Summary of WHO infection prevention and control guideline for covid-19: striving for evidence based practice in infection prevention and control (2024)

Table of Contents
What you need to know WHO guideline development process Evidence review questions Iterations Highlights from the guideline Healthcare facilities 1 Summary of WHO recommendations for healthcare facilities Community settings Research gaps Preparedness, readiness, and response Guidelines into practice How patients were involved in the creation of this article Further information on the guidance Footnotes References
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Practice WHO Guidelines BMJ 2024; 385 doi: https://doi.org/10.1136/bmj.q645 (Published 23 May 2024) Cite this as: BMJ 2024;385:q645

  • Article
  • Related content
  • Metrics
  • Responses
  • Peer review
  1. Kathleen Dunn, WHO consultant1,
  2. Hannah Hamilton Hurwitz, WHO consultant1,
  3. João Paulo Toledo, WHO technical officer1,
  4. Mitchell J Schwaber, professor of medicine2,
  5. May Chu, medical professor3,
  6. Roger Chou, methodologist4,
  7. Nathan Ford, scientist1,
  8. Benedetta Allegranzi, unit head1,
  9. April Baller, WHO health emergencies IPC and WASH team lead1
  10. on behalf of the WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Guideline Development Group
    1. 1World Health Organization, Geneva, Switzerland
    2. 2Israel Ministry of Health, Jerusalem, Israel; Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
    3. 3Colorado School of Public Health, CO, USA
    4. 4Oregon Health and Science University, Portland, OR, USA
    1. Correspondence to: A Baller ballera{at}who.int

    The World Health Organization (WHO) published theseventh version of the infection prevention and control guideline for coronavirus disease 2019 (covid-19) in December 2023. The revision and development process undertaken for this guideline consolidates and updates technical guidance developed and published at the height of the covid-19 pandemic (2020-21) into a single guideline, following WHO guideline development processes.12

    The updated guideline considered the current context of covid-19, the latest evidence supporting infection prevention and control (IPC) interventions, epidemiological trends, the emergence of variants of concern, population immunity, availability and uptake of vaccines, and indoor environmental conditions.

    This article provides an overview of the guideline development process and summarises the current recommendations from WHO for IPC measures when caring for people with or managing covid-19 outbreaks.

    What you need to know

    • WHO has published an updated guideline for infection prevention and control in the context of covid-19

    • In the healthcare facility, WHO recommends consistent application of standard and transmission based precautions to prevent SARS-CoV-2 transmission

    • In community settings, WHO recommends mitigation measures to reduce the risk of SARS-CoV-2 transmission and its impact

    WHO guideline development process

    The guideline development process for this consolidated guideline followed WHO methodology, including conducting systematic reviews of evidence and the use of Grading of Recommendations, Assessment, Development and Evaluation (GRADE) to assess the certainty of evidence and determine the strength of recommendations.12

    To develop the guideline, WHO convened a Guideline Development Group (GDG), which reviewed Population, Intervention, Comparator and Outcome (PICO) questions, prioritised outcomes, interpreted the evidence and assessed evidence quality, formulated recommendations, and established key considerations on behalf of WHO.12 The GDG included experts in IPC, epidemiology, infectious diseases, microbiology, paediatrics, water, sanitation, and hygiene, engineering and aerobiology, and civil society representatives.

    Thirty two research questions were identified and 17 systematic evidence reviews were commissioned.3 In addition, five qualitative evidence syntheses were performed to investigate contextual factors such as health and care workers’ values and preferences related to personal protective equipment (PPE), cleaning and disinfection, and physical barriers and distancing.4

    The recommendations in this guideline are based on evidence available at the time the guideline was developed. For most PICO questions, the available evidence was limited and the overall certainty of the evidence was generally low (box 1).

    Box 1

    Evidence review questions

    • Are there additional precautions needed for handling the deceased beyond the standard requirements?

    • Should the waste generated when providing care for a covid-19 patient be handled as infectious waste in a healthcare facility?

    • Does SARS-CoV-2 require differential laundry techniques, beyond standard procedures, in healthcare facilities?

    • Does SARS-CoV-2 require differential cleaning in healthcare facility settings beyond standard environmental cleaning procedures?

      • What is the frequency of cleaning high-touch surfaces in healthcare settings in the context of covid-19?

      • Which cleaning products and concentrations should be used in healthcare settings in the context of covid-19, and at what contact time and concentrations?

    • Should surfaces and materials in healthcare settings (where providing care to patients with covid-19) be disinfected using a wiping method versus a spraying method?

    • Is ultraviolet germicidal irradiation effective as an environmental (surface) cleaning measure in healthcare settings?

    • Does the operating room with a covid-19 positive patient need to be terminally cleaned after each use?

    • Are there specific interventions that can improve the fit of a medical mask associated with decreased infection risk of SARS-CoV-2?

    • Is universal masking effective for preventing and controlling SARS-CoV-2 transmission in healthcare facilities?

    • Should gowns be worn as part of PPE use when caring for a covid-19 positive patient?

    • Are there any situations where respirators in the absence of the full airborne precautions are called for when caring for suspected or confirmed covid-19 patients?

    • In what situations are airborne precautions needed when caring for confirmed or suspected covid-19 patients?

    • Are the current indoor ventilation standards in healthcare settings effective in reducing the risk of SARS-CoV-2 transmission?

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    • Is equivalent ventilation provided by air cleaning/purifier technologies effective in healthcare settings?

    • Should a physical distance of 1 m be maintained to reduce and mitigate transmission of SARS-CoV-2?

    • Should physical barriers be used in healthcare and community settings to reduce and control SARS-CoV-2 transmission?

    • Does a designated single operating room need to be used for SARS-CoV-2 patients?

    • Should health and care workers be tested following a high risk exposure to SARS-CoV-2?

    • Should routine testing of asymptomatic health and care workers for covid-19 surveillance be conducted?

    RETURN TO TEXT

    Iterations

    Throughout the pandemic response (January 2020 to May 2023), WHO’s processes for developing guidance on IPC for covid-19 evolved. Initially, WHO developed emergency interim IPC guidance to provide advice on emerging issues and address the evolving scientific evidence. This emergency interim guidance was developed rapidly,5 following a guideline development process that differed from the standard WHO guideline development process.2 Beginning in December 2021, the standard WHO requirements for guideline development2 were followed and a comprehensive guideline was published, which consolidated and updated earlier emergency guidance. Since December 2021, seven versions of this consolidated guideline have been published.

    Highlights from the guideline

    Healthcare facilities (HCFs) pose a heightened risk for transmission and amplification of covid-19 outbreaks. A living literature review reported that the proportion of health and care workers worldwide infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ranged from 0.2% to 43.3%.67 Infectious health and care workers can also be a source of nosocomial SARS-CoV-2 transmission and outbreaks among vulnerable patients and other colleagues; similarly, infected patients were the source for transmission to other patients or health and care workers.8 Most SARS-CoV-2 infections acquired by patients and health and care workers; however, have been the result of community transmission rather than nosocomial spread.9 Therefore, public health and social measures are critical to reduce the overall caseload and contain outbreaks (fig 1).

    Fig 1

    Measures to mitigate SARS-CoV-2 transmission. From updated World Health Organization infection prevention and control guideline

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    The guideline is organised into two sections: one for HCFs and another for community settings. The healthcare section consists of 12 recommendations and 12 good practice statements. These statements cover topics ranging from basic principles of IPC to engineering and administrative controls to the use of PPE. The community section consists of seven recommendations and eight good practice statements covering topics such as mask use, care for people at home, and cleaning and disinfection in the home.

    Healthcare facilities

    To prevent transmission of SARS-CoV-2 within the HCF and to minimise spread in the broader community, IPC measures need to be consistently implemented. The covid-19 pandemic reinforced the importance of establishing WHO minimum requirements for IPC programmes.1011

    Integral to the WHO minimum requirements for the IPC programmes is the hierarchy of control measures, which is a framework used in IPC and occupational health to categorise mitigation measures that reduce the risk of disease acquisition (box 2).12 For IPC programmes, the most important categories include engineering controls (ie, reduce transmission risk through HCF design such as modifying ventilation systems or installing protective barriers); administrative controls (ie, reduce transmission risk in HCF through the implementation of policies and trainings—for example, visitor management, patient placements, and sick leave policies); and the appropriate selection and use of PPE.12

    Box 2

    1 Summary of WHO recommendations for healthcare facilities

    Background

    • WHO recommends adhering to the ventilation rate requirements for healthcare facilities in the context of covid-19: 160 L/s/patient for airborne precaution rooms; 60 L/s/patient for general wards and outpatient departments.(Strong recommendation for, very low certainty of evidence)*

    IPC measures for patients with suspected or confirmed covid-19

    • WHO suggests considering the use of physical barriers such as glass or plastic windows for areas where patients first present, such as screening and triage areas, the registration desk at the emergency department and the pharmacy window. (Conditional recommendation for, very low certainty of evidence)*

    • WHO recommends universal masking in healthcare facilities when there is a substantial impact of covid-19 on the health system. (Strong recommendation for, very low certainty of evidence)†

    • WHO suggests targeted continuous medical mask use in healthcare facilities in situations with minimum to moderate impact of covid-19on the health system. (Conditional recommendation for, very low certainty of evidence)†

    • A respirator or a medical mask should be worn along with other PPE—a gown, gloves, and eye protection—by health and care workers providing care to a patient with suspected or confirmed covid-19. (Strong recommendation for, low certainty of evidence)†

    • WHO suggests respirators be used in care settings where ventilation is known to be poor or cannot be assessed, or the ventilation system is not properly maintained. (Conditional recommendation, low certainty of evidence)†

    • A respirator should always be worn along with other PPE by health and care workers performing aerosol generating procedures (AGPs) and by health and care workers on duty in settings where AGPs are regularly performed on patients with suspected or confirmed covid-19, such as intensive care units (ICU), semi-intensive care units or emergency departments. (Strong recommendation for, very low certainty of evidence)†

    • WHO suggests using airborne precautionswhile performing AGPs and based on a risk assessment, when caring for patients with suspected or confirmed covid-19. (Conditional recommendation for, very low certainty of evidence)†

    Special settings

    • WHO suggests that the designation of a specific operatingtheatre for patients with suspected or confirmed covid-19 infectionis not needed. (Conditional recommendation against, very low certainty of evidence)

    Prevention, identification, and management of health and care workers

    • WHO suggests the use of rapid antigen testing to reduce the period of isolation (very low certainty of evidence). (Conditional recommendation for, very low certainty of evidence)*

    • WHOsuggests 10 days of isolation for individuals who are symptomatic due to SARS-CoV-2 infection (very low certainty of evidence). (Conditional recommendation for, very low certainty of evidence)*

    • WHOsuggests 5 days of isolation for individuals whoare asymptomatic with SARS-CoV-2 infection (very low certainty of evidence). (Conditional recommendation for, very low certainty of evidence)*

    • *IPC practitioner

    • †General population

    • See full guideline for implementation considerations across the full scope of the guideline including good practice statements, special settings, management of dead bodies, and water, sanitation, hygiene and waste management

    RETURN TO TEXT

    Prompt identification and recognition of covid-19 signs and symptoms and the immediate isolation of suspected or confirmed cases within HCFs are critical for preventing further transmission. Standard and transmission based precautions are applied based on a risk assessment when caring for patients with suspected or confirmed covid-19.1314

    While the guideline reaffirms the application of standard precautions including hand hygiene, environmental cleaning, handling of linens and laundry, waste management, and handling of the deceased,1314 it also highlights covid-19 specific considerations including targeted and universal use of medical masks, determined according to the level of community transmission. The guideline emphasises the importance of the appropriate selection and use of PPE, particularly during aerosol generating procedures. It also includes a section on prevention, identification, and management of health and care worker infections, to prevent onward transmission.

    Specialised settings that might require a tailored approach in the implementation of IPC measures are dealt with in the guideline, including home care settings, long term care facilities and other specific activities such as vaccination administration.

    Community settings

    This section of the guideline describes mitigation measures, the application of IPC principles, and operational and implementation considerations to reduce SARS-CoV-2 transmission in community settings (table 1).

    Table 1

    Summary of WHO recommendations and good practice statements to reduce SARS-CoV-2 transmission in community settings

    View this table:

    Recommendations on mask use include a strong recommendation for situations where there is an increased risk of exposure to SARS-CoV-2, such as in crowded, enclosed, or poorly ventilated spaces. The strong recommendation for mask use also recommends mask use for those at high risk of severe complications from covid-19, for people following a recent exposure to or those displaying signs or symptoms of covid-19, or those who test positive for covid-19 while sharing a space with others. In addition to the strong recommendation, there is also a conditional recommendation for situations where a risk based approach is more appropriate, which outlines factors to consider when choosing to wear a mask. These factors include the epidemiological trends of covid-19, local vaccination coverage, population immunity and the degree of crowding, quality of ventilation or the presence of individual risk factors, or both. Masks are not recommended for children less than 5 years of age or during vigorous intensity exercise. The guideline also advises against the use of gloves by the general public for routine activities, and provides public health guidance for cleaning, waste management, and laundry. As people with mild covid-19 often experience illness at home, the guideline also includes recommendations for measures that may reduce transmission among layperson caregivers and infected individuals when they are receiving supportive care at home.

    Research gaps

    The guideline development process identified important gaps in the evidence including cost and resource considerations, effects of IPC interventions on equity and other social and cultural factors, and the need for high quality studies (including well conducted randomised controlled trials) evaluating the effectiveness of IPC interventions for reducing SARS-CoV-2 transmission.151617

    IPC measures are often implemented as a package—for example, health and care workers wear PPE while maintaining a physical distance in a HCF with proper ventilation. This bundled approach poses difficulties when designing studies owing to the inappropriateness of decoupling these well established bundles to evaluate the effectiveness of individual measures. To help tackle these challenges, IPC research protocols, which include a multifactorial approach (eg, multi-arm and adaptative trial designs), should be pre-prepared as this would facilitate the timely implementation of studies at the onset of an outbreak of a novel or re-emerging pathogen.181920 Such readiness will help facilitate quick data collection methods and rapidly produce findings to inform best IPC practice. Furthermore, differences in the common understanding of microbial transmission terminology and dynamics complicated evidence synthesis and recommendation development. In response, WHO has recently published a report entitled “global technical report on proposed terminology for pathogens that transmits through the air.”21 However, further research is needed to understand the implications of this new terminology for preventive measures in clinical care settings.

    Preparedness, readiness, and response

    The covid-19 pandemic caused a high disease burden across healthcare settings, notably in fragile, conflict afflicted and vulnerable settings and among at-risk populations. It exposed the challenges facing HCFs globally and highlighted the need to strengthen IPC programmes, increase outbreak surge capacity, and reform services to improve care delivery.2223

    Strengthening IPCpreparednessandoperational readinessis critical for an effective outbreak response, averting healthcare associated infections and protecting health systems from becoming overwhelmed.202223 Well prepared HCFs experience lower morbidity and mortality rates, and more efficient resource allocation during response, resurgence, and recovery.2425 In addition to investing in the core components of IPC programmes1011 strengthening IPC health emergency capacity at the national and HCF levels reduces the risk of healthcare associated transmission and contributes to timely outbreak containment.202122 WHO emphasises the importance of applying lessons learnt from covid-19 at all levels—global, regional, national, and HCF—to enhance health systems and prepare for future pandemics.1819

    Guidelines into practice

    • Considering the recommendations, are there gaps or areas for improvement in your healthcare facility?

    • Are there factors to consider in the healthcare environment, to ensure effective implementation of IPC measures?

    How patients were involved in the creation of this article

    Patient experiences were captured by Guideline Development Group (GDG) members who have experience in caring for covid-19 patients. Additionally, the GDG encompassed two individuals who were civil society representatives.

    Further information on the guidance

    The full guideline including references can be accessed here: Infection prevention and control in the context of COVID-19: a guideline, 21 December 2023 (who.int) and on the MAGIC App platform. Details of the guideline development process are fully described in section 3 (methodology) of the guideline.

    Footnotes

    • Acknowledgments: WHO recognises the valuable contribution of the Guideline Development Group, WHO steering committee and Secretariat, as they all play an integral role in the development and updating of IPC recommendations for covid-19, offering a diverse range of perspectives to ensure comprehensive and effective guidance in the context of the pandemic.

    • WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Guideline Development Group: Yewanda Alimi(Africa Centres for Disease Control and Prevention, Ethiopia),Jameela Alsalman(Ministry of Health of Bahrain, Bahrain),Baba Aye(Public Services International, France—Civil Society Representative),May C Chu(Colorado School of Public Health, Center for Global Health, USA),John Conly(Cumming School of Medicine, University of Calgary, Canada),Barry David Cookson(Division of lnfection and lmmunity, University College London, UK),Nizam Damani(Sindh Institute of Urology and Transplant Centre, Karachi, Pakistan (Dow University of Health Sciences, Pakistan), Fernanda C Lessa(US Centers for Disease Control and Prevention, USA),Dale Fisher(Infectious Disease Division, Department of Medicine, National University Health System, Singapore),Tiouiri Benaissa Hanene(Ministry of Health of Tunisia, Tunisia),Kushlani Jayatilleke(Sri Jayewardenepura General Hospital, Nugegoda, Sri Lanka, Sri Lanka),Souha Kanj(American University of Beirut Medical Center, Lebanon),Daniele Lantagne(Tufts University, USA),Anna Levin(University of São Paulo, Hospital das Clinicas, FM-USP, Brazil),Yuguo Li(Department of Mechanical Engineering, The University of Hong Kong, Hong Kong Special Administrative Region (Hong Kong SAR)),Moi Lin Ling(Singapore General Hospital, SingHealth, Singapore),Caline Mattar(Division of Infectious Diseases, Washington University in St Louis, USA),Mary-Louise McLaws(Honorary Clinical Epidemiology—University of New South Wales, Australia),Geeta Mehta(Journal of Patient Safety and Infection Control, India),Shaheen Mehtar(Infection Control Africa Network, South Africa),Ziad Memish(Ministry of Health of Saudi Arabia, Kingdom of Saudi Arabia),Tochi Okwor(Nigeria Centre for Disease Control, Nigeria),Mauro Orsini(Ministry of Health of Chile, Chile),Diamantis Plachouras(European Centre for Disease Prevention and Control, Sweden),Mathias W Pletz(Institute for Infectious Diseases and Infection Control of the University Hospital of the Friedrich Schiller University, Germany),Marina Salvadori(Public Health Agency of Canada, Canada ),Ingrid Schoeman(TB Proof, South Africa—Civil Society Representative),Mitchell J. Schwaber(Israel Ministry of Health, Israel),Mark Sobsey(University of North Carolina and Aquagenx, LLC, United States of America),Paul Ananth Tambyah(National University of Singapore, Singapore),Walter Zingg(Clinic for Infectious Diseases and Hospital Epidemiology, Zurich University Hospital, Zurich, Switzerland).

    • Methodologist: Roger Chou (methodologist, Department of Medicine and Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, USA)

    • The joint WHO-UNICEF Guideline Development Group for Masks for children in the context of COVID-19 (for update on masks for children, 7 March 2022): Yewande Alimi (Africa CDC, Ethiopia), Jameela Alsalman (Ministry of Health, Bahrain), Shelina Bhamani (Aga Khan University, Pakistan), Katherine Holland (Perkins International, USA), Kushlani Jayatilleke (Sri Jayewardenepura General Hospital, Sri Lanka), Roberta Petrucci (Médecins Sans Frontières (MSF), Geneva, Switzerland), Mathias Pletz (Jena University Hospital/Friedrich-Schiller-University, The Netherlands), Fiona Russell (Department of Paediatrics, University of Melbourne, Australia), Marina Salvadori (Public Health Agency of Canada, Canada), Paul Anath Tambyah (National University Hospital, Singapore), Russell M. Viner (Faculty of Population Health Sciences, University College London and Royal College of Paediatrics and Child Health, UK), Heather Zar (School of Child and Adolescent Health at the University of Cape Town, South Africa).

    • WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Steering Group: Benedetta Allegranzi (WHO/HQ), Lisa Askie(WHO/HQ),April Baller (WHO/HQ), Anshu Banerjee(WHO/HQ), Adriana Velazquez Berumen(WHO/HQ),Astrid Lydia Chojnacki(WPRO),Landry Kabego Cihambanya(AFRO),Jennifer Collins(EURO),Giorgio Cometto(WHO/HQ),Janet Victoria Diaz(WHO/HQ), Kathleen Dunn (WHO/HQ), Sergey Eremin(WHO/HQ), Dennis Falzon(WHO/HQ),Luca Fontana(WHO/HQ),Nathan Ford (WHO/HQ), Melinda Frost(WHO/HQ),Bruce Allan Gordon(WHO/HQ), Hannah Hamilton Hurwitz (WHO/HQ), Iman Heweidy(EMRO),Maha Talaat Ismail(EMRO),Ivan Dimov Ivanov(WHO/HQ),Kathryn Johnston(PAHO),Ying Ling Lin(WHO/HQ),Tendai Makamure(AFRO),Madison Moon(WHO/HQ),Leandro Pecchia(WHO/HQ),Mark Perkins(WHO/HQ),Ana Paula Coutinho Rehse(EURO), Nahoko Shindo(WHO/HQ), Alice Simniceanu(WHO/HQ),Aparna Singh Shah (SEARO),Valeska Stempliuk(PAHO),João Paulo Toledo (WHO/HQ), Maria Van Kerkhove(WHO/HQ), Victoria Willet(WHO/HQ).

    • UNICEF Steering Committee members observers: Nagwa Hasanin(UNICEF),Raoul Kamadjeu(UNICEF),Pierre Yves Oger(UNICEF).

    • Funding: WHO gratefully acknowledges the financial support of Canada, Germany, France, Saudi Arabia, and the UStowards the development and publication of thismanuscript.

    • Contributors: All authors contributed to this paper including the conception and design of the work, critically drafting, and revising and have given final approval of the version to be published. KD and HH wrote the first and subsequent drafts, which all authors then reviewed and critiqued. All authors approved the final versions of this manuscript and agreed to be held accountable for the work. AB and BA were co-leads on behalf of WHO.

    • Competing interests: RC received funding from the Agency for Healthcare Research and Quality to conduct a review on masks. He also received funding from WHO to conduct a review on risk factors for transmission in HCWs, and consulting fees as the methodologist for the WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Guideline Development Group.

    • Provenance and peer review: commissioned; not externally peer reviewed.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License (https://creativecommons.org/licenses/by-nc/3.0/igo/), which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited.

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    Summary of WHO infection prevention and control guideline for covid-19: striving for evidence based practice in infection prevention and control (2024)
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    Introduction: My name is Ouida Strosin DO, I am a precious, combative, spotless, modern, spotless, beautiful, precious person who loves writing and wants to share my knowledge and understanding with you.