Coronavirus precautions for businesses and healthcare facilities

The 2019 Novel Coronavirus (2019-nCoV) was first discovered in Wuhan, China. The World Health Organization (WHO), which has officially named it COVID-19, declared this highly contagious virus a Public Health Epidemic of International Concern (PHEIC) on January 30, 2020¹. This virus raises concerns about a potential pandemic for global businesses and the healthcare industry.

What is COVID-19?

COVID-19 is an acute viral respiratory illness caused by a novel coronavirus. It appeared in Wuhan, Hubei Province, China, in December 2019. The highly contagious COVID-19 spreads from human to human even when the carrier shows no symptoms². According to the WHO, the number of cases of COVID-19 continues to rise steadily. Concerns about COVID-19 becoming a pandemic threat exist.

As the result of the PHEIC declaration by the WHO, many nations have taken steps to limit travel to and from China and international airlines have suspended service to China. Some countries have closed their borders to visitors who have traveled to China in the previous 14 days. Travelers should consult the Travel Health Notices from the Centers for Disease Control and Prevention (CDC) or the Government of Canada when planning a trip.

As with any emerging-disease outbreak, the information on COVID-19 is changing rapidly and current references should be monitored periodically for up-to-date information. A list of useful references is included at the end of this document.

Coronavirus overview
COVID-19 is a member of the coronavirus family. While some coronaviruses cause illnesses in humans, many others circulate among animals. These viruses may rarely evolve to infect humans and then spread, as seen with both Middle Eastern Respiratory Syndrome (MERS) and Sudden Acute Respiratory Syndrome (SARS)³. Reports of COVID-19 first appeared in December 2019 in Wuhan and diagnoses of the illness increased in subsequent weeks.

Wuhan serves as a major transportation hub for both domestic and international travel⁴. The timing of this outbreak is troublesome as it coincides with both the peak of seasonal influenza and the Lunar New Year period when many people travel across China and the globe.

In response to COVID-19, the CDC issued a “Level 3” travel warning for China⁵. With this warning, the CDC recommends avoiding all non-essential travel to China. Acting on the CDC’s information, the U.S. Department of State reiterated the “Level 3 – Avoid Non-Essential Travel” advisory for China and issued a “Level 4 – Do Not Travel” advisory for Wuhan and Hubei province⁶. Likewise, on January 31, 2020, Canada issued a “Level 3 – Avoid non-essential travel” warning for its citizens.⁷

Coronavirus symptoms

Typical symptoms of COVID-19 are fever, cough and shortness of breath, which may progress to pneumonia.⁸ The virus appears to more severely affect people with weakened immune systems, such as children, the elderly and those with chronic diseases such as diabetes, cancer and chronic lung disease.

The virus appears to have originated in an animal market where both raw meats and live animals were sold. Public health officials have confirmed that the disease has been spread from human to human. Another source of transmission is in the healthcare setting, where multiple healthcare personnel have been infected.⁹

Unlike most coronaviruses, COVID-19 may be spread even when the carrier shows no signs of illness.² As a result, isolation for 14 days (the apparent incubation period) after exposure is recommended. Exposure may be due to travel or close contact with someone known to have the virus.

With confirmation of person-to-person transmission (even when asymptomatic), COVID-19 is considered a “serious public health threat” but the risk to the individual is based on their exposure. Healthcare personnel caring for patients with this virus and others in close contact with those patients have increased risk of contracting the virus. For the general public, both the CDC¹⁰ and the Public Health Agency of Canada¹¹ consider the risk of this virus to be low at this time but continue to reevaluate that stance as information becomes available.

Coronavirus considerations for global businesses

To reduce employee exposure to COVID-19, companies should consider these prudent steps necessary to help protect their employees when traveling to affected areas, such as:

• Evaluate options to achieve business objectives using remote collaboration.
• Educate employees about the enhanced precautions suggested by the U.S. CDC.
• Purchase Travel Protection Services for the employee before the trip.
• If the trip is necessary, have the employee:
  • Consult their physician regarding appropriate vaccinations and health concerns before the trip. (NOTE: No vaccination or prophylactic drug therapy exists for COVID-19.)
  • Be prepared to participate in secondary screening in both Wuhan and upon their return.
  • Practice enhanced precautions before, during and after the trip (see box).
  • Avoid public transit or crowded areas wherever possible to prevent close contact with potentially ill people.
  • Work remotely for up to 14 days upon their return from China.
• Ensure cleaning staff use Environmental Protection Agency (EPA)-suggested disinfectants and cleaning methods when dealing with ill employees or visitors while on premises.

Coronavirus precautions for employees who travel

Employees who have traveled to any of the areas where outbreaks have occurred (particularly Wuhan or the Hubei province) should monitor themselves for symptoms for 14 days. If these employees develop symptoms, they should not come to work, seek medical attention immediately and use a surgical mask to minimize possible disease spread. It is recommended that they contact their healthcare provider prior to visiting the healthcare facility to report their recent travel and/or contact with others who have traveled to Wuhan or Hubei province. Healthcare personnel may need to enact special precautions to protect other patients and staff or may direct the traveler to a facility equipped to handle the virus.

If travelers begin to note symptoms or feel ill, they should seek medical care locally before returning home to help minimize the chances of disease spread. Travel protection services may assist in identifying appropriate medical providers and in providing other assistance to the traveler.

Coronavirus precautions for healthcare personnel and facilities

As this is a rapidly evolving public health issue, information about the scope of clinical illness associated with COVID-19 is limited. In addition, there is no vaccine or specific treatment for COVID-19 infection. Hence, care is supportive with symptom management.

Per guidance from the U.S. CDC, the clinical criteria for a COVID-19 patient under investigation (PUI) is based on what is known about previous coronavirus outbreaks (i.e., MERS-CoV and SARS-CoV). The CDC plans to update guidance as additional information becomes available¹². The CDC refers healthcare providers to the guidance for evaluating and reporting a PUI for COVID-19 to the criteria for MERS-CoV13.

Patient care guidelines

Clinical presentation among reported cases of COVID-19 infection varies in severity from asymptomatic infection or mild illness to severe or fatal illness. For patients presenting with fever and acute respiratory illness, healthcare providers, particularly in the emergency department, urgent care and primary care clinics, should obtain a detailed travel history and any known contact with a COVID-19 case to determine if both exposure and illness are present. 

Patients meeting the following criteria should be evaluated as a COVID-19 PUI if they present with fever and symptoms of lower respiratory illness (e.g., cough, shortness of breath) and the person has:^{8, 12}

• Had close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset, including healthcare personnel.
• A history of travel from Hubei province, China, within 14 days of symptom onset.
• A history of travel from mainland China within 14 days of symptom onset requires hospitalization.

Immediately notify infection control personnel at your facility and your local, state, provincial or territorial health department in the event of a PUI for COVID-19.

From an infection control standpoint, while there is still more to learn about the modes of transmission for COVID-19, we know that similar coronaviruses are spread from person to person by close contact (about 6 feet) and via respiratory droplets when an infected person coughs or sneezes.¹² Therefore, the CDC recommends a cautious approach to PUIs to minimize the chance for exposure. Measures should be implemented before patient arrival, upon arrival, and throughout the duration of the affected patient’s presence in the healthcare setting. ¹⁴ Rapid triage procedures to detect PUIs before or immediately upon arrival to the healthcare facility is critical. For example, various engineering controls may be employed to guide patients through the triage process, e.g., physical barriers or partitions, curtains, and appropriate air-handling systems. Healthcare facilities should implement strict procedures for respiratory hygiene and cough etiquette by placing a face mask over the patient’s nose and mouth, and isolate the PUI in an Airborne Infection Isolation Room (AIIR), if available.

Coronavirus precautions for medical staff

Staff should follow standard precautions, contact precautions, airborne precautions and use eye protection (e.g., goggles or a face shield). The use of a NIOSH-certified disposable N95 filtering facepiece respirator is recommended to ensure respiratory protection.¹⁵ Airborne precautions should be followed when performing aerosol-generating procedures, which have been associated with increased risk of transmission of SARS-CoV and MERS-CoV, including: tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy. Healthcare facilities should ensure staff training on how to properly put on, use, take off and dispose personal protective equipment (PPE) to prevent self-contamination. Procedures should be in place to manage ill or exposed healthcare personnel. A log should be maintained of all persons who care for or enter rooms and care areas of PUIs. The duration of precautions should be determined on a case-by-case basis in consultation with your local health department.¹⁵

Cleaning and disinfecting guidelines for healthcare facilities

Healthcare facilities should reinforce strict adherence to hand hygiene, respiratory hygiene and cough etiquette precautions among staff, visitors and patients. Face masks, hand hygiene products, tissues, and no-touch receptacles for disposal should be available at all points of entry to healthcare facilities, including waiting rooms and patient registration areas. Establish procedures for managing visitor access and movement within the facility for PUIs.¹⁵

Healthcare facilities should implement routine cleaning and disinfection procedures, as appropriate, for COVID-19 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed. Products with EPA-approved emerging viral pathogens claims are recommended for use against COVID-19.¹⁵

The CDC will continue to assist local and state health departments with the collection and storage of specimens, as well as provide diagnostic testing capability to qualified state and local public health labs to test for the virus nationally.¹⁶ Testing for other respiratory pathogens – e.g., influenza, respiratory syncytial virus (RSV) – should be conducted as clinically indicated.

The Public Health Agency of Canada (PHAC) is working with provinces, territories and international partners, including the World Health Organization, to actively monitor the situation. Canada's National Microbiology Laboratory has implemented testing to diagnose COVID-19 from clinical specimens. The laboratory is working collaboratively with Canadian provincial public health laboratories to ensure there is additional testing capacity in multiple jurisdictions.¹⁷

Coronavirus precautions for home care of patients

The CDC has developed interim guidance for the home care and isolation of patients who have been evaluated in an outpatient setting or patients who are discharged home following a hospitalization with confirmed or suspected COVID-19 infection, including patients under investigation.¹⁸ Home precautions should be conservative based on general recommendations for other coronaviruses, like MERS, and may last up to 14 days.¹⁸ In addition, there is interim guidance to help prevent the virus from spreading among people in their homes and in other residential communities.¹⁹ Key prevention steps may include: staying home in isolation except to get medical care; use of a separate bathroom, if possible; calling ahead before visiting their physician; wearing a face mask when around other people; following strict hand hygiene and cough etiquette; avoiding the sharing of personal household items; and monitoring their symptoms.¹⁹

Phishing risks due to coronavirus

There is concern that the healthcare industry may be at risk for malicious phishing campaigns linked to the COVID-19.²⁰ There are reports that phishing attacks have occurred through emails with attached Word documents offering supposed guidance on infection prevention, as well as PDF and MP4 file attachments.²⁰ Healthcare facilities should remind staff not to click on suspicious emails, links or attachments and to use a warning banner on emails originating outside the organization.

Conclusion

World health organizations are activating to prevent the spread of the coronavirus COVID-19. Companies need to take action to limit employee exposure to this potentially deadly virus. While limiting travel may hamper efforts to achieve business objectives, taking action to protect employees and prevent the spread of this illness supports risk management efforts. Likewise, healthcare facilities should be proactive by educating staff, applying universal precautions and taking steps to actively recognize and treat patients who show signs of COVID-19 infection.

As with any emerging disease outbreak, the information on COVID-19 is rapidly changing and current references should be monitored frequently for up-to-date information.

Visit our coronavirus resource hub for more information.

Krishna Lynch is Senior Healthcare Risk Engineering Consultant for the Healthcare Professional Liability practice group at Zurich North America.

Fred Myatt is Assistant Vice President - Casualty Technical Director for Zurich North America.

Clayton Shoup is Technical Director, Large Casualty - Risk Engineering for Zurich North America.

References
1. “International Health Relations (IHR) Emergency Committee for Pneumonia due to the Novel Coronavirus 2019-nCoV Transcript of a press briefing – 30 January 2020”. World Health Organization. 30 January 2020.
2. “Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany”. The New England Journal of Medicine. 4 February 2020.
3. “Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) in Wuhan, China.” Emergency Preparedness and Response, U.S. Centers for Disease Control and Prevention. 15 January 2020.
4. “Asia Taking No Chances with New China Virus as WHO Meeting Looms.” China News | Al Jazeera, Al Jazeera. 22 January 2020.
5. “Novel Coronavirus in China - Alert Warning - Level 3, Avoid Nonessential Travel.” U.S. Centers for Disease Control and Prevention. 5 February 2020.
6. “Novel Coronavirus in Hubei Province, China.” U.S. Department of State – Bureau of Consular Affairs. 5 February 2020.
7. “Novel Coronavirus in China.” Government of Canada Travel Health Notices. 31 January 2020.
8. “Epidemiological and Clinical Characteristics of 99 Cases of 2019 Novel Coronavirus Pneumonia in Wuhan, China: A Descriptive Study.” The Lancet. 30 January 2020.
9. Schnirring, Lisa. “New Coronavirus Infects Health Workers, Spreads to Korea.” CIDRAP (Centers for Infectious Disease Research and Policy). University of Minnesota. 20 January 2020.
10. “2019 Novel Coronavirus (2019-nCoV) Situation Summary.” 2019 Novel Coronavirus, Wuhan, China, U.S. Centers for Disease Control and Prevention. 7 February 2020.
11. “2019 Novel Coronavirus Infection (Wuhan, China): Outbreak Update.” Public Health Agency of Canada, Government of Canada. 21 January 2020.
12. “Criteria to Guide Evaluation of Persons Under Investigation (PUI) for 2019-nCoV.”  Centers for Disease Control and Prevention. 2 February 2020.
13. “MERS Interim Guidance for Healthcare Professionals.” Middle East Respiratory Syndrome Coronavirus (MERS). U.S. Centers for Disease Control and Prevention. 2 August 2019.
14. “Flowchart to Identify and Assess 2019 Novel Coronavirus.” Centers for Disease Control and Prevention. 1 February 2020.
15. ”Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Persons Under Investigation for 2019-nCoV in Healthcare Settings.” 3 February 2020.
16. “FDA Takes Significant Step in Coronavirus Response Efforts, Issues Emergency Use Authorization for the First 2019 Novel Coronavirus Diagnostic.” U.S. Food and Drug Administration. 4 February 2020.
17. “2019 Novel Coronavirus: Outbreak Update.” Government of Canada. 10 February 2020.
18. “Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for 2019 Novel Coronavirus (2019-nCoV).” Centers for Disease Control and Prevention. 31 January 2020.
19. “Interim Guidance for Persons Who May Have 2019 Novel Coronavirus (2019-nCoV) to Prevent Spread in Homes and Residential Communities.” Centers for Disease Control and Prevention. 1 February 2020.
20. American Hospital Association. “HHS Alerts Health Sector to Coronavirus-Related Phishing Campaigns.” 3 February 2020.