Strategic priority infection prevention and control (IPC) activities for containment and prevention of COVID-19 cases at healthcare facilities in non-US settings

1. Use of this document

This document is intended to guide national-level coordination, healthcare facilities, and implementing partners in considering and planning high-priority IPC activities to prevent healthcare-associated transmission of SARS-CoV-2 (COVID-19 virus). Aspects of this document are relevant for all countries, but a focus is placed on priorities for low- and middle-income settings given resource constraints.

The goal of IPC activities in the coronavirus disease 2019 (COVID-19) response is to support the maintenance of essential healthcare services by preventing healthcare-associated transmission of SARS-CoV-2 among healthcare workers (HCW) and patients.

This requires:

• Rapid identification of suspect cases
• Immediate isolation and referral for testing
• Safe clinical management
• Adherence to standard IPC precautions

This document focuses on implementation of rapid identification of COVID-19 in healthcare facilities, which forms the basis for subsequent isolation, testing and management decisions.

Planning and coordination of activities should be conducted in collaboration with emergency response officials, in addition to relevant public health officials (e.g., Ministry of Health, sub-national health offices, facility administration).

This document addresses specific details on prioritized activities around rapid identification of COVID-19 in healthcare facilities under four different epidemiological scenarios of COVID-19 transmission. However, national and sub-national public health authorities and healthcare facilities in all countries should be doing certain core activities to support and prepare for the start of any of the activities outlined in section 5, regardless of the current state of COVID-19 transmission in the country.

2. National activities to support and enable prioritized facility IPC activities

National and sub-national public health authorities play a critical role in enabling priority IPC activities at healthcare facilities. Specific areas of focus for national and sub-national authorities should include:

• Development of national or sub-national policies and guidance on implementation of priority activities outlined in section 5 of this document in healthcare facilities (e.g., HCW screening, triage at facilities, isolation and cohorting in facilities, facilitating safe home care for cases with mild symptoms, movement and monitoring of exposed HCW)
• Linkage of Ministry of Health and sub-national IPC focal points to COVID-19 preparedness planning work (e.g., epidemiology and laboratory pillars)
• Development of forecasting plans for personal protective equipment (PPE) and other IPC consumables (e.g., alcohol-based hand rub) that prioritize:
  • Healthcare system needs
  • Development of plans for stockpiling PPE
  • Deploying stocks when need arises
  • Communication with facilities to ensure continuity of stocks
• Assessment of IPC readiness for facility inpatient areas for priority activities (outlined in section 5) and use this information to do the following:
  • Define national referral networks to direct suspected or confirmed cases to designated, prepared hospitals
    • Note: this is most relevant during containment phase of the response (epidemiologic scenarios 1 and 2, below) when there are relatively few cases that are epidemiologically linked
  • Strengthen priority IPC areas at all hospitals, starting with highest risk, in preparation for limited and widespread community transmission
• Development of national policies and procedures to avoid overwhelming healthcare facilities from influx of suspected COVID-19 cases, particularly mild cases. This should include:
  • Consideration of remote triage capabilities for suspected COVID-19 cases through hotlines, telemedicine or other modalities
  • Communicating with symptomatic contacts of known COVID-19 cases to alert designated authorities in advance of presenting for medical care
  • Development of messaging on this topic for healthcare facilities and general population (e.g., stay at home except to get medical care)
• Ensuring the availability of COVID-19 laboratory testing in country and linkages to healthcare facilities that may need testing services
• Development of training materials on priority IPC activities to prevent healthcare-associated spread of COVID-19
  • Dissemination of training materials toto professional societies, sub-national public health authorities, healthcare facilities, and front-line healthcare workers

3. Core facility IPC activities regardless of epidemiologic scenario

• Develop plans to carry out actions outlined in section 5 in order to prevent the spread of acute respiratory infections (ARI), such as COVID-19, within the facility
• Develop SOPs for environmental cleaning procedures, particularly for the triage and isolation areas where suspected or confirmed COVID-19 patients will be placed
• Develop staffing plans to adequately staff isolation areas and consider whether cohorting staff is feasible
• Develop contingency plans for PPE shortages and other IPC consumable (e.g., alcohol-based hand rub) shortages in collaboration with national and sub-national public health authorities
• Develop communication plans to ensure adequate internal and external communication regarding COVID-19
• Educate HCW, patients, and visitors on COVID-19 signs, symptoms, and required IPC protocols
• Develop policies for visitor restriction (e.g., restrict visitors who are sick with ARI)
• Develop policies to identify and risk stratify HCW exposed to COVID-19 cases and monitor their movement and return to work
• Establish communication channels between healthcare facilities and public health authorities who can facilitate linkages with laboratory testing and epidemiology/contact tracing

4. Epidemiologic scenarios

1. No known cases in country
2. Confirmed cases, but no known community transmission
   1. If secondary cases present, all are linked to other confirmed cases
3. Confirmed cases, limited community transmission
   1. Limited amount of unlinked cases identified in the community
4. Confirmed cases, widespread community transmission
   1. Many unlinked cases identified in the community

Note: there may be situations within a country whereby different geographic areas meet different scenario criteria. Ministries of Health, in coordination with relevant stakeholders, should consider the appropriateness and feasibility of applying a single set of prioritized IPC activities across the country matched to the most severe transmission scenario met versus implementing multiple sets of prioritized IPC activities in differently affected geographic units. Experience in this pandemic has shown that once a region is at scenario 2 (confirmed cases, no known community transmission), aggressive testing strategies of undiagnosed respiratory infections may quickly reveal underlying community transmission. This can result in a rapid progression to scenario 4 (widespread community transmission), sometimes within a little as a week. Thus it is absolutely critical that countries prepare aggressively for future epidemiologic scenarios even as the implement activities for their current situation. Ministries of Health and healthcare facilities must act quickly once cases are identified to prevent and prepare for scenario 4 (widespread community transmission).

5. Prioritized IPC activities for prevention and containment of COVID-19 cases, by epidemiologic scenario

¹ High-risk facilities should be defined by public health authorities considering: proximity to facilities or communities with known COVID-19 cases, including those across administrative or international borders as well as prioritizing facilities seeing large numbers of patients at high risk of being a COVID-19 case and where introduction would be highly disruptive (e.g., large referral hospitals)

6. Additional considerations for inpatient facilities with admitted cases of confirmed COVID-19

Regardless of epidemiologic scenario in a country, once an inpatient facility is housing suspected or confirmed COVID-19 cases, specific IPC precautions for isolation will apply. These are outlined by the World Health Organization and accessible at the links below. Pursuant to this document, facilities with confirmed cases may need to carry out prioritized activities from other epidemiologic scenarios even if those scenarios do not represent the country-wide COVID-19 situation. This could include, for instance, a hospital with confirmed COVID-19 cases choosing to conduct active screening of healthcare workers for signs and symptoms of COVID-19, despite this not being listed under the routine priority activities in that country’s epidemiologic scenario.

7. Additional resources for IPC and COVID-19

National readiness (WHO): https://www.who.int/publications-detail/national-capacities-review-tool-for-a-novelcoronavirusexternal icon

Facility readiness (CDC): https://www.cdc.gov/coronavirus/2019-ncov/hcp/preparedness-checklists.html

WHO COVID-19 surveillance definition: https://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov)external icon

WHO guidance on infection prevention and control: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and-controlexternal icon

WHO Pandemic flu planning checklist (see section 4.0): https://www.who.int/influenza/preparedness/pandemic/influenza_risk_management_checklist_2018/en/external icon

8. Acknowledgements

CDC would like to acknowledge April Baller, MD, Infection Prevention and Control Lead, World Health Emergency Programme and Maria Clara Padoveze RN, PhD, Technical officer, IPC unit at the World Health Organization.