Dr Adrian Hyzler
Chief Medical Officer
The current COVID-19 pandemic 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.
As the total number of confirmed COVID-19 cases around the world continues to escalate, the focus of the spread of the virus has shifted to Europe and the United States. China is reporting no new community transmission in mainland China, with all new cases being imported into China.
Major outbreaks continue in Iran and in regions of South Korea and Italy, along with a number of European nations, most notably Spain where the situation is becoming more worrying. Many countries are now experiencing community spread and are beginning to scale back containment with the efforts now focused on strategies to delay the spread. The World Health Organisation (WHO) declared COVID-19 to be a ‘pandemic’ on 11th March and is urging all countries to take the global emergency seriously and act before it is too late. Dr Tedros Adhanom Ghebreyesus, the Director General of the WHO, said that this pandemic’ is a threat for every country in the world, rich and poor. He added that this coronavirus remains the only pandemic that can still be stopped, if the world unites to make the right political decisions.
The below travel recommendations are not in line with any specific government advice but are the result of data gathering over a wide variety of sources including, but not limited to, the WHO, CDC, UK government, Australian government, Chinese CDC and other scientific sources. The advice takes into account:
- The absolute number of confirmed cases as well as the proportion per population
- The rate of increase of case numbers
- The ratio of deaths to case numbers
- The evidence of community spread
- The messages coming out from the health authorities of individual countries
- Our assessment of the healthcare capabilities of that country in responding to the emergency.
Is it safe to travel?
- We advise against all travel to Band A countries / territories
- We advise against non-essential travel to Band B countries/territories
- We advise that adults over 60 or with pre-existing conditions (see below) should consider postponing non-essential travel to Band C countries / territories
- We advise that all travellers should consider postponing travel on cruise ships whether within Asia or the rest of the world. The population of a cruise ship is drawn from all nationalities and the likelihood of a case of COVID-19 on board is ever increasing.
NOTICE: Please be aware that a vast number of countries in all parts of the world have introduced strict border restrictions with some closing their borders completely, others have restricted arrivals only to their own citizens and residents, some insisting on 14 day mandatory quarantines for all travellers (including Australia, New Zealand, Israel and Singapore) and others poised to do the same. As a result international flights have been scaled down to an unprecedented level with up to 85% reduction in flights with major international airlines.
The knock-on effect is that there is a practical difficulty in keeping up with international requirements and responding with plans that allow business continuity while dealing with the uncertainty of repatriation of staff to their home countries.
Our advice is based on developments from a medical perspective in relation to the COVID-19 pandemic. We are not able to update the evolving changes in country/airline restrictions in this communication.
High risk countries / territories
- Hubei province (China)
- South Korean special care zone*
- San Marino
- Vatican City
- South Korea (excluding special care zone*)
- China (excluding Hubei province)
Europe & CIS
- NEW. Albania
- NEW. Bosnia
- Czech Republic
- Faroe Islands
- NEW. Herzegovina
- NEW. Lithuania
- NEW. Montenegro
- North Macedonia
- Republic of Ireland
- NEW. Romania
- NEW. Serbia
- The Netherlands
- NEW. Mauritius
- NEW. Réunion
- French Polynesia
- Hong Kong
- NEW. New Zealand
- NEW. Canada
- NEW. Chile
- NEW. Costa Rica
- NEW. Dominican Republic
- French Guiana
- NEW. Brunei
- NEW. Lebanon
- NEW. UAE
*South Korea special care zone:
- Daegu city
- Cheongdo county
- Gyeongsan city
Coronavirus guidance to returning travellers
The US government has updated the travel ban to include all travellers from the UK and the Republic of Ireland as well as the 26 Schengen countries. This ban will not apply to US citizens. The Schengen countries are as follows:
Austria, Belgium, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Slovakia, Slovenia, Spain, Sweden, and Switzerland.
The European countries that are not part of the Schengen zone, and whose citizens are therefore exempt from Trump’s ban are:
Albania, Andora, Armenia, Azerbaijan, Belarus, Bosnia & Herzegovina, Bulgaria, Croatia, Cyprus, Georgia, Kosovo, North Macedonia, Moldova, Monaco, Montenegro, Romania, Russia, San Marino, Serbia, Turkey, Ukraine, and Vatican City.
Note that the ban applies to where people are flying from, not an individual’s nationality, so a Russian citizen flying from a Schengen country will still be covered by the ban.
The WHO have classified the COVID-19 disease as a ‘pandemic’. In effect this will not change the approach of individual countries in how they attempt to stop transmission of the disease and care for the patients. They will still employ strategies to contain the disease but there will be implications regarding increased funding allocation to resource poor nations and Dr Tedros Ghebreyesus, Director General of the WHO, hopes that this may act as a wake-up call to world leaders who “do not appear to be taking COVID-19 seriously enough”.
The UK government response to this pandemic has four basic stages:
- Contain: detect early cases, follow up close contacts, and prevent the disease taking hold in the country for as long as is reasonably possible.
- Delay: the delay phase aims to slow the spread of infection in the country if it does take hold, lowering the peak impact and pushing it away from the winter season.
- Research: better understand the virus and the actions that will lessen its effect on the population; innovate responses including diagnostics, drugs and vaccines; use the evidence to inform the development of the most effective models of care.
- Mitigate: provide the best care possible for people who become ill, support hospitals to maintain essential services and ensure ongoing support for people ill in the community to minimise the overall impact of the disease on society, public services and on the economy.
The US Centres for Disease Control and Prevention (CDC) have raised the threat alert to Level 3 for most European countries including the UK and Republic of Ireland – China, South Korea, Iran and Italy are already on the list. These countries are experiencing ‘sustained, community spread’ of COVID-19. Large numbers of cases continue to be reported from specific regions which are the source of most cases in their respective countries. Cases elsewhere in the world have also been linked to these regions. A Level 2 alert is in place for Japan. Older adults (over 60 years of age) and those with chronic medical conditions (see risk groups below) should consider postponing non-essential travel to countries with evidence of sustained community spread of the virus. 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 national public health authority helpline and report their symptoms and travel history. The UK Foreign Office has amended its travel advice to reflect the same.
The UK PHE (Public Health England) continues to advise increased precautions to cover 13 countries/territories in South East Asia:
- South Korea
- Hong Kong
All over Europe countries are enforcing specific entry restrictions, travel bans and restrictions on gatherings and entertainment. These are changing on a daily basis and we would advise that before considering travel to any European country to check the individual government advice.
Returning travellers with no symptoms of COVID-19
Returning from countries / territories listed in Band A
Self-isolate for 14 days. See below advice for if you develop symptoms.
Returning from countries / territories listed in Band B
Self-isolate for 14 days. See below advice for if you develop symptoms.
Returning from countries / territories listed in Band C
Self-monitor for 14 days and self-isolate immediately and do not go to work if you develop even the most minor symptoms. Check with your company’s HR department to find out whether there is a requirement to work from home during this period. See below advice for if you develop symptoms.
Returning travellers with symptoms of COVID-19
If you become unwell within 14 days of returning from countries / territories in Bands A, B ,C
Self-isolate immediately and seek prompt medical advice if you develop symptoms by calling your national public health authority helpline, reporting on your recent travel history to let them know that you may have been exposed. In the UK for example you will call NHS 111.
- 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.
“At risk” group of COVID-19
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 the following pre-existing conditions:
- cardiovascular disease
- diabetes mellitus
- respiratory disease
- cerebrovascular disease
- Anyone who is immunosuppressed or who has reduced function of the spleen
- Pregnant women who may find it hard to access routine care in overstretched healthcare systems. There is currently no evidence that pregnant women are at greater risk specific to COVID-19 and no evidence of vertical transmission to the baby but research into this is not available.
- Anyone with 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 ten. 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.
Symptoms of COVID-19
The symptoms are very similar to those you would experience with the common cold or perhaps the ‘flu’ virus. The predominant symptoms are:
- Dry cough
- Difficulty breathing
- Shortness of breath
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 telephone the emergency services and request medical assistance.
Severe cases of COVID-19 can develop pneumonia, respiratory failure, sepsis and kidney failure. The case fatality rate of coronavirus infection is unclear at this time but current estimates put it between 2.5% and 3.4%. This is likely to come down as the numbers of mild and asymptomatic cases are added to the total once epidemiological data can be analysed.
There is no specific licenced treatment and no vaccine or cure available for the novel coronavirus.
Definition of a contact
A contact is a person who experienced any one of the following exposures during the 2 days before and the 14 days after the onset of symptoms of a probable or confirmed case:
1. Face-to-face contact with a probable or confirmed case within 1 meter and for more than 15 minutes;
2. Direct physical contact with a probable or confirmed case;
3. Direct care for a patient with probable or confirmed COVID-19 disease without using proper personal protective equipment OR
4. Other situations as indicated by local risk assessments.
Note: for confirmed asymptomatic cases, the period of contact is measured as the 2 days before through the 14 days after the date on which the sample was taken which led to confirmation.
When can I come out of self-isolation?
If you have been advised to self-isolate you can return to normal community activities when you meet the following conditions:
- If you were advised to self-isolate because you have respiratory symptoms and HAVE NOT had a COVID-19 test, you can leave home isolation when you meet ALL of the following conditions:
- You have not had a fever for at least 72 hours (three days) and you have not taken any medications such as paracetamol / acetaminophen / tylenol to reduce your temperature.
- Your other symptoms have improved, such as cough or shortness of breath. Note that a cough may persist for a few weeks but it will be less frequent and not get in the way of daily living.
- It is at least 7 days since your symptoms, such as fever or cough, FIRST started.
- If you were advised to self-isolate for 14 DAYS because you were a close contact of someone with respiratory symptoms OR a close contact of a confirmed case of COVID-19, you can leave home isolation when you meet the following condition:
- You have had no symptoms in the 14 day period. If you develop respiratory symptoms during this fourteen day self-isolation period please refer to the above and follow those directions.
- If you were advised to self-isolate because you HAD A COVID-19 test that was POSITIVE, you can leave home isolation when you meet ALL of the following conditions:
- You no longer have a fever, and you have not taken any medications such as paracetamol / acetaminophen / tylenol to reduce your temperature.
- You have had two NEGATIVE COVID-19 tests at least 24 hours apart. Note that in your country you may only be given a single COVID-19 test to determine your status.
These are suggested guidelines but you should always follow the advice of your healthcare provider.
Regarding when you can go back to work you should always refer to your company’s medical advisers or your HR department before returning to work after a period of self-isolation.
Coronavirus advice to travellers, employers and employees
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 (ABHR), 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 sanitiser 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 against COVID-19 in areas with sustained community transmission:
- 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 practise social distancing (maintain a distance of approximately six feet, if possible) whenever out in
- Avoid crowds, stores, crowded public transit, 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 areas with sustained community transmission:
- If you become unwell with symptoms of COVID-19 (fever, cough, difficulty breathing) you must immediately take precautions to isolate yourself from colleagues and family members.
- Healix clients should call Healix immediately if you feel unwell. We can advise whether or not you should work from home, self-isolate, present for COVID-19 testing or contact the emergency services. In some countries you will be directed to specialist government infection control hospitals. 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 ‘infection control hospitals’. Some health authorities (China, South Korea, UK) have initiated community swab teams to perform home testing and also ‘drive-through’ testing, in order to minimise contact with other symptomatic people.
- 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.
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 they think they 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 plans around the world, both business and leisure, to areas of high risk of transmission: Consider cancelling all travel to Band A countries / territories. Review all travel plans to the affected regions on a regular basis, making use of electronic remote conferencing facilities wherever possible.
Review all business travel to countries/territories with sustained community transmission for high risk groups: Employers should consider postponing business travel to countries / territories in Bands B and C 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 Band B. Employers with a risk adverse perspective should consider instituting a 14 day work from home period for all travellers returning from countries/territories in Bands B and C. 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.
Evacuate non-essential personnel from countries / territories in Bands A and B: Consider the controlled evacuation out of these countries / territories for all at-risk groups (see above), all dependants, and all non-essential staff back to their home countries, depending on individual circumstances. Consider the withdrawal of such personnel from Band C.
Remote working: Make provision, as far as practicable in the office based environment, for working from home and teleconferencing in order to minimise contact with business colleagues and to reduce using public transport and coming into contact with crowds of people. It may be advisable to run a working from home drill in order to highlight any logistical or IT problems prior to any enforced period of remote working We recognise that this advice applies only to employees who can work remotely and still complete their duties. There is a more challenging situation with supply and manufacturing sectors where it is not possible to work off-site and other measures need to be put in place to protect both the work-force and the business continuity.
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.
If you have been 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.
- 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 have been 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. 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.
If you have been advised to work from home…
- Do not come in to work or attend any external business meetings
- Do not meet with work colleagues, either in a business or leisure capacity, during this period of working remotely
- Keep in touch with your HR department and keep them informed of your health status
- Continue your normal everyday activities but take note of the national health advisories regarding self-monitoring
- Should you develop any symptoms of fever, cough or difficulty breathing, however mild, you should immediately self-isolate and contact your national public health authority helpline and also inform your HR department
- If you are tested for COVID-19, inform your HR department as soon as you receive the results of the testing.
The use of medical face masks against COVID-19
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 COVID-19 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 Centres 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.
- Ensure that mask fits securely over the bridge of the nose and chin, minimising gaps in the fit. People with facial hair that restricts a close fit between mask and face will not have the same level of protection/prevention.
- 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 70% 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.
Coronavirus case numbers, death rate and map of spread
To track the coronavirus outbreak, Johns Hopkins University have developed an online dashboard, bringing together data from several official bodies including the WHO and the Centres for Disease Control. The dashboard maps locations and reports on figures of confirmed and suspected cases, fatalities, and recoveries linked to COVID-19 in real-time.