| Interim guidance Dated: 21 March 2020 |
Background
On 30 January 2020, WHO announced that the COVID-19 outbreak was a Public Health Emergency of International Concern. Initially, most cases were reported from China and among individuals with travel history to China. Please refer to the latest situation reports for COVID-19.
COVID-19 is an acute respiratory illness caused by a novel human coronavirus (SARS-CoV-2, called COVID-19 virus), which causes higher mortality in people aged ≥60 years and in people with underling medical conditions such as cardiovascular disease, chronic respiratory disease, diabetes and cancer.
Long-term care facilities (LTCFs), such as nursing homes and rehabilitative centers, are facilities that care for people who suffer from physical or mental disability, some of who are of advanced age. The people living in LTCF are vulnerable populations who are at a higher risk for adverse outcome and for infection due to living in close proximity to others. Thus, LTCFs must take special precautions to protect their residents, employees, and visitors. Note that infection prevention and control (IPC) activities may affect the mental health and well-being of residents and staff, especially the use of PPE and restriction of visitors and group activities. For further information on resilience during the time of COVID, see Mental health and psychosocial considerations during COVID-19 outbreak.
This interim guidance is for LTCF managers and corresponding IPC focal persons in LTCF. The objective of this document is to provide guidance on IPC in LTCFs in the context of COVID-19 to 1) prevent COVID-19-virus from entering the facility, 2) prevent COVID-19 from spreading within the facility, and 3) prevent COVID-19 from spreading to outside the facility. WHO will update these recommendations as new information becomes available. All technical guidance for COVID-19 is available online.
System and service coordination to provide long-term care
- Coordinate with relevant authorities (e.g. Ministry of Health, Ministry of Social Welfare, Ministry of Social Justice, etc.) should be in place to provide continuous care in LTCFs.
- Activate the local health and social care network to facilitate continuous care (clinic, acute-care hospital, day-care center, volunteer group, etc.)
- Facilitate additional support (resources, health care providers) if any older person in LTCFs is confirmed with COVID19.
Prevention
IPC focal point and activities
LTCFs should ensure that there is an IPC focal point at the facility to lead and coordinate IPC activities, ideally supported by an IPC team with delegated responsibilities and advised by a multidisciplinary committee. WHO guiding principles for IPC can be found online.
At a minimum, the IPC focal point should:
- Provide COVID-19 IPC training 1to all employees, including:
– an overview of COVID-19: https://openwho.org;
– hand hygiene and respiratory etiquette;
– standard precautions; and
– COVID-19 transmission-based precautions.2 - Provide information sessions for residents on COVID-19 to inform them about the virus, the disease it causes and how to protect themselves from infection
- Regularly audit IPC practices (hand hygiene compliance) and provide feedback to employees.
- Increase emphasis on hand hygiene and respiratory etiquette:
– Ensure adequate supplies of alcohol-based hand rub (ABHR) (containing at least 60% alcohol) and availability of soap and clean water. Place them at all entrances, exits and points of care
– Post reminders, posters, flyers around the facility, targeting employees, residents, and visitors to regularly use ABHR or wash hands.
– Encourage hand washing with soap and water for a minimum of 40 seconds or with ABHR for a minimum of 20 seconds.3
– Require employees to perform hand hygiene frequently, in particular at the beginning of the workday, before and after touching residents, after using the toilet, before and after preparing food, and before eating.
– Encourage and support residents and visitors to perform hand hygiene frequently, in particular when hands are soiled, before and after touching other people (although this should be avoided as much as possible), after using the toilet, before eating, and after coughing or sneezing.
– Ensure adequate supplies of tissues and appropriate waste disposal (in a bin with a lid).
– Post reminders, posters, flyers around the facility, targeting employees, residents, and visitors to sneeze or cough into the elbow or to use a tissue and dispose of the tissue immediately in a bin with a lid. - A guide to local production of WHO-recommended ABHR is available
- Maintain high standards of hygiene and sanitation practice. Guidance on water, sanitation, laundry, and waste management for COVID-19 is available.
- Provide annual influenza vaccination and pneumococcal conjugate vaccines to employees and staff, according to local policies, as these infections are important contributors to respiratory mortality in older people.
Physical distancing in the facility
Physical distancing in the facility should be instituted to reduce the spread of COVID-19:
- Restrict the number of visitors (see below)
- For group activities ensure physical distancing, if not feasible cancel group activities
- Stagger meals to ensure physical distance maintained between residents or if not feasible, close dining halls and serve residents individual meals in their rooms
- Enforce a minimum of 1 meter distance between residents
- Require residents and employees to avoid touching (e.g., shaking hands, hugging, or kissing).
Visitors
In areas where COVID-19 transmission has been documented, access to visitors in the LTCFs should be restricted and avoided as much as possible. Alternatives to in-person visiting should be explored, including the use of telephones or video, or the use of plastic or glass barriers between residents and visitors.
All visitors should be screened for signs and symptoms of acute respiratory infection or significant risk for COVID-19 (see screening, above), and no one with signs or symptoms should be allowed to enter the premises.
A limited number of visitors who pass screening should be allowed entry to long-term care only on compassionate grounds, specifically if the resident of the facility is gravely
ill and the visitor is their next-of-kin or other person required for emotional care. Visitors should be limited to one at a time to preserve physical distancing. Visitors should be instructed in respiratory and hand hygiene and to keep at least 1 meter distance from residents. They should visit the resident directly upon arrival and leave immediately after the visit.
Direct contact by visitors with residents with confirmed or suspected COVID-19 should be prohibited.
Note that in some settings, complete closure to visitors is under the jurisdiction of local health authorities.