2/WHO-MERS-LAB-15.1-Rev1-2018- eng.pdf?sequence=1, accessed 17 January 2020). 17. Laboratory biosafety manual, third edition. Geneva: World Health Organization; 2004 (https://apps.who.int/iris/handle/10665/42981, accessed 17 January 2020). © 世界卫生组织 2020年。保留部分版权。本作品可在知识共享署名——非商业性使用——相同方式共享 3.0 政府间组织（CC-BY-NC-SA 3.0 IGO）许可协议下使用。 ISBN 978-92-4-000095-7（网络版） ISBN 978-92-4-000096-4（印刷版） WHO reference number: WHO/2019-nCoV/IPC/2020.2
-1- Профилактика инфекций и инфекционный контроль при оказании медицинской помощи пациентам с подозрением на новую коронавирусную инфекцию (nCoV) Временные рекомендации 25 января 2020 г. Введение Настоящее первое издание Руководства по стратегиям профилактики инфекций и инфекционного контроля (ПИИК) предназначено для применения при подозрении на инфекцию, вызванную новым коронавирусом (2019-nCoV). Оно представляет собой адаптированный вариант руководства ВОЗ «Профилактика инфекций и инфекционный контроль во время оказания медицинской помощи при вероятных или подтвержденных случаях инфекции, вызванной коронавирусом ближневосточного респираторного синдрома (MERS-CoV)»1, подготовленный на основании текущей информации о ситуации в Китае и других странах, в которых были выявлены случаи заболевания, а также опыта оказания медицинской помощи при тяжелом остром респираторном синдроме (SARS)-CoV и MERS-CoV2. ВОЗ будет обновлять эти рекомендации по мере поступления новой информации. Данное руководство предназначено для медицинских работников, руководителей в сфере здравоохранения и групп ПИИК, работающих на уровне учреждений, но также актуально для национального уровня и уровня районов/провинций. Полный вариант руководство можно получить в ВОЗ2. Принципы стратегий ПИИК при оказании медицинской помощи пациентам с подозрением на nCoV Для достижения высшей степени эффективности ответных мер на вспышку 2019-nCoV при использовании стратегий и методов, рекомендованных в настоящем документе, должна быть принята программа ПИИК для осуществления целевой специально подготовленной группой или, по крайней мере, координатором ПИИК, и данная программа должна быть поддержана руководством страны и соответствующих учреждений3. Страны, в которых стратегии ПИИК являются ограниченными или отсутствуют, должны начать с обеспечения того, чтобы, по крайней мере, в возможно короткие сроки были выполнены минимальные требования ПИИК как на национальном уровне, так и на уровне учреждений, и постепенно перейти к полному выполнению всех требований основных компонентов ПИИК в соответствии с местными приоритетными планами.4 Стратегии ПИИК по предотвращению или ограничению передачи вируса в медицинских учреждениях включают следующее: 1. обеспечение разделения пациентов на потоки (сортировка), раннее распознавание и контроль источника инфекции (изоляция пациентов с подозрением на инфекцию, вызванную nCoV); 2. применение стандартных мер предосторожности для всех пациентов; 3. реализация основанных на практических соображениях дополнительных мер предосторожности (меры предосторожности для защиты от воздушно-капельных и контактных инфекций и, при необходимости, меры предосторожности для защиты от воздушно- капельных инфекций при выполнении процедур, ведущих к образованию аэрозоли) в случаях подозрений на заражение nCoV; 4. реализация административного контроля; 5. реализация контроля за состоянием окружающей среды и инженерно-технических систем. 1. Обеспечение разделения пациентов на потоки (сортировка), раннее распознавание и контроль источника инфекции Клиническая сортировка включает в себя систему оценки всех пациентов при поступлении, обеспечивая раннее выявление возможной инфекции, вызванной 2019-nCoV, и немедленную изоляцию пациентов с подозрением на инфекцию, вызванную nCoV, в зоне, отделенной от других пациентов (контроль источника инфекции). Чтобы облегчить раннее выявление случаев предполагаемой инфекции, вызванной nCoV, медицинские учреждения должны: • ввести для медицинских работников высокий индекс клинического подозрения; • создать хорошо оборудованные сортировочные пункты при приемных отделениях медицинских учреждений и обеспечить соответствующую подготовку персонала; • ввести скрининговые анкеты, составленные в соответствии с обновленным определением случая заболевания (https://www.who.int/publications-detail/global- surveillance-for-human-infection-with-novel- coronavirus-(2019-ncov); и • разместить в общественных местах плакаты с описаниями симптомов и призывами обращаться к медицинским работникам. Важной профилактической мерой служит пропаганда гигиены рук и гигиены дыхательных путей. Профилактика инфекций и инфекционный контроль при оказании медицинской помощи пациентам с подозрением на новую коронавирусную инфекцию (nCoV) -2 2. Применение стандартных мер предосторожности для всех пациентов Стандартные меры предосторожности включают гигиену рук и гигиену дыхательных путей, использование соответствующих средств индивидуальной защиты (СИЗ) в соответствии с текущей оценкой риска, меры по обеспечению безопасности при выполнении инъекций, безопасную утилизацию отходов, использование надлежащего постельного белья, уборку окружающего пространства и стерилизацию оборудования, используемого при оказании медицинской помощи. Обеспечить применение следующих мер гигиены дыхательных путей: • убедиться, что все пациенты при кашле или чихании прикрывают нос и рот тканью или местом локтевого сгиба; • выдать медицинские маски пациентам с подозрением на инфекцию, вызванную 2019-nCoV, когда они находятся в местах ожидания/общественных местах или в комнатах скопления людей; • проводить гигиену рук после контакта с выделениями из дыхательных путей. Медицинские работники перед контактом с пациентом, выполнением любой чистой или асептической процедуры, а также после контакта с биологическими жидкостями, контактом с пациентом и контактом с окружающим пространством пациента должны выполнять «Пять рекомендаций ВОЗ в отношении гигиены рук» 5. • гигиена рук включает в себя очищение рук с помощью либо дезинфицирующего состава для рук на спиртовой основе (ABHR), либо воды и мыла; • если руки визуально не загрязнены, предпочтительны дезинфицирующие составы для рук на спиртовой основе; • если руки визуально загрязнены, их необходимо вымыть с использованием воды и мыла. Снизить распространение патогенных микроорганизмов также помогает рациональное, правильное и последовательное использование СИЗ. Эффективность использования СИЗ в значительной степени зависит от достаточных регулярных поставок материалов, надлежащей подготовки персонала, правильной гигиены рук и особенно надлежащего поведения человека2,5,6. Важно обеспечить, чтобы процедуры очистки и дезинфекции окружающего пространства выполнялись последовательно и надлежащим образом. Тщательное очищение поверхностей окружающего пространства водой и моющим средством и применение обычно используемых дезинфицирующих средств на уровне больницы (таких как гипохлорит натрия) являются эффективными и достаточными процедурами7. Медицинские приборы и оборудование, прачечная, кухонные принадлежности и медицинские отходы a Медицинские маски — это хирургические или процедурные маски, плоские или складчатые (некоторые похожи на чашечки), которые фиксируются на голове при помощи тесемок2 должны обрабатываться в соответствии со стандартными процедурами безопасности2,8. 3. Реализация основанных на практических соображениях дополнительных мер предосторожности 3.1 Меры предосторожности для защиты от воздушно-капельных и контактных инфекций: • в дополнение к стандартным мерам предосторожности, все лица, включая членов семьи, посетителей и медработников, должны перед входом в помещение, в котором содержатся пациенты с предполагаемой или подтвержденной инфекцией, вызванной nCoV, применять меры предосторожности для защиты от воздушно-капельных и контактных инфекций; • пациентов следует размещать в хорошо проветриваемых одноместных палатах. Для общих палат с естественной вентиляцией достаточной считается вентиляция воздуха в 60 л/с на пациента9; • при отсутствии отдельных палат пациенты с подозрением на инфекцию nCoV изолируются группами; • койки пациентов располагаются на расстоянии не менее 1 м независимо от наличия подозрения на инфекцию nCov; • в целях снижения риска передачи инфекции по возможности следует создавать отдельные команды медицинских работников, которые занимаются исключительно случаями подозрения на заражение или подтвержденного заражения; • медработники должны использовать медицинские маски a (технические характеристики см. в ссылке 2); • для предотвращения загрязнения слизистых оболочек медработники должны носить защиту для глаз (очки) или защиту для лица (щиток для лица); • медработники должны носить чистый, нестерильный халат с длинными рукавами; • медицинские работники также должны использовать перчатки; • в ходе обычных процедур ухода использование бахил, комбинезона и фартука не требуется; • после ухода за пациентом необходимо соответствующим образом удалить и утилизировать все СИЗ и провести гигиену рук5,6. Кроме того, для ухода за следующим пациентом должен быть использован новый набор СИЗ; • необходимо использовать либо одноразовое оборудование, либо специально выделенное оборудование (например, стетоскопы, манжеты кровяного давления и термометры). Если оборудование предназначено для многократного использования, то перед использованием для Профилактика инфекций и инфекционный контроль при оказании медицинской помощи пациентам с подозрением на новую коронавирусную инфекцию (nCoV) -3 каждого следующего пациента производится его очистка и дезинфекция (например, с помощью 70-процентного этилового спирта)8; • медицинские работники должны воздерживаться от прикосновения к глазам, носу или рту руками с надетыми на них потенциально контаминированными перчатками или без них; • избегать перемещения и транспортировки пациентов из палаты или зоны, если это не связано с медицинской необходимостью. Использовать специальное портативное рентгеновское и/или другое диагностическое оборудование. Если требуется транспортировка, использовать заранее определенные маршруты транспортировки, чтобы минимизировать контакты с персоналом, другими пациентами и посетителями; пациент должен использовать медицинскую маску; • убедиться, что медицинские работники, транспортирующие пациентов, выполняют гигиену рук и используют соответствующие СИЗ, как описано в этом разделе; • как можно раньше уведомить зону, принимающую пациента, о любых необходимых мерах предосторожности до прибытия пациента; • регулярно очищать и дезинфицировать поверхности, с которыми контактирует пациент; • ограничить количество медицинских работников, членов семьи и посетителей, которые контактируют с пациентом в случае подозрения на заражение или подтвержденного заражения 2019-nCoV; • вести учет всех лиц, входящих в палату пациента, включая сотрудников и посетителей. 3.2 Меры предосторожности для защиты от воздушно-капельных инфекций при выполнении процедур, ведущих к образованию аэрозоли Некоторые процедуры, при выполнении которых образуется аэрозоль, сопряжены с повышенным риском передачи коронавирусов (SARS-CoV и MERS-CoV): например, интубация трахеи, неинвазивная вентиляция легких, трахеотомия, сердечно-легочная реанимация, искусственная вентиляция легких с помощью ручных аппаратов перед интубацией и бронхоскопия10,11. Необходимо обязать медицинских работников, проводящих процедуры, при выполнении которых образуется аэрозоль: • выполнять процедуры в хорошо проветриваемом помещении, например, с поступлением воздуха в объеме не менее 160 л/с на пациента или с обеспечением минимум 12-кратного воздухообмена в час в помещениях с отрицательным давлением или с принудительной вентиляцией при применении механической вентиляции9; • использовать противоаэрозольный респиратор, по крайней мере, со следующим уровнем защиты: сертифицированный Национальным институтом США по охране труда и промышленной гигиене респиратор N95, сертифицированный Европейским союзом (ЕС) респиратор FFP2 – или эквивалентный респиратор2,12. При использовании одноразового противоаэрозольного респиратора обязательно проводится проверка герметичности12. Необходимо учитывать, что в случае пользователей, имеющих волосы на лице (например, бороду), возможна неправильная посадка респиратора12; • использовать защиту для глаз (например, защитные очки или защитный щиток для лица); • носить чистый нестерильный халат с длинными рукавами и перчатки. Если халаты не являются водостойкими, при осуществлении процедур, в ходе которых ожидается работа с большими объемами жидкостей, которые могут проникнуть в халат, необходимо использовать водонепроницаемые фартуки2; • ограничить число лиц, посещающих палату, строго необходимым для оказания помощи и ухода за пациентом. 4. Реализация административного контроля Меры административного контроля2 и меры политики по профилактике и предотвращению передачи в медицинских учреждениях инфекций, вызванных 2019-nCoV, включают в себя, в числе прочего, организацию устойчивой инфраструктуры и мероприятий по ПИИК, обучение лиц, осуществляющих уход за пациентами, разработку политики раннего выявления острой респираторной инфекции, которая может быть вызвана 2019-nCoV, обеспечение доступа к оперативным лабораторным исследованиям для выявления этиологического агента, предотвращение переполненности помещений, особенно в отделении неотложной помощи, создание специальных зон для ожидания пациентов с симптомами заболевания, надлежащую изоляцию госпитализированных пациентов, обеспечение достаточных поставок СИЗ, обеспечение соблюдения мер политики и процедур ПИИК во всей сфере здравоохранения. 4.1. Административные меры, касающиеся медицинских работников: • обеспечение надлежащей подготовки медицинских работников; • обеспечение надлежащего соотношения пациентов и медицинского персонала; • организация процесса эпиднадзора за острыми респираторными инфекциями, которые могут быть вызваны вирусом nCoV среди медицинских работников; • обеспечение понимания медработниками и общественностью важность своевременного обращения за медицинской помощью; Профилактика инфекций и инфекционный контроль при оказании медицинской помощи пациентам с подозрением на новую коронавирусную инфекцию (nCoV) -4 • мониторинг соблюдения медицинскими работниками стандартных мер предосторожности и при необходимости обеспечение механизмов их совершенствования. 5. Реализация контроля за состоянием окружающей среды и инженерно- технических систем Данные средства контроля касаются базовой инфраструктуры медицинских учреждений13. Они призваны обеспечить наличие надлежащей вентиляции9 во всех помещениях медицинских учреждений, а также необходимой уборки окружающего пространства. Кроме того, между пациентами необходимо обеспечить свободной пространство не менее 1 метра. Пространственное разделение и достаточная вентиляция могут помочь снизить распространение некоторых патогенных микроорганизмов во время оказания медицинской помощи.14 Необходимо обеспечить, чтобы процедуры очистки и дезинфекции окружающего пространства выполнялись последовательно и правильно8. Очищение поверхностей окружающего пространства водой и моющим средством и применение обычно используемых в больницах дезинфицирующих средств (таких как гипохлорит натрия) является достаточной эффективной процедурой7. Прачечная, кухонные принадлежности и медицинские отходы должны обрабатываться в соответствии со стандартными процедурами безопасности. Длительность мер предосторожности для защиты от заражения контактным и воздушно-капельным путем от пациентов с инфекцией, вызванной nCoV Стандартные меры предосторожности должны применяться все время. Дополнительные меры предосторожности для защиты от контактного и воздушно-капельного заражения следует применять до полного разрешения симптомов у пациента. Для определения продолжительности дополнительных мер предосторожности необходима более полная информация о путях передачи инфекции, вызванной 2019-nCoV. Забор и обращение с лабораторными образцами от пациентов с предполагаемой инфекцией, вызванной 2019-nCoV Все образцы, взятые для лабораторных анализов, следует рассматривать как потенциально инфицированные. Медицинские работники, которые осуществляют забор или транспортировку клинических образцов, должны строго придерживаться стандартных мер предосторожности, чтобы свести к минимуму возможность контакта с патогенами15,16,17. Необходимо: • обеспечить медицинских работников, которые осуществляют забор образцов, соответствующими СИЗ (т. е. защита глаз, медицинская маска, халат с длинными рукавами, перчатки). Если забор образца производится путем процедуры, ведущей к образованию аэрозоли, персонал должен носить противоаэрозольные респираторы со следующим уровнем защиты: сертифицированный Национальным институтом США по охране труда и промышленной гигиене респиратор N95, сертифицированный ЕС респиратор FFP2 – или эквивалентный респиратор; • убедиться, что персонал, осуществляющий транспортировку образцов, прошел обучение безопасным методам обращения с материалами и процедурам по проведению обеззараживания (деконтаминации) в случае протечки инфекционного материала7; • поместить образцы для перевозки в герметичные пакеты для образцов, в которых имеется отдельный герметичный карман для образцов (т. е. пластиковый пакет для образцов, представляющих биологическую опасность); на контейнере с образцом должна быть наклейка с информацией о пациенте и к нему должно прилагаться ясно составленное направление на исследование; • убедиться, что лаборатории при медицинских учреждениях соблюдают передовые методы и процедуры обеспечения биобезопасности при работе с соответствующим типом микроорганизмов; • во всех случаях, когда это возможно, обеспечить доставку образцы только курьерской службой. НЕ использовать системы пневматической почты для транспортировки образцов; • обеспечить четкое указание в направлении на исследование имени, фамилии и даты рождения пациента и названия предполагаемой nCoV. В возможно короткие сроки информировать лабораторию о направлении образцов. Рекомендации по амбулаторному лечению Основные принципы ПИИК и стандартные меры предосторожности должны применяться во всех медицинских учреждениях, в том числе для амбулаторного лечения и оказания первичной медицинской помощи. В случае, вызванной 2019-nCoV, принимаются следующие меры: • сортировка и раннее выявление; • акцент на гигиене рук, респираторной гигиене и ношении медицинских масок пациентами с респираторными симптомами; • надлежащие применение мер предосторожности по защите от контактного и воздушно-капельного пути распространения во всех подозрительных случаях; • приоритет в лечении пациентов с симптомами; • организация отдельной зоны ожидания для пациентов с симптомами, если такие пациенты не могут быть осмотрены незамедлительно; • информирование пациентов и членов семей о симптомах, проявляющихся на ранних этапах, Профилактика инфекций и инфекционный контроль при оказании медицинской помощи пациентам с подозрением на новую коронавирусную инфекцию (nCoV) -5 основных мерах предосторожности и медицинских учреждениях, в которые необходимо обращаться. Выражение благодарности Первоначальная версия руководства ПИИК по MERS- CoV1 была подготовлена при участии Глобальной сети ВОЗ по профилактике инфекций и инфекционному контролю и Сети по клинической оценке недавно возникших инфекционных заболеваний и реагированию, а также других международных экспертов. ВОЗ выражает благодарность всем, кто принимал участие в разработке и обновлении документов ПИИК для MERS-CoV. Данный документ был разработан при участии Глобальной сети ВОЗ по профилактике инфекций и инфекционному контролю. ВОЗ благодарит следующих лиц за предоставленные ими материалы (в порядке английского алфавита): • Абдулла М. Ассири, генеральный директор Службы инфекционного контроля Министерства здравоохранения Саудовской Аравии; • Майкл Белл, заместитель директора Отдела повышения качества здравоохранения Центра по контролю и профилактике заболеваний г. Атланта, США; • Гейл Карсон, директор по развитию сети Международного центра поддержки ISARIC, консультант по инфекционным заболеваниям и почетный консультант Службы общественного здравоохранения Англии, Соединенное Королевство; • Джон М. Конли, Отдел медицины, микробиологии, иммунологии и инфекционных заболеваний, Институт хронических болезней им. Кальвина, Фебе и Джоан Синдер, Медицинский факультет Университета Калгари, Канада; • Барри Куксон, Отделение инфекций и иммунитета, Университетский колледж, Лондон, Соединенное Королевство; • Бабакар Н. Дуай, член правления Сети инфекционного контроля, Дакар, Сенегал; • Катлин Данн, менеджер Секции инфекций, связанных с здравоохранением, профилактики инфекций и инфекционного контроля Центра по профилактике инфекционных болезней и инфекционному контролю Агентство здравоохранения Канады; • Дейл Фишер, член руководящего комитета Глобальной сети оповещения о вспышках болезней и ответных мерах; • Фернанда Лесса, эпидемиолог Отдела повышения качества здравоохранения Центра по контролю и профилактике заболеваний г. Атланта, США; • Мои Лин Линь, директор Отдела инфекционного контроля Сингапурская клинической больницы и президент Азиатско-Тихоокеанского общества инфекционного контроля (APSIC); • Фернандо Отайза О’Раян, руководитель Национальной программы ПИИК Министерства здравоохранения, Сантьяго, Чили; • Диамантис Плачурас, Отдел наблюдения и поддержки реагирования, Европейский центр профилактики и контроля заболеваний; • Вин Хун Сето, Кафедра общественной медицины Факультета общественного здравоохранения Университета Гонконга, Гонконг, Китайская Народная Республика; • Нандини Шетти, микробиолог-консультант Справочной службы микробиологии, г. Колиндейл, Агентство защиты здоровья, Соединенное Королевство. ВОЗ: Бенедетта Аллегранци, Эйприл Баллер, Ана Паула Коутиньо, Джанет Диаз, Кристина Фрэнсис, Мария Клара Падовезе, Жуан Паула де Толедо, Мария Ван Керхове Библиография 1. Профилактика инфекций и борьба с ними во время оказания медицинской помощи при вероятных или подтвержденных случаях инфицирования коронавирусом ближневосточного респираторного синдрома (БВРС-КоВ), обновлено 4 июня 2015 г. Женева, Всемирная организация здравоохранения; 2019 г. (WHO/MERS/IPC/15.1; https://apps.who.int/ iris/handle/10665/174652, по состоянию на 17 января 2020 г.). 2. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ 10665/112656/, по состоянию на 17 января 2020 г.). 3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. (По адресу: https://www.who.int/gpsc/ipc-components- guidelines/en/, по состоянию на 20 января 2020 г. 4. Minimum requirements for infection prevention and control. Geneva: World Health Organization; 2019. (По адресу: https://www.who.int/infection- prevention/publications/min-req-IPC-manual/en/, по состоянию на 20 января 2020 г.). 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge – clean care is safer care. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44102, по состоянию на 17 января 2020 г.). 6. How to put on and take off personal protective equipment (PPE). Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/ putontakeoffPPE/en/, по состоянию на 17 января 2020 г.). 7. CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (По адресу: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html и http://www.icanetwork.co.za/icanguideline2019/, по состоянию на 20 января 2020 г.). Профилактика инфекций и инфекционный контроль при оказании медицинской помощи пациентам с подозрением на новую коронавирусную инфекцию (nCoV) -6 8. Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Geneva: World Health Organization; 2016 (По адресу: https://www.who.int/ infection-prevention/publications/decontamination/en/, по состоянию на 20 января 2020 г.). 9. Atkinson J, Chartier Y, Pessoa-Silva CK, Jensen P, Li Y, Seto WH, editors. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/ 10665/44167, по состоянию на 17 января 2020 г.). 10. Hui DS. Epidemic and emerging coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome). Clin Chest Med. 201738:71−86. doi:10.1016/j.ccm.2016.11.007. 11. 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. doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26. 12. How to perform a particulate respirator seal check. Geneva: World Health Organization; 2008 (http://www.who.int/csr/resources/publications/respirat orsealcheck/en/, по состоянию на 17 января 2020 г.). For the latest information, please consult the WHO coronavirus webpage at http://www.who.int/csr/ disease/coronavirus_infections/en/. 13. Основные стандарты гигиены окружающей среды в медицинских учреждениях/Редакторы John Adams, Jamie Bartram, Yves Chartier. Женева, Всемирная организация здравоохранения; 2008 г. (https://apps.who.int/iris/handle/10665/43767, по состоянию на 17 января 2020 г.). 14. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. 2011, 7:CD006207. По адресу http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD006207.pub4/abstract;jsessio nid=074644E776469A4CFB54F28D01B82835.d03t02. по состоянию на 17 января 2020 г.). 15. Laboratory testing for 2019 novel coronavirus (2019-nCoV) in suspected human cases: interim guidance January 2020. Geneva: World Health Organization https://www.who.int/health- topics/coronavirus/laboratory-diagnostics-for-novel- coronavirus по состоянию на 20 января 2020 г.). 16. Laboratory testing for Middle East respiratory syndrome coronavirus: interim guidance (revised), January 2018. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/ handle/10665/259952/WHO-MERS-LAB-15.1-Rev1- 2018-eng.pdf?sequence=1, по состоянию на 17 января 2020 г.). 17. Практическое руководство по биологической безопасности в лабораторных условиях. Третье Издание. Женева, Всемирная организация здравоохранения; 2004 г. (https://apps.who.int/ iris/handle/10665/42981, по состоянию на 17 января 2020 г.). © Всемирная организация здравоохранения 2020. Все права защищены. ВОЗ продолжает внимательно следить за ситуацией на предмет любых изменений, которые могут повлиять на эти временные рекомендации. В случае изменения каких- либо факторов ВОЗ выпустит дополнительную обновленную информацию. В противном случае срок действия этих временных рекомендаций истекает через 2 года после даты публикации. © Всемирная организация здравоохранения, 2020. Некоторые права защищены. Данная работа распространяется на условиях лицензии CC BY-NC-SA 3.0 IGO. ISBN 978-92-4-000109-1 (Версия онлайн) ISBN 978-92-4-000110-7 (Версия для печати) WHO reference number: WHO/2019-nCoV/IPC/2020.2
-1- مقدمة هذه هي الط�عة الأولى من الإرشــادات المتعلقة �اســترات�ج�ات الوقا�ة من الاشــــــت�اه في الإصــــــا�ة �فیروس �ورونا عندُتســــــتخدم العدوى ومكافحتها . وقد اقُت�ســـــــــــت من وث�قة المنظمة المعنونة(VoCn-9102) المســـــــــــتجد الإصـــــــــا�ة الوقا�ة من العدوى ومكافحتها أثناء الرعا�ة الصـــــــــح�ة لحالات المحتملة أو المؤ�دة �عدوى فیروس �ورونا المســــــــــــبب لمتلازمة الشــــــــــــرق �الاســـتناد إلى المعرفة الحال�ة �الوضـــع في الصـــین 1،الأوســـط التنفســـ�ة وغیرها من البلدان حیث �ُشـــــــــــــف عن حالات إصـــــــــــــا�ة �الفیروس، و�لى الخبرات المكتسـ�ة من مكافحة فیروس �ورونا المسـبب للمتلازمة التنفسـ�ة فیروس �ورونا المســــــــــبِّب لمتلازمة الشــــــــــرق الحادة الوخ�مة )ســــــــــارس( و 2.الأوسط التنّفس�ة وستحّدث المنظمة هذه التوص�ات �مجرد توافر معلومات جدیدة. وهذه الإرشــــــــــادات موجهة لكل من العاملین في مجال الرعا�ة الصــــــــــح�ة ومكافحتهاالوقا�ة من العدوى المعن�ة � ومدیري الرعا�ة الصـــــــــــح�ة والفرق على مسـتوى المرافق الصـح�ة، ولكنها مفیدة أ�ضـً ا على المسـتوى الوطني ومســـتوى المنطقة/ المقاطعة. و�مكن الحصـــول على النســـخة الكاملة من 2الم�ادئ التوجیه�ة من المنظمة. م�ادئ اســــــــــــترات�ج�ات الوقا�ة من العدوى ومكافحتها المتصــــــــــــلة �الرعا�ة إصابتها �عدوى فیروس �ورونا المستجدالصح�ة للحالات المشت�ه في لتحقیق أعلى مســـتوى من الفعال�ة في الاســـتجا�ة لفاشـــ�ة فیروس �ورونا �اســـــتخدام الاســـــترات�ج�ات والممارســـــات الموصـــــى بها في هذه المســـــتجد �ضــــم الوقا�ة من العدوى ومكافحتهامعني � الوث�قة، ین�غي إنشــــاء برنامج الوقا�ة من الأقل مر�ز اتصـ ــال معني � فر�قا متخصـــصـ ــا ومدر�ا، أو على من الإدارة العل�ــا الوطن�ــة والإدارة ، و�كون مــدعومــا ًالعــدوى ومكــافحتهــا الوقا�ة من وفي البلدان التي تكون فیها أنشــــــــــ ــطة 3العل�ا للمرافق الطب�ة. محدودة أو منعدمة، من الضروري البدء �ضمان توافر العدوى ومكافحتها على الأقل في أقرب وقت �ة من العدوى ومكافحتهالوقال الُدن�االمتطل�ات ممكن، ســــــــواء على المســــــــتوى الوطني أو على مســــــــتوى المرفق الطبي، والمضـــــــــــــي قدما �شـــــــــــــكل تدر�جي نحو تحقیق متطل�ات جم�ع المكونات تحق�قا على أكمل وجه، وفقا ً لوقا�ة من العدوى ومكافحتهال الأســــــــ ــاســــــــ ــ�ة 4لخطط الأولو�ات المحل�ة. منع انتقال الوقا�ة من العدوى ومكافحتها الرام�ة إلى اسـترات�ج�اتوتشـمل العدوى في مرافق الرعا�ة الصح�ة أو الحد منه، ما یلي: ضــــــــــــمان الفرز والتعّرف الم�كر والتحكم في المصــــــــــــدر)عزل -1 كورونا فیروس المرضـــــــى الذین �ُشـــــــت�ه في إصـــــــابتهم �عدوى المستجد(؛ م�ع المرضى؛تطبیق الاحت�اطات النموذج�ة على ج -2 تنفیــذ احت�ــاطـات إضـــــــــــــ ــاف�ــة تجر�ب�ــة )احت�ــاطـات الوقـا�ـة من -3 العـدوى المنقولـة �ـالقطیرات والملامســــــــــــــة، وعنـد الاقتضــــــــــــــاء، احت�ــاطــات الوقــا�ــة من العــدوى المنقولــة �ــالهواء( �ــالنســـــــــــــ�ــة كورونا المستجد؛ للحالات المشت�ه في إصابتها �عدوى فیروس تطبیق الضوا�ط الإدار�ة؛ -4 تطبیق الضوا�ط البیئ�ة والهندس�ة. -5 ضمان الفرز والتعّرف الم�كر والتحكم في المصدر -1 �شــمل الفرز الســر�ري نظاًما لتقی�م حالة جم�ع المرضــى عند دخولهم إلى المرفق الصـحي، مما یت�ح التعرف الم�كر على الإصـا�ة المحتملة �عدوى للمرضى الذین �ُشت�ه في إصابتهم والعزل الفوري فیروس �ورونا المستجد في مكان منفصــل عن المكان الذي یوجد فیروس �ورونا المســتجد �عدوى ف�ه المرضـــــى الآخرون )التحكم في المصـــــدر(. ولت�ســـــیر التعرف الم�كر فیروس �ورونا المســــــــتجد، على الحالات المشــــــــت�ه في إصــــــــابتها �عدوى یلي: ین�غي أن تقوم مرافق الرعا�ة الصح�ة �ما تشــــــ ــج�ع العاملین في مجال الرعا�ة الصــــــ ــح�ة على التحلي بدرجة • عال�ة من الاشت�اه السر�ري؛ إنشــــــــــــــاء محطـة فرز مجهزة تجهیًزا جـیًدا عـند مـدخـل مرفق الرعـا�ة • الصح�ة، بدعم من موظفین مدر�ین؛ بدء العمل �استب�انات التحري وفًقا لتعر�ف الحالات المحّدث • (snoitacilbup/tni.ohw.www//:sptth-labolg/liated- ecnallievrus-rof-namuh-noitcefni-htiw-levon- csurivanoro-9102(-vocn) ي المناطق العموم�ة لتذ�یر المرضـــــى الذین تظهر نشـــــر لافتات ف • علیهم أعراض المرض �إبلاغ العاملین في مجال الرعا�ة الصـ ــح�ة �الأمر. و�عد تعز�ز نظافة الیدْین والجهاز التنفسي من التدابیر الوقائ�ة الأساس�ة. تطبیق الاحت�اطات النموذج�ة على جم�ع المرضى -2 النموذج�ـة على نظـافـة الـیدین والجهـاز التنفســـــــــــــي، تشـــــــــــــمـل الاحت�ـاطـات لتقی�م المخاطر، ا ًوفق واســــــ ــتعمال معدات الوقا�ة الشــــــــخصــــــ ــ�ة المناســــــ ــ�ة وممارســات مأمون�ة الحقن، والإدارة المأمونة للنفا�ات، واســتخدام الأقمشـة والملا�س المناس�ة، وتنظ�ف البیئة، وتعق�م المعدات المستعملة في رعا�ة المرضى. التأكد من اتخاذ التدابیر المتصلة بنظافة الجهاز التنفسي التال�ة: و�رجى التــأكــد من أن جم�ع المرضـــــــــــــى �غطون أنفهم وفمهم �منــدیــل أو • �المرفق عند السعال أو العطس؛ توفیر قناع طبي للمرضـــــــــ ــى الذین �ُشـــــــــ ــت�ه في إصـــــــــ ــابتهم �عدوى • فیروس �ورونــا المســـــــــــــتجــد أثنــاء تواجــدهم في أمــاكن الانتظــار/ ماكن العموم�ة أو في الغرف المختلطة؛الأ ممارسة نظافة الیدین �عد ملامسة إفرازات الجهاز التنفسي. • و�ن�غي للعـاملین في مجـال الرعـا�ـة الصـــــــــــــح�ـة أن یلتزموا بنهج المنظمـة �شــأن اللحظات الخمس لنظافة الیدین قبل ملامســة المر�ض، وقبل اتخاذ التعق�م، و�عد التعرض لســــ ــوائل الجســــ ــم، أي إجراء متصــــ ــل �التنظ�ف أو 5و�عد ملامسة المر�ض، و�عد ملامسة مح�ط المر�ض. تشـــــــــــــمـل نظـافـة الیـدین تنظ�ف الیـدین �ـاســـــــــــــتعمـال مطّهر الیـدین • كحولي، أو الصابون والماء؛ال كحولي في حال عدم اتســـــــــاخ ال�ُفضـــــــــّ ل اســـــــــتعمال مطّهر الیدین • الیدین �شكل واضح؛ �الماء والصـــــابون إذا �انتا متســـــختین �شـــــكل ین�غي غســـــل الیدین • واضح. كما �ســــــ ــاعد الاســــــ ــتعمال الرشــــــ ــید والصــــــ ــح�ح والمتســــــ ــق لمعدات الوقا�ة الشـــــخصـــــ�ة على الحد من انتشـــــار الُممّرضـــــات. وتتوقف فعال�ة معدات الوقا�ة الشـ ــخصـ ــ�ة �شـ ــكل أسـ ــاسـ ــي على توافر الإمدادات على نحو �اف الوقـا�ـة من العـدوى ومكـافحتهـا أثنـاء الرعـا�ـة الصــــــــــــــح�ـة عنـد الاشــــــــــــــت�ـاه في (VoCn) الإصا�ة �عدوى فیروس �ورونا المستجد إرشادات مبدئ�ة 0202ینایر �انون الثاني/ 52 إرشادات مبدئ�ة )VoCn(: الإصا�ة �عدوى فیروس �ورونا المستجدالوقا�ة من العدوى ومكافحتها أثناء الرعا�ة الصح�ة عند الاشت�اه في -2- ف، ونظافة الیدین �شــــــــ ــكل ومنتظم، وحصــــــــ ــول الموظفین على تدر�ب �ا 6 ،5 ،2سلوك �شري مناسب �صفة خاصة. ملائم، وتبني ومن المهم ضــــمان التقّید �إجراءات التنظ�ف والتطهیر البیئیْین على نحو متســــق وصــــح�ح. و�عّد تنظ�ف الأســــطح البیئ�ة �الماء والمنّظفات تنظ�فا ً المسـتشـف�ات والاسـتعانة �المطهرات الشـائعة الاسـتعمال على مسـتوى جیدا ً و�ن�غي أن ُیدار 7)مثل هیبو�لور�ت الصودیوم( إجراءْین فعالْین و�افیْین. واني الط�خ والنفا�ات كل من الأجهزة والمعدات الطب�ة وغسیل الملا�س وأ 8 ،2روتین�ة مأمونة. لإجراءات ا ًالطب�ة وفق تنفیذ احت�اطات إضاف�ة تجر�ب�ة -3 احت�اطات الوقا�ة من العدوى المنقولة �الملامسة والقطیرات 1-3 ین�غي لجم�ع الأشـــــــــــــخـــاص، �من فیهم أفراد الأســـــــــــــرة والزائرون • والعاملون في مجال الرعا�ة الصـح�ة، أن �ط�قوا احت�اطات الوقا�ة من العدوى المنقولة �الملامســـــــة والقطیرات قبل الدخول إلى الغرفة في إصــــــــــــابتهم �فیروس �ورونا المشــــــــــــت�ه حیث یوجد المرضــــــــــــى المسـتجد أو الذین تأكدت إصـابتهم �ه، وذلك �الإضـافة إلى تطبیق الاحت�اطات النموذج�ة؛ ین�غي أن یوضـع المرضـى في غرف مفردة جیدة التهو�ة. و�النسـ�ة • للغرف العــامــة ذات التهو�ــة الطب�ع�ــة، فــإن معــدل التهو�ــة الملائم 9ثان�ة لكل مر�ض؛ /لترا ً 06هو تتوفر غرف مفردة، ین�غي وضـــــــــع المرضـــــــــى المشـــــــــت�ه في مإذا ل • �فیروس �ورونا المستجد في نفس الغرفة؛ إصابتهم ین�غي ألا تقل المســـــافة عن متر واحد على الأقل بین أســـــّرة جم�ع • �عدوى المرضـــــى، �غض النظر عما إذا �ان �ُشـــ ــت�ه في إصـــ ــابتهم فیروس �ورونا المستجد أم لا؛ یثما أمكن، فر�ق من العاملین في مجال الرعا�ة ین�غي أن �ُعّین، ح • الصـــــح�ة لیتولى �شـــــكل حصـــــري رعا�ة الحالات المشـــ ــت�ه فیها أو المؤ�دة بهدف الحد من مخاطر انتقال العدوى؛ ین�غي للعاملین في مجال الرعا�ة الصــــــــــــح�ة أن �ســــــــــــتعملوا قناعا ً • (؛2)للاطلاع على مواصفاته، انظر المرجع أ ًطب�ا للعینین لین في مجال الرعا�ة الصــــــح�ة أن یرتدوا واق�ا ًین�غي للعام • للوجه( لتجنب تلّوث للوجه )سـ ــاترا ً )نظارات واق�ة للعینین( أو واق�ا ً إصا�ة الأغش�ة المخاط�ة؛ ین�غي للعاملین في مجال الرعا�ة الصـح�ة أن یرتدوا سـرابیل نظ�فة • غیر معقمة وطو�لة الأكمام؛ الرعا�ة الصح�ة أن یرتدوا قفازات؛ین�غي للعاملین في مجال • ل�س من الضـروري تغط�ة الجسـم �الكامل �ارتداء الأحذ�ة الطو�لة • والمر�لة والمئزر أثناء تقد�م الرعا�ة الروتین�ة؛ �عد الانتهاء من تقد�م الرعا�ة للمرضــى، ین�غي خلع جم�ع معدات • الوقـا�ـة الشـــــــــــــخصـــــــــــــ�ـة ونظـافـة الـیدین والتخلص منهـا على النحو وعلاوة على ذلك، �جـب اســـــــــــــتعمـال مجموعة جدیدة 6 ،5ئم.الملا من معدات الوقا�ة الشخص�ة عند تقد�م الرعا�ة لمر�ض آخر؛ ین�غي أن تكون المعدات أحاد�ة الاســـــ ــتعمال و�مكن التخلص منها • أو مخصــــ ــصــــ ــة )مثل الســــ ــماعات الطب�ة و�فة ق�اس ضــــ ــغط الدم نفس المعدات وأجهزة ق�اس الحرارة(. و�ذا تطّلب الأمر اســــــــــتعمال لعــدة مرضـــــــــــــى، فلابــد من تنظ�فهــا وتعق�مهــا �مجرد الانتهــاء من اســـــــــتعمالها على �ل مر�ض )�اســـــــــتعمال الكحول الأثیلي بنســـــــــ�ة 8(؛٪ مثلا ً07 الأقنعة الطب�ة هي أقنعة جراح�ة أو إجرائ�ة مسطحة أو مطو�ة )ال�عض أ منها �ش�ه الكؤوس(؛ وتوضع على الرأس �استعمال أحزمة ر�ط ین�غي للعاملین في مجال الرعا�ة الصـح�ة أن �متنعوا عن ملامسـة • العینین أو الأنف أو الفم �قفازات أو أیدي عار�ة قد تكون ملوثة؛ ن�غي تجنـب تحر�ـك المرضـــــــــــــى ونقلهم خـارج غرفهم أو أمـاكنهم ی • من الناح�ة الطب�ة. و�ن�غي اســــــــــ ــتعمال ا ًلم �كن ذلك ضــــــــــــرور� ما معدات الأشـــــعة الســـ ــین�ة المحمولة المخصـــــصـــــة و/ أو غیرها من ن ، فیتعی معدات التشـ ــخ�ص المخصـ ــصـ ــة. و�ذا �ان النقل ضـ ــرور�ا ً من تعرض بهـدف الحـد ا ًاســـــــــــــتخـدم طرق النقـل المحـددة مســـــــــــــ�ق ـ الموظفین والمرضــــــى والزوار للخطر، مع ضــــــمان ارتداء المر�ض لقناع طبي؛ ین�غي ضـــــــــــــمان تقید العاملین في مجال الرعا�ة الصـــــــــــــح�ة الذین • ینقلون المرضـــــــــــــى �قواعـد نظـافـة الیـدین وارتـدائهم معـدات الوقـا�ـة ؛الفرعالشخص�ة المناس�ة على النحو المبین في هذا الجناح الذي یتلقى المر�ض �أي احت�اطات ضـــرور�ة ین�غي إبلاغ • في أقرب وقت ممكن قبل وصول المر�ض؛ یتعین الحرص على التنظ�ف والتعق�م الروتینیین للأســـــــــــــطح التي • یلامسها المر�ض؛ ین�غي الحـد من عـدد العـاملین في مجـال الرعـا�ـة الصـــــــــــــح�ـة وأفراد • مؤ�د إصـــــابته الأســـــرة والزائر�ن المخالطین للمر�ض الُمشـــــت�ه أو ال �فیروس �ورونا المستجد؛ إنشـاء سـجل لجم�ع الأشـخاص الذین یدخلون غرفة المر�ض، �من • فیهم جم�ع الموظفین والزائر�ن. احت�ـاـطات الوـقا�ـة من الـعدوى المنقوـلة �ـالهواء في ســـــــ ــ�ـاق 2-3 الإجراءات التي یتوّلد عنها الضبوب ارت�طت �عض الإجراءات التي یتوّلد عنها الضـــــــــبوب بز�ادة خطر انتقال فیروســــــــات �ورونا )فیروس �ورونا المســــــــبب للمتلازمة التنفســــــــ�ة الحادة (، ق الأوســـــط التنّفســـــ�ةفیروس �ورونا المســـــبِّب لمتلازمة الشـــــر الوخ�مة و مثل التنبیب الفموي الرغامي والتهو�ة غیر ال�اضـــــــــــعة و�ضـــــــــــع الُرغامى والإنعـــــ ــاش القلبي الرئوي والتهو�ـــــ ــة الیـــــ ــدو�ـــــ ــة قبـــــ ــل التنبیـــــــب وتنظیر و�ن�غي الـتأكـد من ق�ـام العـاملین في مجـال الرعـا�ـة 11 ،01القصـــــــــــــ�ـات. یلي: الصح�ة الذین �ضطلعون �الإجراءات التي یتوّلد عنها الضبوب �ما الق�ــام �ــالإجراءات التي یتولــّ د عنهــا الضـــــــــــــبوب في غرفــة جیــدة • التهو�ــــة، أي تهو�ــــة طب�ع�ــــة �معــــدل تــــدفق الهواء لا �قــــل عن ف ســال�ة الضــغط تنطوي ثان�ة لكل مر�ض، أو في غر /لترا ً 061 في الساعة على الأقل، مع التحكم في اتجاه هوائ�ا ً تغّیرا ً 21على 9تدفق الهواء عند استخدام التهو�ة الم�كان�ك�ة؛ �قل اســـــتعمال جهاز تنفس جســـــ�مائي یوفر مســـــتوى من الوقا�ة لا • المعتمـــد من المعهـــد 59Nعلى ذلـــك الـــذي یوفره جهـــاز التنفس حة المهن�ة في الولا�ات المتحدة، أو جهاز الوطني للســ ــلامة والـص ـــ المطـابق لمعـاییر الاتحـاد الأورو�ي، أو مـا �عـادل 2PFFالتنفس وعندما �سـ ــتعمل العاملون في مجال الرعا�ة الصـ ــح�ة 21، 2لك.ذ جهاز تنفس جســــ�مائي أحادي الاســــتعمال، �جب أن یتحققوا دائًما و�رجى ملاحظة 21الجز�ئات.من إحكام القناع المانع لاســـتنشـــاق أنه إذا �ان مرتدي جهاز التنفس لد�ه شـعر في الوجه )أي لح�ة(، 21فقد �صعب عل�ه تر�ی�ه على النحو الصح�ح؛ استعمال واقي العینین )نظارات واق�ة للعینین أو ساتر الوجه(؛ • ارتداء ســـــــــــــرابیل وقفازات نظ�فة وغیر معقمة وطو�لة الأكمام. و�ذا • ل غیر مانعة للســـــــــوائل، فین�غي للعاملین في مجال كانت الســـــــــرابی للبلل عند الاضــطلاع ا ً مقاوما ًالرعا�ة الصــح�ة أن �ســتخدموا مئزر �أعمال من المتوقع أن ُتســــــــــتخدم فیها �م�ات �بیرة من الســــــــــوائل 2�ُحتمل أن تخترق السرابیل الواق�ة؛ إرشادات مبدئ�ة )VoCn(: الإصا�ة �عدوى فیروس �ورونا المستجدالوقا�ة من العدوى ومكافحتها أثناء الرعا�ة الصح�ة عند الاشت�اه في -3- خفض عـدد الأشـــــــــــــخـاص المتواجـدین في الغرفـة إلى الحـد الأدنى • ق المطلوب لرعا�ة المر�ض ودعمه.المطل تطبیق الضوا�ط الإدار�ة -4 والســ�اســات المتعلقة �الوقا�ة من انتقال عدوى 2تشــمل الضــوا�ط الإدار�ة ومكافحته في ســـــــ ــ�اق الرعا�ة (VoCn-9102فیروس �ورونا المســـــــــتجد) الصح�ة ما یلي على سبیل المثال لا الحصر: إنشاء بنى تحت�ة وأنشطة مســـــــــــــتــدامــة للوقــا�ــة من العــدوى ومكــافحتهــا؛ وتثق�ف مقــدمي الرعــا�ــة عدوى الجهاز للمرضــــى؛ ووضــــع ســــ�اســــات �شــــأن التعرف الم�كر على التي �ُحتمل أن �سـببها فیروس �ورونا المسـتجد؛ وضـمان التنفسـي الحادة إتاحة الفحوص المختبر�ة �شـــــــــــكل ســـــــــــر�ع بهدف التعرف على مســـــــــــبب لاســـــــــــــ�مـا في قســـــــــــــم الطوارئ؛ وتوفیر أمـاكن و المرض؛ ومنع الازدحـام، للانتظار مخصـصـة للمرضـى الذین تظهر علیهم أعراض المرض؛ وعزل المرضــــــى في المســــ ــتشــــــفى على نحو صــــــح�ح؛ وضــــــمان الإمداد الكافي �معدات الوقا�ة الشــخصــ�ة؛ وضــمان الالتزام �ســ�اســات و�جراءات الوقا�ة ح�ة.من العدوى ومكافحتها في جم�ع جوانب الرعا�ة الص الت ــدابیر الإدار� ــة المتعلق ــة � ــالع ــاملین في مجــال الرعــا� ــة 1-4 الصح�ة توفیر التدر�ب المناسب للعاملین في مجال الرعا�ة الصح�ة؛ • ضمان نس�ة �اف�ة من العاملین لكل مر�ض؛ • إرســــ ــاء عمل�ة ترصــــ ــّ د للأمراض التنفســــ ــ�ة الحادة بین العاملین في • �ُحتمل أن �ســـــــــــببها فیروس �ورونا مجال الرعا�ة الصـــــــــــح�ة التي المستجد؛ ضــمان فهم �ل من العاملین في مجال الرعا�ة الصــح�ة والجمهور • لأهم�ة التماس الرعا�ة الطب�ة على وجه السرعة؛ رصـــــــــــد امتثال العاملین في مجال الرعا�ة الصـــــــــــح�ة للاحت�اطات • النموذج�ة وتوفیر آل�ات التحسین حسب الحاجة. بیئ�ة والهندس�ةتطبیق الضوا�ط ال -5 31،تتعلق هذه الضـوا�ط �البن�ة التحت�ة الأسـاسـ�ة لمرافق الرعا�ة الصـح�ة في جم�ع أرجاء مرفق الرعا�ة 9وتهدف إلى ضـــمان توافر تهو�ة مناســـ�ة الصح�ة، فضلا عن تنظ�ف بیئي مناسب. و�الإضــــافة إلى ذلك، ین�غي أن ُتترك مســــافة قدرها متر واحد على الأقل جم�ع المرضـــى. و�مكن أن �ســـاعد �ل من الفصـــل المكاني والتهو�ة بین المناســــ�ة على الحد من انتشــــار العدید من الممرضــــات في المكان الذي 41ُتقدم ف�ه الرعا�ة الصح�ة. و�ن�غي ضـــــــــــــمـان التقیـّ د �ـإجراءات التنظ�ف والتطهیر البیئیْین على نحو والمنّظفات و�عد تنظ�ف الأســـــــــــطح البیئ�ة �الماء 8متســـــــــــق وصـــــــــــح�ح. واسـتعمال المطهرات المسـتخدمة عادًة في المسـتشـف�ات )مثل هیبو�لور�ت و�ن�غي أن ُیدار �ل من غســـــــیل 7الصـــــــودیوم( إجراءْین فعالْین و�افیْین. لإجراءات روتین�ة مأمونة. ا ًواني الط�خ والنفا�ات الطب�ة وفقالملا�س وأ �الملامســــــــ ــة والقطیرات مدة تطبیق احت�اطات الوقا�ة من العدوى المنقولة �النس�ة للمرضى المصابین �عدوى فیروس �ورونا المستجد ین�غي أن ُتطبق الاحت�اطات النموذج�ة طوال الوقت، �ما ین�غي مواصـلة تطبیق احت�ـاطـات إضــــــــــــــاف�ـة للوقـا�ـة من العـدوى المنقولـة �ـالملامســــــــــــــة معلومــات أدّق والقطیرات حتى اختفــاء أعراض المرض. ولابــد من توافر عن نمط انتقال عدوى فیروس �ورونا المســـــــــتجد �ي یتســـــــــنى تحدید مدة الاحت�اطات الإضاف�ة. أخذ ومناولة العینات المختبر�ة المأخوذة من المرضـــــــى الذین �ُشـــــــت�ه في إصابتهم �عدوى فیروس �ورونا المستجد الاســـــــــــــتقصـــــــــــــ ــاءات ین�غي اعت�ــار أن �ــل العینــات التي تؤخــذ لأغراض ، �ما ین�غي للعاملین في مجال الرعا�ة الصح�ة تكون معد�ة المختبر�ة قد الذین یتولون أخذ العینات الســر�ر�ة أو مناولتها أو نقلها أن یلتزموا التزاما ً بتدابیر الوقا�ة المع�ار�ة وممارسات السلامة البیولوج�ة التال�ة من صارما ً 51،61،71ضات.مر ِأجل الحد من احتمال التعرض للم ُ التأكد من أن العاملین في مجال الرعا�ة الصـــــــــح�ة الذین یتولون • أخذ العینات �سـتعملون معدات الوقا�ة الشـخصـ�ة المناسـ�ة )واقي (. للعینین، وقـناع طبي، وســـــــــــــر�ـال طو�ـل الأكمـام، وقفـازات مثلا ً و�ذا ُأخـذت العیـنات �ـات�ـاع إجراء یتولّـد عـنه الضـــــــــــــبوب، فین�غي للعـاملین أن یرتدوا جهـاز تنفس جســـــــــــــ�مـائي یوفر مســـــــــــــتوى من المعتمـد 59Nالوقـا�ـة لا �قـل على ذلـك الـذي یوفره جهـاز التنفس من المعهـد الوطني للســـــــــــــلامـة والصـــــــــــــحـة المهن�ـة في الولا�ـات بق لمعــ ــاییر الاتحــ ــاد المطــ ــا 2PFFالمتحــ ــدة، أو جهــ ــاز التنفس الأورو�ي، أو ما �عادل ذلك؛ التــأكــد من أن جم�ع العــاملین الــذي یتولون نقــل العینــات مــدر�ون • على ممارسـات المناولة المأمونة و�جراءات إزالة التلوث الناتج عن 7تسرب العینات؛ أك�ــاس العینــات المــانعــة وضـــــــــــــع العینــات التي ین�غي نقلهــا في • المزودة �جیب منفصــــــــــــل �غلق (ثانو�ةالحاو�ات الأي )للتســــــــــــرب أي الك�س البلاسـ ــت�كي المخصـــص للعینات ) �إحكام لوضـــع العینة ، ووضــــع ملصــــق �حمل اســــم (بیولوج�ةالتي تنطوي على مخاطر ، و�رفـاق نموذج (الحـاو�ـة الأول�ـةأي )المر�ض على حـاو�ـة العینـة ؛�خط واضح المختبر مكتو�ا ًطلب مرفق الرعا�ة الصـــــــــح�ة تلتزم �ممارســـــــــات التأكد من أن مختبرات • الســــــــــــلامة البیولوج�ة الملائمة وشــــــــــــروط النقل وفقًا لنوع الكائنات ؛مناولتهاالتي �جري الح�ة ُنظم الأنابیب عدم اســتخدام. تســل�م جم�ع العینات �الید �لما أمكن • ؛الهوائ�ة في نقل العینات ذ�ر الاسـم الكامل لكل مر�ض وتار�خ میلاده واسـم فیروس �ورونا • المســتجد )المشــت�ه ف�ه( المحتمل �شــكل واضــح على نموذج طلب جاري �خطار المختبر في أســـرع وقت ممكن �أن العینة و المختبر. .نقلها ةالخارج�الع�ادة رعا�ة توص�ة �شأن للوقــا�ــة من العــدوى ومكــافحتهــا تطبیق الم�ــادئ الأســــــــــــــــاســـــــــــــ�ــة ین�غي في جم�ع مرافق الرعا�ة الصـــــــــــح�ة، �ما في ذلك النموذج�ةوالاحت�اطات فیروس �ورونا �النســــــ ــ�ة لعدوى و الأول�ة. والرعا�ةالخارج�ة الع�ادة رعا�ة :، ین�غي اعتماد التدابیر التال�ةالمستجد والتعّرف الم�كر؛لفرز ا • اســــــــــتعمال لجهاز التنفســــــــــي و االیدین و �ل من لى نظافة التر�یز ع • ة؛عراض التنفس� ذوي الألمرضى لالأقنعة الطب�ة احت�اطات الوقا�ة من العدوى المنقولة �القطیرات والملامسة تطبیق • ؛جم�ع الحالات المشت�ه فیهاعند رعا�ة على النحو السل�م اضأعر تظهر علیهم إعطــاء الأولو�ــة لرعــا�ــة المرضـــــــــــــى الــذین • المرض؛ المرض أعراضتظهر علیهم عنـدمـا �ُطلـب من المرضـــــــــــــى الـذین • مخصص لهم؛انتظار ین�غي التأكد من وجود مكان الانتظار، التعرف الم�كر على الأعراض �شــــــــأن وأســــــــرهمتثق�ف المرضــــــــى • صـــــح�ة الرعا�ة الومرفق الواجب تطب�قها والاحت�اطات الأســـ ــاســـ ــ�ة الذي ین�غي التوجه إل�ه. يف ها�تشلاا دنع ة�حصلا ة�اعرلا ءانثأ اهتحفاكمو ىودعلا نم ة�اقولادجتسملا انورو� سوریف ىودع� ة�اصلإا :(nCoV) ة�ئدبم تاداشرإ -4- ریدقتو ركش نم ة�اقولا نأـــش� تاداـــشرلإا نم ة�لـــصلأا ةخـــسنلا تدُعأ سوریف ىودع ة�ــسفنتلا طــسولأا قرــشلا ةمزلاتمل ببــسملا انوروك1 اهتحفاكمو رواــشتلا� عم ةحـصلا ةمظنمل ةع�اتلا اهتحفاكمو ىودعلا نم ة�اقولل ة�ملاعلا ةك�ـشلا ة�ملاعلااهل ة�اجتـــــــسلااو ةدجتـــــــسملا ضارملأل ير�رـــــــسلا م�یقتلا ةك�ـــــــشو .ن�رخآ نییلود ءاربخو ىلإ ركـــــــــشلا� ةمظنملا مدقتتو نم ل� يف كراـــــــــش قا�ــــــــــــــس يف اـهتحفاـكمو ىودـعلا نم ة�ـاـقولا قئاـثو ثـیدـحتو دادـعإ سوریف ة�سفنتلا طسولأا قرشلا ةمزلاتمل ببسملا انوروك. و ىودعلا نم ة�اقولل ة�ملاعلا ةك�ـــــــــــــشلا عم رواـــــــــــــشتلا� ةق�ثولا هذه تدُعأ ن�رخآ نییلود ءاربخو ة�ملاعلا ةحـــصلا ةمظنمل ةع�اتلا اهتحفاكمو . مدقتتو ضارعتـسلاا ة�لمع ىلع مهؤامـسأ ة�لاتلا صاخـشلأا ىلإ ركـشلا� ةمظنملا اهب اوماق يتلا )ة�زیلكنلإا فرحلأا بیترتل ًاقفو:( • Abdullah M 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, Atlanta, USA • Gail Carson, ISARIC Global Support Centre, Director of Network Development, Consultant in Infectious Diseases & Honorary Consultant Public Health England, United Kingdom • John M Conly, Department of Medicine, Microbiology, Immunology and Infectious Diseases, Calvin, Phoebe and Joan Synder Institute for Chronic Diseases, Faculty of Medicine, University fo Calgary, Calgary, Canada • Barry Cookson, Division of Infection and Immunity, University College, London, United Kingdom • Babacar N Doye, Board Member, Infection Control Network, Dakar, Senegal • Kathleen Dunn, Manager, Healthcare Associated Infections and Infection Prevention and Control Section, Centre for Communicable Disease Prevention and Control, Public Health Agency of Canada • Dale Fisher, Global Outbreak Alert and Response Network steering committee • Fernanda Lessa, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA. • Moi Lin Ling, Director, Infection Control Department, Singapore General Hospital, Singapore and President of Asia Pacific Society of Infection Control (APSIC) • Fernando Otaiza O’Rayan, Head, National IPC Program Ministry of Health, Santiago, Chile • Diamantis Plachouras, Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control • 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 WHO: Benedetta Allegranzi, April Baller, Ana Paula Coutinho, Janet Diaz, Christine Francis, Maria Clara Padoveze, Joao Paulo de Toledo, Maria Van Kerkhove عجارملا 1- ىودــعلا نم ةــ�اــقولا اــهتحفاــكمو تلااــحل ةــ�حـــــــــــــصلا ةــ�اــعرلا ءاــنثأ ة�ـاــ ــــــــــــصلإا ةدـ�ؤملا وأ ةـلمتحملا � بـبـــــــــــــسملا اـنورو� سوریف ىودـع ة�ـــــسفنتلا طـــــسولأا قرـــــشلا ةمزلاتمل: تاداـــــشرإ ة�ئدبم ، ثّدحمة يف /لولأا ن�ـرــــــــــــــشتر�ـوـتـكأ 2019ف�ــنـج .: ةـــــــحــــــــــــــصلا ةــ ـــــمـظـنـم ة�ملاعلا؛ 2019 (ة�زیلكنلإا�) WHO/MERS/IPC/15.1 Rev. 1 https://apps.who.int/iris/handle/10665/174652 ) يف علاطلاا مت17 نونا� ریانی /يناثلا2020.( 2- ةداحلا يـــــــسفنتلا زاهجلا ضارمأ� ىودعلا نم ة�اقولا ببـــــــست دق يتلا حئاوجو ةــئ�وأ ئداــ�ملا :ةــ�حـــــــــــــصلا ةــ�اــعرلا لاــجم يف اــهتحفاــكمو ل ةـ�هیجوتلا ةـحـــــــــــــصلا ةـمظنم :ف�نج .ةـ�ملاـعلا ةـحـــــــــــــصلا ةـمظنم ؛ ة�ملاعلا2014 (ة�زیلكنلإا�) )10665/112656/ http://apps.who.int/iris/، علاــطلاا مــت يف17 ریانی /يناثلا نونا�2020.( 3- لا ئدا�ملا نأــ ــــش� ة�هیجوترــ ــــصانعلا نم ة�اقولا جماربل ة�ــ ــــساــ ــــسلأا تلااح ىلع اهتحفاكمو ىودعلالا ىوتـــــــسم ىوتـــــــسمو ينطولا قفارم ة�حـصلا ة�اعرلا ة�ـضرملا تلااحلل حـصلا ةمظنم :ف�نج .ةداحلا ة ؛ ة�ملاعلا2016 :يلاتلا ط�ارلا للاخ نم ةحاتم) .(ة�زیلكنلإا�) -components-https://www.who.int/gpsc/ipc guidelines/en/ ) يف علاطلاا مت20 ریانی /يناثلا نونا�2020.( 4- .اـهیلع ةرط�ـــــــــــــسلاو ىودـعلا نم ةـ�اـقولل تاـ�لطتملا نم ىندلأا دـحلا ؛ ة�ملاعلا ةحــ ـــــــــــصلا ةمظنم :ف�نج2019 ةحاتم) (ة�زیلكنلإا�) . :يلاــــــتلا ط�ارلا للاخ نم -tionhttps://www.who.int/infec manual/en/-IPC-req-prevention/publications/min ، يف علاطلاا مت20 ریانی /يناثلا نونا�2020.( 5- ةفاظن نأـــــش� ة�ملاعلا ةحـــــصلا ةمظنم تاداـــــشرإيدیلأا لاجم يف ة�حــصلا ة�اعرلا: ىــضرملا ةملاــس نأــش� لولأا يملاعلا يدحتلا- رثكأ ةــ�اــعر ةــف�ظنلا ةــ�اــعرلاةــ�نومأــم ةــحـــــــــــــصلا ةــمظنم :ف�نج . ؛ ةــ�ملاــعلا2009 :يلاــتلا ط�ارلا للاخ نم ةــحاــتم) (ةــ�زیلكنلإاــ�) https://apps.who.int/iris/handle/10665/44102، مــــــــــــت يف علاطلاا17 انی /يناثلا نونا� ری2020.( 6- .ة�صخشلا ة�اقولا تادعم علخو ءادترا ةق�رط ةمظنم :ف�نج ة�ملاعلا ةحصلا ؛2008 https://www.who.int/csr/resources/publications/Doc9_PPEpo sterweb.pdf?ua=1 ) يف علاطلاا مت17 ریانی /يناثلا نونا�2020.( 7 CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. (Available at: https://www.cdc.gov/hai/prevent/resource- limited/environmental-cleaning.html and http://www.icanetwork.co.za/icanguideline2019/, accessed 20 January 2020) إرشادات مبدئ�ة )VoCn(: الإصا�ة �عدوى فیروس �ورونا المستجدالوقا�ة من العدوى ومكافحتها أثناء الرعا�ة الصح�ة عند الاشت�اه في -5- .مرافق الرعا�ة الصح�ة لالأجهزة الطب�ة معالجةإزالة التلوث و�عادة -8 متاحة )�الإنكلیز�ة( ) .6102جن�ف: منظمة الصـــــــــــ ــحة العالم�ة ؛ من خلال الرا�ط التالي: noitcefni/tni.ohw.www//:sptth- /ne/noitanimatnoced/snoitacilbup/noitneverp (.0202�انون الثاني/ ینایر 02تم الاطلاع في ) nesneJ ,KC avliS-aosseP ,Y reitrahC ,J nosniktA 9 rof noitalitnev larutaN .srotide ,HW oteS ,Y iL ,P :aveneG .sgnittes erac-htlaeh ni lortnoc noitcefni 9002 ;noitazinagrO htlaeH dlroW ,76144/56601/eldnah/siri/tni.ohw.sppa//:sptth( ..)0202 yraunaJ 71 dessecca sesurivanoroc gnigreme dna cimedipE .SD iuH 01 elddiM dna emordnys yrotaripser etuca ereves( .deM tsehC nilC .)emordnys yrotaripser tsaE .700.11.6102.mcc.j/6101.01:iod .68−17:837102 ,LC avliS-aosseP ,M nreveS ,K nomiC ,K narT 11 ksir dna serudecorp gnitareneg losoreA .J ylnoC ot snoitcefni yrotaripser etuca fo noissimsnart fo SoLP .weiver citametsys a :srekrow erachtlaeh :iod .79753e:7;2102 .enO .62 rpA 2102 bupE .7975300.enop.lanruoj/1731.01 طر�قـة التحقق من إحكـام القـناع المـانع لاســـــــــــــتنشــــــــــــ ــاق الجز�ـئات. -21 .8002جـــــنـــــ�ـــــف: مـــــنـــــظـــــمـــــ ــة الصـــــــــــــــــ ــحـــــ ــة الـــــعـــــ ــالـــــمـــــ�ـــــ ــة ؛ oD/snoitacilbup/secruoser/rsc/tni.ohw.www//:sptth) �انون 71تم الاطلاع في ، 1=au?fdp.bewkcehclaeS_01c حصـــــــــــــول على أحدث المعلومات، یرجى لل(. 0202الثاني/ ینایر فیروس �ورونا�شـــــأن منظمة الإلكترون�ة لل صـــــفحةالاطلاع على ال )�الإنكلیز�ة(على الرا�ط التالي: itcefni_surivanoroc/esaesid/rsc/tni.ohw.www//:ptth /ne/sno laitnessE .srotide ,Y reitrahC ,J martraB ,J smadA 31 .erac htlaeh ni sdradnats htlaeh latnemnorivne 8002 ;noitazinagrO htlaeH dlroW :aveneG ,76734/56601/eldnah/siri/tni.ohw.sppa//:sptth( .)0202 yraunaJ 71 dessecca ,E inorreF ,L yelooD ,BC raM leD ,T nosreffeJ 41 lacisyhP .la te AG reezawaB ,AL yrasnA-lA fo daerps eht ecuder ro tpurretni ot snoitnevretni .tsyS esabataD enarhcoC .sesuriv yrotaripser ta elbaliavA .702600DC:7 ,1102 .veR 5815641/2001.01/iod/moc.yeliw.yrarbilenilno//:ptth 77E446470=dinoissesj;tcartsba/4bup.702600DC.8 dessecca .20t30d.53828B10D82F45BFC4A9646 .)0202 yraunaJ 71 إصـــــــابتها لحالات ال�شـــــــر�ة المشـــــــت�ه فيالفحوص المختبر�ة على ا -51 إرشــــــــــــادات مبدئ�ة. :(VoCn-9102) �ورونا المســــــــــــتجدفیروس � منظمـة الصـــــــــــــحـة العـالم�ـة :. جن�ف0202ینـایر كـانون الثـاني/ )�الإنكلیز�ة( htlaeh/tni.ohw.www//:sptth- yrotarobal/surivanoroc/scipot-scitsongaid-rof- nlevo-surivanoroc (.0202�انون الثاني/ ینایر 02تم الاطلاع في ) فیروس �ورونا المســـــبِّب لمتلازمة لكشـــــف عن بر�ة لت الفحوص المخ -61 إرشـادات مبدئ�ة )مراجعة(، �انون الثاني/ : التنّفسـ�ةالشـرق الأوسـط 8102 منظمـــــة الصـــــــــــــحـــــة العـــــالم�ـــــة: . جن�ف8102ینـــــایر )�الإنكلیز�ة( /eldnah/maertstib/siri/tni.ohw.sppa//:sptth OHW/259952/56601-SREM-BAL-1.51-1veR- 8102-1=ecneuqes?fdp.gne (.0202الثاني/ ینایر �انون 71تم الاطلاع في ) لمختبر، الط�عـة الثـالثـة. جن�ف: في ا البیولوج�ـةدلیـل الســـــــــــــلامـة -71 )�الإنكلیز�ة( 4002العالم�ة؛ منظمة الصحة ، تـــــــــم 18924/56601/eldnah/siri/tni.ohw.sppa//:sptth) (.0202الثاني/ ینایر �انون 71الاطلاع في .جم�ع الحقوق محفوظة. 0202منظمة الصحة العالم�ة © تواصـ ــل منظمة الصـ ــحة العالم�ة رصـ ــد الأوضـ ــاع عن �ثب للكشـ ــف عن وفي حـال تغیر أي . أي تغیرات ـقد تؤثر على هـذه الإرشــــــــــــــادات المـبدئ�ـة ،عـامـل من العوامـل ســـــــــــــوف تصــــــــــــــدر المنظمـة تحـدیثـًا آخر للمعلومـات .من تار�خ النشر عامینفسوف تنتهي صلاح�ة هذه الإرشادات �عد و�لا YB CC-CN-OGI 0.3 ASترخیص ال بعض الحقوق محفوظة. ھذا المصنف متاح بمقتضى. 0202منظمة الصحة العالمیة © ( نسخة الإلكترونیة) 7-701000-4-29-879 NBSI (نسخة مطبوعة) 4-801000-4-29-879 NBSI 2.0202/CPI/VoCn-9102/OHW :rebmun ecnerefer OHW