Coronavirus: latest advice to travellers and employers

Coronavirus in China

Dr Adrian Hyzler
Chief Medical Officer

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Recommendations for travel

The current COVID-19 (as the novel coronavirus has been officially named) epidemic is an evolving situation and our advice is under regular review based on emerging information about the number of cases and spread of the infection from person to person. We are advising highly precautionary measures to limit the potential spread of infection.

Within China the number of confirmed cases appears to have stabilised but the death rate continues on a steady trajectory; transport links remain suspended across much of the country and around half the population remain under some form of restrictions; diagnostic kits for COVID-19 remain in short supply; the Chinese government has appealed to other countries for personal protective equipment; most major commercial airlines have suspended flights in and out of China; governments have either withdrawn or are seeking authorisation to withdraw their staff; more and more countries have imposed entry restrictions on Chinese nationals and are restricting entry to foreign travellers who have been in mainland China in the previous 14 days. The WHO has declared this outbreak a Public Health Emergency of International Concern (PHEIC).

The Chinese government is now having to balance the very difficult task of getting workers back to the factories and children back to schools while still trying to control the spread of the virus. Further restrictions on movement are to be anticipated and are likely to be imposed without prior warning. China remains in a period of enforced lockdown.

For these reasons, and also taking account of the advice issued by the health authorities of the United Kingdom and the United States of America, our current recommendations on travel to China and the affected region are as follows:

  • We advise against all travel to Hubei Province
  • We advise against all travel to mainland China, Daegu and Cheongdo (South Korea)
  • NEW: We advise against non-essential travel to the rest of South Korea
  • REVISED: We advise that adults over the age of 60 and those with chronic medical conditions should consider postponing non-essential travel to Japan and Iran, and avoiding affected towns in the Lombardy and Veneto regions of northern Italy (see below).

Our advice to organisations with expatriate staff resident in China is to urgently withdraw individuals in the following categories

  • Non-essential staff
  • Dependants
  • Anyone in an “at risk group” (further details below)

Latest advice

The US Centres for Disease Control and Prevention (CDC) have raised the threat alert to Level 2 for Japan, Iran and Italy. these countries are experiencing ‘sustained, community spread’ of COVID-19. Older adults (over 60 years of age) and those with chronic medical conditions (see risk groups below) should consider postponing non-essential travel. Anyone returning home from these countries should be aware that if they feel sick with fever, cough or difficulty breathing within 14 days of their return should phone their doctor or emergency department and report their symptoms and travel history.

The UK Foreign Office has amended its travel advice for South Korea as cases of the new coronavirus, and the disease it causes,have increased. It advises against non-essential travel to the cities of Daegu and Cheongdo in the country, which have been declared “special care zones” by South Korean authorities.

The Italian government has imposed a lockdown of 11 small towns in the regions of Lombardy and Veneto in Northern Italy due to high case numbers:

  • Codogno
  • Castiglione d’Adda
  • Casalpusterlengo
  • Fombio
  • Maleo
  • Somaglia
  • Bertonico
  • Terranova dei Passerini
  • Castelgerundo
  • San Fiorano
  • Vo’ Euganeo

The UK PHE (Public Health England) continues to advise increased precautions to cover nine countries/territories:

  • China
  • Thailand
  • Japan
  • Republic of Korea
  • Hong Kong
  • Taiwan
  • Singapore
  • Malaysia
  • Macau

For anyone returning home from the nine south-east Asian countries/territories (excluding Hubei Province) listed above with no symptoms

We advise a 14 day period of self-monitoring. During this time you should watch out for any symptoms of fever, cough or sore throat, or generally feeling unwell and lethargic. If you experience any of these symptoms you should immediately self-isolate and telephone your healthcare provider or the emergency department immediately and seek their advice. If you have no symptoms within the 14 day period you are considered not to have COVID-19 and to be no risk to others.

For anyone returning home from the nine south-east Asian countries/territories (excluding Hubei Province) listed above or from northern Italy* with mild respiratory symptoms

We advise a 14 day period of self-isolation. Mild symptoms include mild fever, intermittent cough, sore throat or generally feeling unwell and lethargic. If during this period, you become more unwell, have a persistent high temperature, uncontrollable cough or if you develop breathing difficulties then you should telephone your healthcare provider or the emergency department immediately and seek their advice. Once the symptoms resolve you no longer need to be isolated but you should continue to self-monitor for the rest of the 14 day period since leaving mainland China.

For everyone returning home from Wuhan (Hubei Province), Iran, special care zones in South Korea (Gaegu and Cheongdo), and the lockeddown towns in northern Italywith or without respiratory symptoms

We advise a 14 day period of self-isolation. If during this period, you become more unwell or develop breathing difficulties then you should telephone your healthcare provider or the emergency department immediately. It is likely that you will need to be tested to exclude COVID-19. After this 14 day period you are considered not to have the coronavirus and to be no risk to others.

Who is an “at risk group”?

The Chinese Centre for Disease Control (CCDC) has released epidemiological data from the first 40 days of the outbreak until 11th February. This gives information on the first 72,314 cases of COVID-19 found in China. It highlights that certain groups of patients are at greater risk of developing severe disease if they become infected with ‘Sars-CoV-2’ (the virus that causes COVID-19). Accordingly, we have reviewed the high risk groups as follows:

  • Those with cardiovascular disease, diabetes mellitus, respiratory disease, hypertension, cancer and cerebrovascular disease.
  • Anyone who is immunosuppressed or who has reduced function of the spleen
  • Pregnant women
  • Significant obesity (body mass index ≥40)
  • Persons over 60 years of age. **Note that children have been removed from the list.

**The published mortality rates of people aged between 10 and 40 years old are 1 in 500 (compared with the currently estimated overall rate of all cases of 1 in 38). There have been no deaths recorded in children under the age of nine. It should be carefully noted that children will generally find it more difficult to comply with hygienic practices and are also more prone to developing other ‘flu-like’ illnesses that masquerade as COVID-19 and cause increased anxiety for all concerned.

What are the symptoms of novel coronavirus?

The symptoms are very similar to those you would experience with the common cold or perhaps the ‘flu’ virus. They include:

  • Fever
  • Dry cough
  • Sore throat
  • Lethargy

Some patients will go on to develop more severe symptoms and may require hospitalisation. The first sign of severe illness is usually difficulty in breathing but any patient who feels very unwell should seek medical help.

Severe cases of COVID-19 can develop pneumonia, respiratory failure, sepsis and kidney failure. The mortality rate of coronavirus infection is unclear at this time but current estimates put it at around 2.5%.

There is no vaccine available for the novel coronavirus.

*Northern Italy is defined by a line above, and not including, Pisa, Florence and Rimini, or the specific lockdown towns above.

Our advice

General precautions against COVID-19 wherever you are:

  • Wash your hands regularly with soap and water (for at least 20 seconds) or with an alcohol-based hand rub, especially after coughing and sneezing and before handling and consuming food.
  • When coughing and sneezing, use disposable tissues and dispose of them carefully and promptly – if you have no tissues immediately to hand use the inner elbow of your clothing – avoid using your hands to cover your mouth.
  • Consider carrying an alcohol-based hand sanitizer with you.
  • Avoid touching your face, in particular mouth, eyes and nose.
  • Avoid shaking hands with people – instead simply greet people with hands by your side or use a novel approach such as an elbow-to-elbow.
  • Clean and disinfect frequently touched objects and surfaces, not forgetting that the virus can settle on your cellphone.

Additional precautions within China, Thailand, Japan, South Korea, Hong Kong, Taiwan, Singapore, Malaysia, Macau, Iran, northern Italian towns on lockdown (see above):

  • Avoid close contact with people who appear unwell or who are coughing or sneezing, and avoid sharing personal items.
  • Minimise going out into the general population and use social distancing (maintain a distance of approximately six feet, if possible) whenever out in public.
  • Avoid crowds, stores, crowded public transport, sporting or mass entertainment events, and other situations likely to attract large numbers of people.
  • Take your temperature with a thermometer twice a day and watch for cough or difficulty breathing. Fever means feeling hot/sweaty or having a measured temperature of 100.4F / 38C or higher.
  • Stay home wherever possible.
  • Thoroughly cook all meat and eggs before consuming.
  • Avoid unprotected contact with wild or domestic farm animals (alive or dead).

If you become unwell in China, Thailand, Japan, South Korea, Hong Kong, Taiwan, Singapore, Malaysia, Macau, Iran or northern Italian towns on lockdown (see above):

  • If you become unwell with symptoms of COVID-19 (fever, cough, sore throat) you must immediately take precautions to isolate yourself from colleagues and family members.
  • If you are a Healix client, call Healix immediately if you feel unwell.
  • All patients with these symptoms who seek medical care in China will be directed to their local government-designated ‘fever centre’ for assessment. However, a number of private hospitals have been designated as pre-hospital screening centres and are able to perform testing for COVID-19 – all positive cases will, nevertheless, be referred to government appointed ‘fever hospitals’.
  • Healix advises that individuals with mild symptoms manage their illness at home, ensuring that they take steps to isolate themselves from family members (see below).
  • All patients with severe symptoms (including shortness of breath) must seek medical care immediately at a designated hospital, remembering that they should always telephone ahead to advise of their symptoms and any relevant travel history.

If you become unwell within 14 days of returning from China, Thailand, Japan, South Korea, Hong Kong, Taiwan, Singapore, Malaysia, Macau, northern Italy (defined above) or if you suspect that you came into contact with a confirmed case of COVID-19 in the affected regions of northern Italy or Iran:

  • Seek prompt medical advice if you develop symptoms – always call ahead to alert the medical facility, warning them about your recent travel and that you may have been exposed.
  • Try to limit contact with others if you become unwell after travel until you have been assessed by a health professional.
  • Wash your hands regularly with soap and water (for at least 20 seconds) or with an alcohol-based hand rub, especially after coughing and sneezing and before handling and consuming food.
  • When coughing and sneezing, use disposable tissues and dispose of them carefully and promptly – if you have no tissues use the inner elbow of your clothing – do not use your hands to cover your mouth.
  • Wearing a surgical face mask consistently may help to prevent spread to others- it should be removed and carefully disposed of when it becomes wet or dirty and immediately replaced – caution should be taken not to touch your mouth or face under the mask, as this will potentially transmit virus.

If you’ve advised to ‘self-isolate’ at home with your family:

  • Remain in one room as much as possible.
  • No one else should enter this room unless absolutely necessary.
  • Just one person (the same person every time) should enter the room when required. This will usually be a spouse/partner.
  • If more than one bathroom is available, assign one for the use of the isolated person. Otherwise ensure that the bathroom is well-ventilated and that surfaces are cleaned daily with regular household disinfectant.
  • Those entering the room should wear a facemask. After leaving the room, dispose of the mask carefully and wash hands thoroughly.
  • Family members should wash hands thoroughly after using any shared areas (e.g. the bathroom) or use alcohol-based hand sanitiser (minimum 60% alcohol.
  • Use paper towels to dry hands after washing and dispose of them carefully.
  • There should be a ready supply of tissues for the isolated individual to use for coughs and sneezes. These must be disposed of in a sealed bag or by flushing down the lavatory.
  • Used bedclothes, pyjamas etc. should be washed at 60ºC or more. They should stay in the isolation room until ready to go straight into the washing machine. Hands must be washed with soap and water or with an alcohol-based sanitiser (minimum 60% alcohol) after handling soiled clothes.

If you’ve advised to ‘self-isolate’ in a hotel room:

  • Remain in your hotel room with the ‘Do Not Disturb’ sign on your door.
  • You should wear a medical face mask (if available) consistently, adhering to mask management protocol.
  • Just one nominated person (the same person every time) should enter the room when required. This person should remain at a distance of at least one meter from you and avoid touching any surfaces.
  • Anyone entering the room should wear a facemask (if available). After leaving the room, the mask should be disposed of carefully into a sealed plastic bag and hands washed thoroughly with soap and water or an alcohol-based hand sanitiser (minimum 60% alcohol).
  • The nominated person will need to bring:
    • Food on disposable plates and plastic utensils, that are then disposed of in a sealed plastic bag
    • Medication if required to reduce temperature such as paracetamol
    • A digital thermometer
    • Supplies of disposable tissues
    • Alcohol-based hand sanitisers (minimum 60% alcohol)
    • Multiple bin bags for disposal of waste products
    • A supply of disposable plates, cups and utensils
    • Bottled water (if appropriate).
  • No-one else should use the bathroom facilities.
  • Temperature should be taken and recorded every 12 hours.
  • Hands must be washed regularly with soap and water primarily, or with an alcohol-based hand sanitiser (minimum 60% alcohol) using paper towels to dry hands after washing and disposing of them carefully.
  • Obtain a ready supply of tissues to use for coughs and sneezes. These must be disposed of in a sealed bag or by flushing down the lavatory. Hands should then be washed thoroughly with soap and water or an alcohol-based hand sanitiser (minimum 60% alcohol).
  • Used bedclothes, pyjamas etc. should stay in the hotel room and placed carefully into sealed plastic bags. Hands must be washed with soap and water or with an alcohol-based hand sanitiser (minimum 60% alcohol) after handling soiled clothes.

Provide clear information

Make sure that all individuals have clear, consistent and regularly updated guidance on: how to recognise symptoms in themselves and others; what precautions to take to prevent exposure; and who to contact if you think you may have symptoms. All employees should be informed that if they develop symptoms of fever/cough/sore throat, they should inform a manager and their healthcare provider immediately, but they should not come into the office.

Cancel all travel to China

Consider cancelling all travel to mainland China. Review all travel plans to the affected region on a regular basis, making use of electronic remote conferencing facilities wherever possible.

Review business travel to and from South East Asia

Employers should consider postponing business travel to Japan and Iran for employees aged over 60 years of age and those with chronic health conditions (see high risk group above) and to cancel all non-essential business travel to South Korea.

Air New Zealand has cancelled flights between Auckland and Seoul and other airlines are likely to follow suit.

Employers with a risk averse perspective should consider instituting a 14 day work from home period for all travellers returning from Thailand*, Japan*, South Korea*, Hong Kong*, Taiwan*, Singapore*, Malaysia* or Macau*, the northern Italian towns on lockdown* and Iran*. This is to avoid the possibility of workplace disruption in the event of a returning traveller developing flu-like symptoms at work

*PLEASE NOTE: different corporations have adopted personalised management strategies. Please follow your employer’s guidance should it differ from the current Healix recommendations. Travellers are advised to liaise with their Human Resources and / or travel risk departments to familiarise themselves with any travel restrictions or business continuity contingencies implemented in response to the virus outbreak.

The UK PHE (Public Health England) extended its advice to cover nine countries/territories. Consequently, we have extended our recommendations for China (excluding Hubei province) to also cover:

  • Thailand
  • Japan
  • South Korea
  • Hong Kong
  • Taiwan
  • Singapore
  • Malaysia
  • Macau

Evacuate non-essential personnel from China

Consider the controlled evacuation out of China for all at-risk groups (see above), all dependants, and all non-essential staff back to their home countries, depending on individual circumstances.

Remote working

Make provision, as far as practicable, for essential travellers and employees within China, and neighbouring countries with confirmed cases, to work from home in order to reduce using public transport and coming into contact with crowds of people.

  • NEW: South Korea – consider working from home for employees. Seoul has raised the virus alert to “red” its highest level in the four-tier system – the first time it has been elevated to red in more than a decade. Given the recent explosion in numbers over the weekend, travel restrictions are likely to be imposed.
  • NEW: Japan – consider working from home for employees. There are currently no travel restrictions at present.
  • NEW: Iran – consider working from home for employees. Iran has had an explosion of declared cases and deaths over the last few days and it is highly likely that there are many, many more cases that have not been declared. Given these circumstances, sudden travel restrictions are likely to be imposed without warning within Iran. Commercial airlines are likely to cancel flights in and out of Iran.

Wash stations and alcohol-based hand sanitiser (minimum 60% alcohol) dispensers

Employers should consider whether it is appropriate to the specific location of their workplace to install alcohol-based hand sanitisers (minimum 60% alcohol) at key locations such as lift areas, food areas and near exit and entry points. Clear signage should accompany these stations to give information about the benefits of sensible use. Office sanitation measures should also be reviewed to reflect local risk. A member of the Chinese CNHC Experts Group said that their research had shown that the novel coronavirus can survive on smooth surfaces for several hours – if the temperature and humidity are appropriate, it can survive for several days. The virus can contaminate the surface of contacted objects, such as elevator buttons, door handles, work surfaces, desk spaces, computer keyboards and mice, but will not drift significantly in the air. The WHO is advising that people receiving packages are not at risk of contracting the new coronavirus. From experience with other coronaviruses, we know that these types of viruses don’t survive long on objects, such as letters or packages.

Review vaccination policy

Advise employees of the benefits of the ‘seasonal flu vaccine’ to help prevent infection with ‘flu’ that may be confused with the new coronavirus* – as well as helping to protect them from the flu virus that kills half a million people annually.

*Caution should be taken not to confuse employees with this notice – the ‘seasonal influenza’ vaccine will not prevent Wuhan Coronavirus – we suggest that this should be advised in a separate notification when the timing is appropriate.

The use of medical face masks

Simple medical face masks are omnipresent in South East Asia but never more so than during this current outbreak. There has been such a clamour for everyone to don a face mask that China’s production of 20 million masks a day is inadequate to meet this demand and the Chinese authorities have appealed to external governments for support.

With the current information available, it is suggested that the route of human-to-human transmission of the novel coronavirus is either via respiratory droplets or direct contact with respiratory secretions. Any person who is in close contact (within three feet / one metre) with someone who has respiratory symptoms such as sneezing or coughing, is at risk of being exposed to potentially infective respiratory droplets.

Wearing a disposable medical face mask is recommended for the hospital setting and for suspected or confirmed cases of coronavirus, and also to carers of people with symptoms suggestive of the virus.

The US Centers for Disease Control and Prevention (CDC) and the WHO are in agreement that it is not medically advised for people without symptoms to wear masks, unless dictated by the local authorities.

Masks may be culturally appropriate and, in a population where the vast majority of people are wearing face masks, it may be out of place not to wear one – in fact, it may be viewed by others as ‘irresponsible’, thus introducing a social pressure to wear a mask. Moreover, if a person chooses to wear a mask, it is important to be clear that the use of a mask alone is insufficient to provide the adequate level of protection and other equally relevant measures should be adopted. If masks are to be used, this measure must be combined with hand hygiene and other infection control measures to prevent human-to-human transmission of 2019-nCov.

Wearing medical masks when not indicated may cause unnecessary cost, wastage of precious resources and create a false sense of security that can lead to neglecting other essential measures such as hand hygiene practices.

In the community, outside China, we recommend the following face mask advice…

People with NO respiratory symptoms

A medical mask is not required, as no evidence is available on its usefulness to protect non-sick persons. However, masks might be worn in some countries according to local cultural habits. If masks are used, best practices should be followed on how to wear, remove, and dispose of them and on hand hygiene after removal. Follow the below advice regarding appropriate mask management. If the majority of people in a location choose to wear a face mask, the few people not wearing masks may be seen as ‘irresponsible’ because of the perception that they are helping to spread infection.

People with respiratory symptoms or carers of people with symptoms

Wear a medical mask at all times and seek medical care if experiencing fever, cough and difficulty breathing, as soon as possible or in accordance with local protocols. Follow the below advice regarding appropriate mask management.

Mask Management

  • Ensure that mask fits securely over the bridge of the nose and chin, minimising gaps in the fit.
  • Avoid touching the mask.
  • Wear the mask consistently throughout the day.
  • Remove mask using the straps – do not touch the front.
  • Always wash hands with soap and water or with an alcohol-based hand sanitiser (minimum 60% alcohol) after removing the mask.
  • Replace the mask with a new, clean dry mask as soon as it becomes damp/humid.
  • Do not re-use masks.
  • Dispose of used masks immediately into a sealed bag.
  • Remember that use of a mask is only one part of personal protection – not touching your mouth, nose and eyes and regularly washing your hands are strongly recommended.
  • Cotton/gauze masks are not recommended under any circumstances.

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