COVID-19: latest advice to employers and travellers

COVID-19 advice to travellers and employers

Dr Adrian Hyzler
Chief Medical Officer

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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.

On 31st December, 2019, China reported a cluster of pneumonia cases of unknown cause that would later be identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was noted that the majority of these first 41 cases had attended a live seafood market in Wuhan in eastern China. The market, like many in the region, also traded illegally in a wide variety of live animals. Patients with the illness, called coronavirus disease 2019 (COVID-19), frequently present with fever, cough, and shortness of breath within 2 to 14 days after exposure.

By January 2020, the virus which revealed close relationships to coronaviruses such as SARS and MERS, had been isolated and sequenced. In recognition of the widespread global transmission of COVID-19, the World Health Organisation declared COVID-19 to be a pandemic on 11th March, 2020. As of 24th April, a total of 2.75 million people in 210 countries and territories were reported to be infected by SARS-CoV-2, a disease that had led to more than 190,000 deaths. Although the number of new cases has decreased drastically in China, it has rapidly increased in Europe and the United States, with the total number of deaths associated with COVID-19 in Italy, Spain, France, and the United States exceeding that in China. As Europe begins to ease lockdown measures and open up shops and schools, the epicentre has shifted to Central and South America- there are also a growing number of cases in the Arabian Gulf states. Trials are underway to discover effective treatments with no licensed drug at present, while vaccines trials are entering Phase 1, and moving towards Phase 2, human trials in record times. At great economic cost, many countries have adopted unprecedented measures to curb the spread of the virus, such as large-scale use of isolation and quarantine, closing borders, imposing limits on public gatherings, and implementing nationwide lockdowns.

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:

  • Fever
  • Dry cough
  • Difficulty breathing
  • Shortness of breath

As the pandemic has continued to unfold, new symptoms have emerged and the US Centres for Disease Control and Prevention (CDC) has now added six new symptoms for COVID-19 to their website. These additional symptoms will increase the criteria for testing:

  • Shivering
  • Chills
  • Muscle pain
  • Headache
  • Sore throat
  • New loss of smell or taste

Coronavirus pandemic advice in force in the UK since March has required self-isolation for anyone with a new continuous cough or fever. However, the advice has now been updated in guidance agreed by the UK’s four chief medical officers.

Public Health England (PHE) has added that all individuals who experience a key symptom of loss or change in your normal taste or smell (‘anosmia’) should self-isolate immediately- this is in addition to anyone who develops a new continuous cough, or fever. All members of their household must also self-isolate according to current guidelines, unless the individual with symptoms receives a negative test result [these are UK guidelines].

The updated advice follows evidence that anosmia may be a more accurate predictor of COVID-19 infection than fever. France, and 17 other countries, already recognise the loss of taste or smell as a significant symptom of COVID-19. Anosmia is recognised as a minor symptom by the US CDC and the WHO, but it is thought to be very rare for it to be the sole symptom

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 1.8% and 2.5%. 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. Though there are many trials into potential treatments there is no specific licenced treatment and no vaccine available for the novel coronavirus.

“At risk” group of COVID-19

Following analysis of data from countries around the world it is clear that certain groups of people are at greater risk of developing severe disease if they become infected with ‘Sars-CoV-2’ (the virus that causes COVID-19). This group includes those who are:

  • Aged 65 or older (regardless of medical conditions)
  • Resident in an institution such as a nursing home or long-term care facility
  • Aged under 65 with an underlying health condition listed:
  • Pregnant women (there is currently no data to support the view that pregnant women are at greater risk specific to COVID-19 infection and no evidence of vertical transmission to the baby in the womb. However, all pregnant women have a reduced immunity and are more at risk of infections, generally.)

The published mortality rate of people aged between 10 and 40 years old is 0.2% (compared with the currently estimated overall rate of all cases of 1.8-2.5%). Deaths in children under the age of ten have been exceedingly rare and have in most cases been associated with underlying conditions. 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.

We recommend that those who are at increased risk of severe illness from COVID-19 to be particularly stringent in following social distancing measures.

Definition of a contact

A contact is a person who experienced any one of the following exposures during the two 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 two metres / six feet 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 (PPE) OR
  4. Other situations as indicated by local risk assessments.

Note: for confirmed asymptomatic cases, the period of contact is measured as the two days before through the 14 days after the date on which the sample was taken which led to confirmation.

How long does the virus survive outside of the body?

Preliminary studies on the stability of SARS-CoV-2 virus in aerosols and on various surfaces have been published in the highly respected US medical publication “The New England Journal of Medicine”. The virus, though detectable on the surfaces, exhibited exponential decay resulting in loss of viability over time.

Time that SARS-CoV-2 was found to be viable on various materials:

Aerosol* – 3 hours
Copper – 4 hours
Cardboard, clothing – 24 hours
Plastic, stainless steel – 72 hours

*Aerosols are generated, almost exclusively, in hospital environments by equipment such as nebulisers, suctioning and ventilators. Aerosols are not thought to be responsible for significant transmission in everyday life.

The results indicate that aerosol and ‘fomite’ (surface) transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days. These findings are similar to those with SARS-CoV-1, in which these forms of transmission were associated with nosocomial (respiratory) spread and super-spreading events. More detailed testing is ongoing with results expected later in April.

Cleaning of surfaces to prevent fomite transmission can be accomplished with simple measures.

Cleaning and disinfection in non-healthcare settings

Cleaning of surfaces to reduce ‘fomite’ (surface) transmission is vitally important to reduce the risk of spread of the virus. Remember that ‘pre-symptomatic’ (48hrs before symptoms develop) and ‘asymptomatic’ (not showing any symptoms at all) carriers can deposit virus-containing droplets on surfaces just by talking and breathing, as well as coughing and sneezing, and depositing virus containing droplets onto surfaces.

Simply cleaning an area with normal household disinfectant after someone has left the vicinity will reduce the risk of passing any viral infection to others.

  • Disposable gloves and aprons should be worn for cleaning.
  • The surface should first be cleaned with warm soapy water.
  • Then it should be disinfected with normal cleaning products – use disposable cloths or paper roll and disposable mop heads, to clean all hard surfaces, floors, chairs, door handles and sanitary fittings.
  • If a risk assessment of the setting indicates that a higher level of virus may be present (for example, where unwell individuals have slept, such as their hotel room, or their desk and surroundings) then the need for additional PPE to protect the cleaner’s eyes, mouth and nose might be necessary. Avoid creating splashes and spray when cleaning.
  • Hands should be washed regularly with soap and water for 20 seconds, and after removing gloves, aprons and other protection used while cleaning.
  • These items of PPE and all cleaning items should be disposed of in double-bagged bin bags, stored securely for 72 hours* and then thrown away in the regular rubbish.

*The infection risk from COVID-19 following contamination of the environment decreases over time. It is not yet clear at what point there is no risk. However, studies of other viruses in the same family suggest that, in most circumstances, the risk is likely to be reduced significantly after 72 hours.

Specific products for cleaning and disinfection

Cleaning should be with a neutral detergent followed by suitable disinfectants as follows:

  • Sodium hypochlorite 0.1% concentration (dilution 1:50 of household bleach at an initial concentration of 5% is used)
  • Ethanol 70% concentration is also suitable for decontamination
  • Chlorine solution with a minimum concentration of 5000 ppm or 0.5%.

When other chemical products are used, the manufacturer’s recommendation should be followed and the products prepared and applied according to them. When using chemical products for cleaning, it is important to keep the facility ventilated (e.g. by opening the windows) in order to protect the health of cleaning personnel.

Laundry

Wash items in accordance with the manufacturer’s instructions. Machine washing with warm water at 60−90°C (140−190°F) with laundry detergent is recommended. The laundry can then be dried according to routine procedures.

Dirty laundry that has been in contact with an unwell person can be washed with other people’s items.

Do not shake dirty laundry, this minimises the possibility of dispersing virus through the air.

If a hot-water cycle cannot be used due to the characteristics of the tissues, specific chemicals should be added when washing the textiles (e.g. bleach or laundry products containing sodium hypochlorite, or decontamination products specifically developed for use on textiles). Finally, the laundry should be rinsed with clean water and the linens allowed to dry fully in sunlight.

Clean and disinfect anything used for transporting laundry with your usual products, in line with the cleaning guidance above.

Updated information on the use of face masks / ‘coverings’

There has been much conjecture recently regarding the use of ‘medical face masks’ in people without symptoms of COVID-19. The WHO, US Centers for Disease Control and Prevention (CDC), Public Health England (PHE) and the European CDC (ECDC) have remained united in their stance that there is no scientific evidence to advise that medical face masks (surgical masks, N95, FFP2/3) should be worn by any but the following groups of people:

  • People with COVID-19 or with symptoms of the disease
  • Healthcare workers treating confirmed or suspected cases of COVID-19
  • Carers of confirmed/suspected COVID-19 cases

However, there are growing calls for this guidance to be reviewed, with suggestions that the widespread use of face masks may have played a role in containing outbreaks in some Asian countries.

The WHO is currently considering the advice. This comes after new research suggests that coughs and sneezes may project particles much further into the air than previously thought – 6m / 18ft for a cough and up to 8m / 25ft for a sneeze. WHO stresses that it is critical that medical masks and respirators be prioritised for health care workers. The use of masks made of other materials (e.g. cotton fabric), also known as non-medical masks, in the community setting has not been well evaluated. There is no current evidence to make a recommendation for or against their use in this setting.

The WHO has also stated that there is a period of one to three days prior to `developing symptoms of COVID-19 when you are likely to be contagious. The CDC director, Dr Robert Redfield, has also suggested that around 25% of transmission is via people without any symptoms. Mathematical modelling predicts an even higher percentage of people falling into this group.

There has been a worldwide shortage of Personal Protective Equipment (PPE), primarily of masks, and one reason for the guidance has been that this finite and scarce commodity needs to be reserved for healthcare workers, first responders and other emergency services.

However, the direction towards people without symptoms wearing masks when they are out and among other people, for example while commuting or in an enclosed space, would be to prevent unknowing spread of the virus, rather than as a primary barrier protection against transmission. Thus, the advice would not be to wear a surgical type mask, because medical-grade protective gear is still in short supply and should remain the priority for healthcare settings. However, you should consider wearing a face covering such as a scarf or bandana or home-made cloth mask, in order to reduce the physical emission of droplets from your mouth or nose, and to help to protect others. Secure it carefully so that you don’t have to keep adjusting it, thereby touching the mask. The face covering should be handled carefully so as not to contaminate surfaces and should be washed at least every day at minimum 60C.

It should be remembered that, despite this suggestion, you should:

  • Continue to social distance
  • Only make essential journeys out of your house
  • Self-isolate if you have any respiratory symptoms
  • Continue to practice diligent hand hygiene
  • Do not feel that you are now ‘protected’ if you wear a face covering

There may be benefit in preventing potential transmission to others in donning a home-made ‘face covering’ when you need to go out for essential purposes, such as grocery shopping or to visit the pharmacy, and come into contact with other people. This may help to protect others if you are unknowingly infected.

The CDC has now revised its guidance to acknowledge that there is a benefit in people using face ‘coverings’ in public spaces where other social distancing is hard to maintain. They are not recommending surgical masks but rather, home-made mouth and nose coverings, such as bandannas and scarves, or indeed home-made cloth masks. The cloth face cover is meant to protect other people in case you are infected. They stress that you should NOT use a facemask meant for a healthcare worker.

Health Canada is advising the public, as well as healthcare professionals on important considerations for the use of homemade masks to protect against the transmission of COVID-19. Wearing a facial covering/non-medical mask in the community has not been proven to protect the person wearing it and is not a substitute for physical distancing and hand washing. However, it can be an additional measure you can take to protect others around you, even if you have no symptoms. It can be useful for short periods of time, when physical distancing is not possible in public settings such as when grocery shopping or using public transit.

The following countries have all mandated the wearing of face coverings in public places where social distancing cannot be safely accomplished, such as grocery stores, pharmacies and public transport (this is not an exclusive list):

  • Venezuela
  • Colombia
  • Cuba
  • El Salvador
  • Argentina
  • Jamaica
  • Honduras
  • Czech Republic
  • Slovakia
  • Bosnia and Herzegovina
  • Austria
  • Turkey
  • Poland
  • Germany
  • France
  • Luxembourg
  • United Arab Emirates
  • Israel
  • Bahrain
  • Qatar
  • Cameroon
  • Angola
  • Benin
  • Burkina Faso
  • Equatorial Guinea
  • Ethiopia
  • Gabon
  • Guinea
  • Kenya
  • Liberia
  • Rwanda
  • Sierra Leone
  • Uganda
  • Morocco
  • Zambia
  • Nigeria
  • Vietnam

In many other countries, such as the US and the UK, this practise is advised though not mandated.

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.

World Health Organisation review of Rapid Diagnostic Tests

The WHO scientific group has recently reviewed current testing options and has made recommendations based on the limited amount of research data. There are multiple diagnostic test manufacturers offering easy-to-use testing kits that do not require laboratory analysis. These tests either detect specific proteins from the SARS-CoV-2 virus in throat/nasal swabs (antigen tests) OR they detect the antibody response to the virus in blood samples (antibody tests).

The current gold standard test that is being used around the world is the lab-based ‘RT PCR’ test of throat/nasal swabs and takes approximately 4-6 hours in the lab, and a variable time from point of contact to reporting from around 1-5 days, dependent on logistical issues and lab capacity. The newer ‘Point-Of-Care’ (POC) tests that give results within a short time and require no laboratory input are called Rapid Diagnostic Tests (RDTs). However, these tests need to be validated for accuracy as inadequate tests may miss patients with infection or (false negatives) or falsely categorise people as having COVID-19 when they do not (false positives).

There are two separate RDTs being researched and marketed:

  1. Rapid diagnostic tests that depend on antigen detection: RDTs that extract a small sample of protein from the nasal/throat swab, amplify it in the lab and then bind to reagent on a paper strip generating a visually detectable signal within about 30 minutes. These are only effective when the virus is actively replicating therefore best for acute or early infection. They are dependent on the accuracy of the swab, the amount of virus present and the accuracy of the reagent. Based on comparable influenza tests, the sensitivity is expected to range from 34-80%. At present, based on current evidence, WHO recommends the use of these new point-of-care immunodiagnostic tests only in research settings. They should not be used in any other setting, including for clinical decision-making, until evidence supporting use for specific indications is available.
  2. Rapid diagnostic tests based on host antibody detection: The other POC test for COVID-19 detects the presence of the body’s antibodies produced as a result of the infection. They are produced over days and weeks and are typically detectable in the 2nd week after onset of symptoms, usually during the recovery phase of the illness. The actual antibody response in individuals is dependent on factors including age, nutritional status, medications, co-existing disease, etc. There can be weak, late or absent antibody responses. The antibody test may cross-react with other coronavirus antibodies giving false-positive results. These tests will be critical to support vaccine development and to understand the epidemiological effects of COVID-19 but have limited use in clinical diagnosis. Based on current data, WHO does not recommend the use of antibody-detecting rapid diagnostic tests for patient care but encourages the continuation of work to establish their usefulness in disease surveillance and epidemiologic research.

WHO continues to work with research groups and member states to develop understanding of such tests and individual governments will continue to evaluate the accuracy and efficacy of tests for use in the general population. Beaumont Health, in Michigan, has just rolled out a voluntary program with the aim of testing up to 38,000 employees and healthcare providers with antibody tests in order to assess the credibility of the test kits as well as the degree of protection that follows a positive test. This will be the largest antibody test to date.

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
    public.
  • 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.

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.

Additional guidance:

  • 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.

N.B. For band categorisation, see Appendix.

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.

N.B. Any of our 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.

Please be aware that a vast number of countries in all parts of the world have introduced strict border restrictions with many closing their borders completely, others have restricted arrivals only to their own citizens and residents, some insisting on 14 day mandatory quarantines for all incoming travellers . As a result international flights have been scaled down to an unprecedented level with up to 95% 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.

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.

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:
    • It is at least 7 days since your symptoms, such as fever or cough, FIRST started.
    • 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.
  • 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 are the carer of a small child it will be difficult or impossible to practice social distancing while the child is symptomatic, and therefore the period of 14 day self-isolation may have to start when the child recovers. 
  • 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. It is at least 7 days since the start of symptoms.
    • 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.

Basis of lockdown exit strategies

There are three common key elements that are the foundations for all lockdown exit strategies:

  1. The disease must be under control. This will pose a challenge for some, as it presupposes that national authorities have accurate and timely information on cases and deaths. Measures taken must be judged against their ability to keep the rate of transmission or ‘reproduction number’ (R0), below 1. In other words, each infected person should not infect more than one other.
  2. Countries must ensure that they have sufficient health system capacity, especially to provide intensive care, given the risk of a second wave of infections. Fortunately, there have been many examples of countries with spare capacity, such as Germany and China, offering care to patients from other countries that have been hit especially hard.
  3. There must be sufficient capacity for large scale testing and monitoring, linked to the ability to track and trace contacts of those infected. This too will be challenging for some and will necessitate bringing additional laboratories on board.

One of the important considerations of such a roadmap is that there must be similar measures across borders. There is no point having stringent protocols in place in one country or state and no restrictions at all just across the border. There needs to be communication and close collaboration in lockdown exit strategies between neighbouring countries / regions. Read more on lockdown exit strategies around the world here.

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.

Appendix – Country band categorisation

During this lockdown period we realise that travel recommendations are not currently proving useful to many of our clients. We continue to include Bands A, B and C (A being very severe, B is severe, C is moderate) in our communications to give an indication of country / regional risk rating and categorise using the following criteria:

  • Ongoing cases per capita
  • Deaths per capita
  • Health care capacity
  • Prevalence of testing

Band A

High risk countries / territories

  • Afghanistan
  • Bangladesh
  • Belarus
  • Brazil
  • Chile
  • India
  • Iran
  • Mexico
  • Pakistan
  • Peru
  • Russia
  • South Africa
  • USA – New York, New Jersey, Illinois
  • Yemen

Band B

  • Armenia
  • Argentina
  • Bolivia
  • Cameroon
  • Canada
  • Colombia
  • Djibouti
  • Dominican Republic
  • Egypt
  • El Salvador
  • Guatemala
  • Haiti
  • Honduras
  • Indonesia
  • Iraq
  • Kazakhstan
  • Kuwait
  • Nigeria
  • Oman
  • Poland
  • Panama
  • Qatar
  • Saudi Arabia
  • Singapore
  • Sudan
  • Sweden
  • Tajikistan
  • Turkey
  • UK
  • Ukraine
  • USA – Massachusetts, Texas, California, Virginia, Wisconsin, Alabama, Arkansas, N Carolina.
  • UAE

Band C

Europe & CIS

  • Azerbaijan
  • Belgium
  • Bulgaria
  • Czech Republic
  • France
  • Italy
  • Kazakhstan
  • Portugal
  • Republic of Ireland
  • Romania
  • Spain
  • Serbia
  • The Netherlands
  • Turkmenistan

MENA

  • Bahrain
  • Palestine

Asia Pacific

  • Malaysia
  • Philippines

Americas

  • Cayman Islands
  • Ecuador
  • Guatemala
  • Panama
  • USA – Excl. regions mentioned in A & B

Africa

  • Algeria
  • Democratic Republic of Congo
  • Gabon
  • Ghana
  • Mayotte
  • Morocco
  • Senegal

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