Emerging respiratory viruses, including COVID-19

Emerging respiratory viruses:

Module A:
virus and transmission
 Learning objective

By the end of this unit,

participants will be able
to describe:
§ How viruses emerge
§ What coronaviruses are
§ Who is most at risk from
coronaviruses
§ How to protect yourself

©WHO2020 4
 Timeline of emerging viruses

§ Viruses continue to emerge

and pose challenges to
public health
§ Some examples of emerging
respiratory viruses include:
• 2002: Severe Acute Respiratory
Syndrome coronavirus
(SARS-CoV)
• 2009: H1N1 influenza
• 2012: Middle East Respiratory
Syndrome coronavirus
(MERS-CoV)
• 2019: Novel coronavirus
(COVID-19)
©WHO2020 5
 How do new viruses emerge?

§ Human health, animal health and the state of

ecosystems are inextricably linked
§ 70–80% of emerging and re-emerging infectious
diseases are known to be of zoonotic origin,*
meaning they can be transmitted between Avian influenza
animals and humans
§ Population growth, climate change, increasing
urbanization, and international travel and
migration all increase the risk for emergence
and spread of respiratory pathogens MERS-CoV

*Jones et al (2008) Nature

©WHO2020 6
 What is a coronavirus?

§ Coronaviruses are a large family of viruses

that are known to cause illness ranging
from the common cold to more severe
diseases such as Middle East Respiratory
Syndrome (MERS) and Severe Acute
Respiratory Syndrome (SARS)
§ A novel, or new, coronavirus is
called nCoV

©WHO2020 7
 Where do coronaviruses come from?

§ Coronaviruses also cause disease in a wide

variety of animal species
§ SARS-CoV was transmitted from civet cats
to humans in China in 2002 and MERS-CoV
from dromedary camels to humans in
Saudi Arabia in 2012
§ Several known coronaviruses are circulating
in animals that have not yet infected humans
§ A spillover event is when a virus that is
circulating in an animal species is found
to have been transmitted to human(s)

©WHO2020 8
 People at risk for infection from nCoV

§ People in close contact with § Family members or health

animals (e.g. live animal care workers who are
market workers) caring for a person infected
by a new coronavirus
©WHO2020 9
 How can I protect myself from infection?

§ Wash your hands with soap and water or

alcohol-based hand rub
§ Cover your mouth and nose with a medical mask,
tissue, or a sleeve or flexed elbow when
coughing or sneezing
§ Avoid unprotected close contact with anyone
developing cold or flu-like symptoms and seek
medical care if you have a fever, cough and
difficulty breathing
§ When visiting live markets, avoid direct
unprotected contact with live animals and
surfaces in contact with animals
§ Cook your food and especially meat thoroughly
©WHO2020 10
 Resources

Contact:
Dr Maria Van Kerkhove vankerkhovem@who.int

Further reading:
Coronaviruses
https://www.who.int/emergencies/diseases/novel-coronavirus-2019
Disease outbreak news
https://www.who.int/csr/don/en/

©WHO2020 11
 Enhanced surveillance and outbreak investigations
Module B:
for emerging respiratory pathogens
 Learning objective

By the end of this unit, participants will

be able to describe:
§ Enhanced surveillance
§ How to conduct outbreak
investigations in different settings

©WHO2020 2
 After a case of an emerging
respiratory virus has been confirmed

Several actions need to happen concurrently

to find additional cases and to prevent
further spread, including:
§ Actively find cases
§ Thorough case and outbreak
investigations
§ Conduct enhanced surveillance

©WHO2020 3
 Active case finding

Active case finding involves a wider search,

focusing on:
§ Patients and their visitors in health care
facilities where the confirmed patient
sought treatment
§ Health care providers who cared for or
cleaned the room of an infected patient
§ Social, familial and work contacts of the
infected patient

©WHO2020 4
 Contact tracing

What is 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;
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.

See WHO’s latest guidance on contact definitions here: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/surveillance-and-case-definitions

©WHO2020 5
Contact tracing

Identify contacts of the infected patient and

record:
§ Names, contact, demographic information
§ Date of first and last exposure or date of contact
with the confirmed or probable case, and
§ Date of onset when fever or respiratory
symptoms develop
The common exposures and type of contact with
confirmed or suspected cases should be
thoroughly documented for any contacts that
become infected
©WHO2020 6
 How does contact tracing for COVID-19 work?

No symptoms

Monitoring can stop

after 14 days2
Case is identified Monitor for
Identify
in the community* 14 days
contacts1 from time of last
exposure to case

Isolate, test and

Symptoms treat for COVID-19

Positive, or
1st negative test

Any symptoms
*Most respiratory diseases have an incubation
period of 14 days or less, but the incubation period
for a new virus would need to be determined so that
the length of follow up can be decided accordingly.
1
Considerations for quarantine of individuals in the context of
containment for coronavirus disease (COVID-19):
https://www.who.int/publications-detail/considerations-for-
If positive, Monitor for 2 negative tests >24
identify their 14 days
quarantine-of-individuals-in-the-context-of-containment-for-
hours apart coronavirus-disease-(covid-19)
contacts 2
If feasible, respiratory samples from quarantined persons,
irrespective of whether they develop symptoms, should be sent
for laboratory testing at the end of the quarantine period. To be
released from isolation, confirmed cases must test negative using
PCR testing twice from samples collected at least 24 hours apart.
Repeat contact tracing Where testing is not possible (including for probable cases on
which no initial testing was done), WHO recommends that
cycle until no new cases patients remain isolated for an additional two weeks after
Monitoring symptoms resolve. For asymptomatic confirmed cases, WHO
can stop recommends they remain isolated for 14 days after the sample
was taken which led to the confirmation of COVID-19 infection

©WHO2020 7
 How does contact tracing for COVID-19 work?
No symptoms

Monitoring can stop

after 14 days2

Test HCW contacts regardless

of the development of
symptoms
Monitor for If positive, isolate and
14 days provide care until 2
Identify from time of last consecutive negative
Contacts1 exposure to case
tests

Case in hospital
Isolate, test and
Symptoms treat for COVID-19

If positive, Monitor for
Any symptoms Identify their 14 days
contacts
*Most respiratory diseases have an incubation
Repeat contact tracing
period of 14 days or less, but the incubation period
cycle until no new cases
for a new virus would need to be determined so that
the length of follow up can be decided accordingly.
Positive, or
1st negative test
1
Considerations for quarantine of individuals in the context of
containment for coronavirus disease (COVID-19):
https://www.who.int/publications-detail/considerations-for-
quarantine-of-individuals-in-the-context-of-containment-for-
2 negative tests >24 coronavirus-disease-(covid-19)
2
If feasible, respiratory samples from quarantined persons,
hours apart
irrespective of whether they develop symptoms, should be sent
for laboratory testing at the end of the quarantine period. To be
released from isolation, confirmed cases must test negative using
PCR testing twice from samples collected at least 24 hours apart.
Where testing is not possible (including for probable cases on
which no initial testing was done), WHO recommends that
patients remain isolated for an additional two weeks after
Monitoring symptoms resolve. For asymptomatic confirmed cases, WHO
can stop recommends they remain isolated for 14 days after the sample
was taken which led to the confirmation of COVID-19 infection

©WHO2020 8
 Outbreak investigations for clusters or
outbreaks of emerging respiratory viruses

©WHO2020 9
 Convening an investigation team

Assemble a multi-disciplinary team with expertise

in:
§ Field epidemiology
§ Clinical assessment
§ Biological specimen collection
§ Infection prevention and control
§ Risk communication and community engagement
It is essential that animal health specialists are included in the team – if
warranted.
Additional team members: logisticians, laboratory experts, data managers and
environmental health specialists.
©WHO2020 10
 Convening an investigation team

Before deploying, the team should:

§ Gather preliminary background information
§ Assemble the necessary materials and supplies
(e.g. personal protective equipment, specimen
collection and transport materials) and
§ Inform relevant local public health and animal
health authorities

©WHO2020 11
 Investigation objectives
Prevent future cases through
Public Health Objectives identification of potential
human, animal and/or
Identify other cases and environmental sources of
quickly detect any human exposure, risk factors for
to-human transmission. infection, and implementation
of appropriate prevention and
control measures.

Reduce onward transmission, morbidity and mortality

through rapid identification, isolation, treatment and
clinical management of cases and follow-up of contacts.
©WHO2020 12
 Investigation objectives
Determine key epidemiological,
Knowledge Objectives clinical and virological
characteristics for cases
Determine the size of the including:
geographic area in which the § clinical presentation,
virus is transmitting. § natural history,
§ the mode(s) of transmission
and disease diagnosis,
§ incubation period, period of
transmissibility and
§ best practices for treatment.

Determine if the efficiency of human-to-human

transmission of the virus has changed or increased.
©WHO2020 13
 Investigations in health care settings

Location of the investigation:

§ Within the health care facilities where the patient visited and was treated

Objectives of your investigation:

§ Identify other cases who may have been in contact with the confirmed
case or their biological specimens, including other patients, HCW, visitors
§ Identify how they were infected – that is, what exposures resulted in
infection
§ Quickly recommend measures to stop transmission

©WHO2020 14
Animal health and environmental
investigations
Investigators in public health and animal health should work
together, with the following objectives:
§ Identify the source of infection from animals
§ Measure the extent of infection in people exposed to these
animals
§ Develop measures to prevent further human infections and to
reduce transmission within animals
Field visits to investigate the occurrence of illness among
animals can include:
§ The patient's home and its surroundings
§ Live animal markets or slaughterhouses
§ Any other place the patient visited in the 14 days prior to illness
onset and animals were present
©WHO2020 15
Enhanced surveillance

General surveillance in the area under investigation

should be enhanced for at least one month, focusing
on:
§ Setting up lab testing in the local health care facility,
if feasible, or organizing rapid transfer of specimens
to a laboratory with testing capacity
§ Informing local clinicians of the case definition and
the need for vigilance
§ Surveillance for severe acute respiratory illnesses
(SARI) in health care facilities in the community
§ Increasing testing of SARI cases at local health care
facilities
§ If resources allow, testing of people with milder,
influenza-like illness
©WHO2020 16
 Data analysis
Descriptive analysis of cases should be performed in terms of time, place and person:

Place: geographical location: maps of the locale, case patients’

homes
Person: relationship
Time: Date of onset: (i.e. transmission or family
graphical and/or tabular trees) and demographic
descriptions of cases by characteristics
date of onset: epidemic (e.g. distribution by age and
curve sex) should be developed
Key epidemiological data (e.g. estimation of an incubation period, description
of transmission patterns, attack rates by age, occupation, exposure history etc.)
and clinical data (e.g. spectrum of illness severity, proportion with pneumonia,
deaths) should also be provided
©WHO2020 17
 What do you do with this analysis?

Data is critical for:

§ Analysis and interpretation – conduct a risk assessment
§ Design and implement mitigation measures
§ Share findings of outbreak investigations so that others can learn
from experiences

©WHO2020 18
 Further reading

Contact: Dr Maria Van Kerkhove

vankerkhovem@who.int

Further reading:

Coronaviruses
https://www.who.int/emergencies/diseases/novel-coronavirus-2019

©WHO2020 19
Module B: Unit 2: Laboratory investigations
 Learning objective

By the end of this unit, participants will be

able to describe:
§ the types of sampling needed
§ the type of laboratory investigations
used to confirm cases.

©WHO2017
©WHO2020 2
 Laboratory investigations required
for case confirmation

▪ An infection can be laboratory-confirmed:

• by detection of viral nucleic acid, or
• by possibly using serology to demonstrate antibodies

©WHO2017
©WHO2020 3
 Type of samples to take in people
with symptoms

For PCR
▪ Lower respiratory tract: sputum, lavage, aspirate
▪ Upper respiratory tract: nasopharyngeal and oropharyngeal
swabs; nasopharyngeal wash/nasopharyngeal aspirate
▪ Stool?

©WHO2017
©WHO2020 4
 Types of samples to take in
contacts with no symptoms

For PCR
▪ Nasopharyngeal and oropharyngeal swabs
▪ Samples should be taken within 14 days of the person’s
last documented contact with a COVID-19 case

©WHO2020 5
 Biosafety, storage, and
transportation of samples

▪ All health care workers who collect

specimens from patients suspected or
confirmed to be infected with the
COVID-19 virus must wear appropriate
personal protective equipment (PPE)
▪ All those involved in collection and
transporting specimens should be
trained in safe handling practices
and decontamination procedures

©WHO2020 6
 Biosafety, storage, and
transportation of samples

Storage and transport:

▪ If the specimen will reach the laboratory
in less than 72 hours, store and ship at 4°C
▪ If the specimen will reach the laboratory
in more than 72 hours, store at -80°C and
ship on dry ice or liquid nitrogen

©WHO2020 7
Negative results in infected people

Sometimes, negative results might be

obtained from an infected individual
due to:
▪ poor quality of the specimen
▪ the specimen was collected late or very
early in the illness
▪ the specimen was not handled and
shipped appropriately
▪ technical reasons inherent in the test,
e.g. virus mutation or PCR inhibition

©WHO2020 8
 Retesting patients with negative
results

If a negative result is
obtained from patients
with a high index of
suspicion for infection,
new specimens, Laboratories that have
including some from not validated their
the lower respiratory capacity to detect
tract if possible, should coronavirus should send
be collected and tested the first 5 positive and
the first 10 negative
samples to one of the
international reference
laboratories
©WHO2020 9
 Resources

Contact:
Dr Mark Perkins WHElab@who.int

Guidance and tools:

Laboratory guidance for COVID-19
https://www.who.int/health-topics/coronavirus/laboratory-
diagnostics-for-novel-coronavirus

©WHO2020 10
Module C: Unit 1: Risk communication
 Learning objective

By the end of this unit, participants should be

able to:
§ describe the key risk communication
concerns for emerging respiratory viruses
§ list at least three barriers for effective uptake
of health advice, and
§ identify key interventions for
operationalizing risk communication during
an outbreak or event

©WHO2020 3
What do we mean by risk
communications? – 1

§ The real-time exchange of information,

advice and opinions between experts or
officials and people who face the threat
(from a hazard) to their health or
economic or social well-being.

©WHO2020 4
What do we mean by risk
communications? – 2

§ Purpose – everyone at risk is able to take

informed decisions to mitigate the effects
of the threat (hazard) – such as a disease
outbreak – and take protective and
preventive measures

©WHO2020 5
What do we mean by risk
communications? – 3

§ Domains – communication and social science

interventions; mass communication to
community engagement and interpersonal
communication

©WHO2020 6
 Risk communication intervention
points in epidemics and pandemics

Anticipation and Early detection Mitigation

Containment
preparedness

Emergence Outbreak
Epidemic
(human–animal (localized Control
amplification
interphase) transmission)

©WHO2020 7
 Key risk communication concerns
for spread – 1
1. There may be cross-infection in hospitals caring for patients with infection
(nosocomial or hospital-acquired) transmission
§ Human–to–human transmission
can occur in hospitals
§ Infection prevention and control
(IPC) measures are essential to
stop transmission and contain
an outbreak
§ Immediate implementation of IPC
and early identification of patients
are essential

©WHO2020 8
 Key risk communication concerns
for spread – 2

2. Direct close contact with animals or consumption of raw animal products

§ For zoonotic viruses, initial cases

may have links to animals, animal
products or animal markets

©WHO2020 9
 Key messengers of the risk communication
messages to the target audiences – 1

Key messengers/risk communicators

§ Authorities and spokespersons
§ Health care workers
§ Hospital management personnel
§ NGOs and community organizations
§ Influential individuals/groups in the community
§ Travel and tourism sectors
§ Animal health officials

©WHO2020 10
 Key messengers of the risk
communication messages to the target
audiences – 2
Target audiences
§ General public
§ Health care workers
§ Patients, patients’ relatives, the community,
home care givers
§ Individuals, families and influential groups in
the communities
§ Travellers to and from affected countries
§ Population with animal exposure
§ Other vulnerable groups, e.g. migrant workers

©WHO2020 11
 Example of a message map for the
general public in an outbreak – 1
Stakeholder: General public in an emerging respiratory virus outbreak
Question/concern: How can I avoid contracting the virus?
Key message 1: Frequently clean hands by using alcohol-based hand rub
or soap and water
Supporting message 1: Avoid touching your eyes, nose and mouth with
unwashed hands
Supporting message 2: When hands are visibly dirty, wash hands with soap
and water for at least 30 seconds (or hum the Happy Birthday song from
beginning to the end twice) under running water and wipe your hands dry
Supporting message 3: When hands are not visibly dirty use an alcohol-based
hand rub for 20 seconds or wash hands with soap and water
©WHO2020 12
 Example of a message map for the
general public in an outbreak – 2
Stakeholder: General public in an emerging respiratory virus outbreak
Question/concern: How can I avoid contracting the virus?
Key message 2: When coughing and sneezing cover mouth and nose
with flexed elbow or tissue – throw tissue away immediately and
wash hands
Supporting message 1: If there is no tissue, cough or sneeze in your
upper sleeves
Supporting message 2: Wash hands immediately after throwing tissue away
by using an alcohol-based hand rub or soap and water
Supporting message 3: Small droplets that come out of your nose or mouth
when you cough or sneeze can carry germs
©WHO2020 13
 Example of a message map for the
general public in an outbreak – 3
Stakeholder: General public in an emerging respiratory virus outbreak
Question/concern: How can I avoid contracting the virus?
Key message 3: If you have fever, cough and difficulty breathing seek medical
care early and share previous travel history with your health care provider
Supporting message 1: Provide them with your travel history – the places
you visited
Supporting message 2: Inform them if you have had close contact with a
person with suspected or confirmed infection
Supporting message 3: Inform them if you have visited an animal market or
consumed animal products

©WHO2020 14
 Example key messages for health care
workers – 1

Practice hand hygiene

§ Wash hands with soap and water or alcohol
antiseptic for at least 20 seconds before
• touching any patient
• before aseptic procedure
• after body fluid exposures
• touching patients’ surroundings
• before and after wearing any PPE
(personal protective equipment)
• perform hand hygiene after having
contact with respiratory secretions http://www.who.int/gpsc/5may/
contaminated objects Hand_Hygiene_Why_How_and_
When_Brochure.pdf?ua=1
©WHO2020 15
 Example key messages for health care
workers – 2
Practice respiratory etiquette
§ Cover your cough or sneeze with tissue
and dispose of it in the bin. If tissue is
not available, cough or sneeze in your
upper sleeves
§ Persons with respiratory symptoms may be
asked to wear masks to protect others
§ Ensure that your health care facility has
tissues and bins for disposing of tissues in
the patient waiting areas
§ Droplet precaution should be observed,
e.g. wear a mask when examining patients
with respiratory symptoms
©WHO2020 16
 Example of key messages for
everyone – 1

§ Wash your hands frequently with soap

and water
§ Cover your mouth with a tissue when
coughing or sneezing. If tissue is not
available, cough or sneeze into your
upper sleeves

©WHO2020 17
 Example of key messages for
everyone – 2

§ See your doctor or health worker if you

develop fever, severe cough within 14 days
after returning from an outbreak area and
provide your travel history
§ Inform your health care worker if you have
come into close contact with a person with
suspected or confirmed infection or if you
have visited an animal market or
consumed animal products

©WHO2020 18
 Barriers to uptake of health advice –
1

§ Health care practices and taking care of

sick family members Cultural and
§ Health care seeking behaviours
traditional
§ Close family contact, close living quarters
§ Traditional foods should be well-cooked practices

©WHO2020 19
 Barriers to uptake of health advice –
2

§ Are information sources reliable,

Trust or lack credible?
§ Trust in messenger
thereof in § Are messages and guidance to the
authorities public consistent across several
channels in order to amplify
recommendations?

©WHO2020 20
 Barriers to uptake of health advice
–3

§ Human–to–human transmission
§ Travel and transportation Lack of
§ Hospitals/health care knowledge on
§ Mass gatherings how the disease
§ Contact with infected animals or is transmitted
their products

As more is learned about disease transmission, communication about

these transmission methods must be updated to the public. Until then,
advice must be stated with appropriate uncertainty.
©WHO2020 21
 Barriers to uptake of health advice –
4

§ Languages
Some population § Not visual or easy to understand
groups may not have § Not on channels of their choice
access to appropriate
information Identify key target audiences and use the language
they use and the trusted information channels
they prefer.
Develop communication materials and messages
and test them with members of the target audience.

©WHO2020 22
 Best practices for risk communication
–1
Be first, be fast, be frequent

1 2 3
Awareness of the
Early first disease and the
Be proactive in
announcement situation is key,
information
essential to build especially among
dissemination with
and maintain health care workers
frequent updates
public trust and the populations
at risk

©WHO2020 23
 Best practices for risk communication
–2

Help people take informed decisions

to protect themselves

Develop easy to 6 5 4
Identify and manage Use a mix of tactics
understand materials
in languages and rumours and and approaches for
preferred channels of misinformation quickly risk communication,
affected population including …

©WHO2020 24
 Best practices for risk communication
–3

§ Media communication § Mass awareness initiatives

§ Public statements and
announcements
§ Two-way communication with
affected populations, such as hotlines,
radio call-in shows, monitored and
responsive social media
(including suitable IEC material)
§ Social mobilization and direct
engagement with at-risk
communities
§ Engagement with partners
and communities

©WHO2020 25
 Operationalizing risk communication
–1

§ Risk communication has to be part of the

Health Operations of the Incident
Management System
§ Develop a risk communication plan with
concise objectives, clear outcome and
defined resource requirements
§ Find people, tools and money for
operationalization

©WHO2020 26
 Operationalizing risk communication
–2

Establish:
§ communication coordination mechanism
early, with regular information sharing
§ rumour monitoring with key stakeholders
and partners with a systematic approach
to shift communication strategy to address
misinformation
§ fast-track mechanism for release of
information – clearance procedures,
channels for dissemination, etc.

©WHO2020 27
 Operationalizing risk communication
–3

§ Establish a mechanism for monitoring

the media, social media and rumours,
with clearly defined procedure for timely
management of misinformation which
may escalate

©WHO2020 28
 For further information

Contact:
Melinda Frost mfrost@who.int
Dr Maria Van Kerkhove vankerkhovem@who.int

Further reading:
Coronaviruses
https://www.who.int/emergencies/diseases/novel-coronavirus-2019

©WHO2020 29
Module C: Unit 2: Community Engagement
 Learning objective

By the end of this unit, participants should

be able to:
§ Describe at least three reasons why
responders need to engage communities
during an outbreak
§ List challenges faced in community
engagement (CE) and
§ Describe approaches for effective CE in
detecting, preventing and responding to
an outbreak

©WHO2020 2
 Why do communities need to be
engaged during an outbreak? – 1
Generic public or media
Affected communities
announcements are not
and populations need to
sufficient, trusted or
know how to protect
tailored to communities at
themselves and
high-risk
response teams need to
know how communities
understand the disease
and the response

Engaging with communities allows their direct participation in the

response to address fears, barriers, concerns and to change
transmission-enhancing practices, while promoting protective
behaviors and working together with the response teams
©WHO2020 3
 Why do communities need to be
engaged during an outbreak? – 2
Populations at-risk want
and must be a part of the
solutions to protect lives
and stop an outbreak
©WHO2020
Bi-directional
communication - dialogue -
must be established from
the onset of an outbreak
between affected
communities and response
teams to ensure
participation and mutual
understanding - the base of
trust building
4
 Opportunities for community
engagement

Anticipation and Early detection Containment Mitigation

preparedness

Emergence
Outbreak
(human- Epidemic
(localized Control
animal amplification
transmission)
interphase)

©WHO2020 5
 Response challenges in outbreaks

§ Lack of understanding of community practices,

concerns and fear by response teams
§ Slow/late information release about the disease and
the response could exacerbate community concerns
and amplify the outbreak
§ Lack of information and awareness on protection
measures can aggravate the spread of the disease
§ Starting implementation of measures without the
agreement of communities impacts acceptance of the
response
§ Late/no action taken to stop rumors can lead to
misunderstandings and impact trust in the health
authorities and promotes “dangerous” behaviors

©WHO2020 6
 Examples of some possible
challenges in outbreaks – 1

Nosocomial (health care) outbreaks may

occur due to lack of

§ information and awareness about the virus

among health care workers and/or failure to

apply appropriate infection prevention and
control measures

©WHO2020 7
 Examples of some possible
challenges in outbreaks – 2

Cultural practices related to caregiving and

health care seeking behavior may make it
difficult to control an outbreak:
§ For example, in some cultures, many
relatives will accompany or visit sick family
members when in hospital, and
§ Some people may go to many different
hospitals while sick before they decide
where to seek care (this is sometimes
called doctor or hospital shopping)

©WHO2020 8
 Community engagement strategy in
an outbreak - 1
Assess
contextual
qualitative
information
Define an
engagement and
Monitor the communication
desired impact strategy with the
of your strategy key people
Implement the identified in the
activities defined assessment
in the strategy

©WHO2020 9
Identify and work with key
stakeholders – For example – 1

Government Health care

officials & practitioners
spokespersons

Media & social

Women as main media
1.16"
caregivers at influencers
home

©WHO2020 10
Identify and work with key
stakeholders – For example – 2

General public from

Businesses and
where patients are
employers
being reported

Travel and Workers in health

trade sectors care settings

©WHO2020 11
Identify and work with key
stakeholders – For example - 3

Local government Women and Youth

and civil society associations

Religious and
community
influencers

©WHO2020 12
 Assess the context - 1
§ Consult local colleagues and stakeholders
§ Know and understand needs, concerns, fears as
well as strengths and capacities at community
level
§ Review existing literature: KAP surveys,
ethnographies, political science analyses
§ Apply social science methodologies:
• community walk-through
• focused group discussions (FGD)
• observation
• interviews
§ Explore communities’ preferred communication
means
©WHO2020 13
 Assess the context – 2
§ Identify the health seeking behavior pathway (HSB) for the disease and the factors that condition it
locally:
• socio-cultural factors: including explanatory models, localised gender vision, and power
dynamics,
• economic,
• practical and HEALTH CARE
• empirical factors HOME COMMUNITY PROVIDER

§ Identify the key people who are already

linked to the health seeking behavior (HSB)
pathway for this kind of disease at home,
community and health facility level:
• Gatekeepers Caretaker: mother Caretaker/practitioner: traditional Caretaker/practitioner:
• Decision makers Gatekeeper/decision healers/praying doctors/nurses from public and
house/pharmacy/Chinese medicine private
• Influencers maker: father Gatekeeper/decision maker: Gatekeeper/decision maker:
Influencer: mother in traditional healers/praying house
• Caretakers/health practitioners law /father
doctors/nurses
Influencer: health authority
Influencer: varies
©WHO2020 14
Develop a strategy and plan of
action
§ Define your audience: key actors and target
population
§ Design the communication plan and choose
the communication channels/methods at
three levels:
• Mass media
• Leaders and key people
• Interpersonal communication
§ Develop engagement narratives
§ Develop IEC materials and tools together
with end user groups, test all materials
before use

©WHO2020 15
 Build a feedback system – 1

§ Build a systematic and dynamic way to

collect, analyze and integrate feedback,
rumors and misinformation at the three
levels:
• mass media: media and social
monitoring; radio shows with public
calls
• leaders and key people: health care
workers’ feedback; leaders’ feedback
• interpersonal communication:
community dialogues, community
workers’ feedback
©WHO2020 16
 Build a feedback system – 2

§ Share the information with the other

technical areas of the intervention and
negotiate change and improvement in
implementation according to feedback
§ Ensure the daily collection, analysis and
negotiation of feedback with the response
and always get back to the communities
with answers to their questions
§ “Bridge” the response with the different
communities

©WHO2020 17
 Key Points – 1

§ Communication and information

dissemination is not CE
§ CE is more effective when relationships
and mechanisms exist before an
emergency
§ Engage CE partners routinely and build
trust. Be honest and transparent
§ Connect and bridge the reality of the
community and the reality of the
response

©WHO2020 18
 Key Points – 2
• Communication can be defined as the action of exchanging (sending and receiving) information
• Common barriers to communication
• Language and education
• Cultural and ethnic differences
• Irrelevant message
• Too much information
• Time constraints
• Noise and distractions
• Communication enablers
• Reach the intend audience
• Attract audience attention
• Engagement narrative is:
• Understandable
• Culturally adapted
• Credible and relevant
• Delivered in time
©WHO2020 19
 For further information
Please contact:
Melinda Frost
Lead, Risk Communication
High Impact Events Preparedness
WHO Health Emergencies Programme
World Health Organization
Geneva, SWITZERLAND
email: mfrost@who.int

©WHO2020 20
Module D: Infection prevention and control (IPC)
and clinical care
 Learning objective

By the end of this unit,

participants will be able to
describe the principles of
preventing infection in the
community and in health
care settings.

©WHO2020 3
IPC for the general community – 1

We now know that human-to-human COVID-19

transmission has happened in both household and
community settings. To avoid transmission, the
general community needs to:
§ avoid agglomerations and frequency of closed
crowded spaces
§ maintain distance of at least one metre from any
individual with COVID-19 respiratory symptoms
(e.g. coughing, sneezing)

©WHO2020 4
IPC for the general community – 2

§ perform hand hygiene frequently, using

alcohol-based hand rub if hands are not
visibly soiled (for 20–30 seconds) or soap
and water when hands are visibly soiled
(for 40–60 seconds)
§ if coughing or sneezing cover nose and
mouth with flexed elbow or paper tissue,
dispose of tissue immediately after use
and perform hand hygiene
§ refrain from touching mouth and nose

©WHO2020 5
IPC for the general community – 3

Individuals with respiratory symptoms should:

§ wear a medical mask and seek medical care
if experiencing fever, cough and difficulty
breathing, as soon as possible
or in accordance with local protocols

©WHO2020 6
 IPC measures to prevent transmission in
health care settings – 1

Health care workers may be at risk of

infection
§ early respiratory infection
symptoms can be nonspecific; thus
healthcare workers may not be
prompted to implement additional
precautions to prevent transmission
while providing care
• hence the importance of standard
precautions

©WHO2020 7
 IPC measures to prevent transmission in
health care settings – 2

Use standard precautions for ALL

patients, in ALL settings, at ALL time
regardless of symptoms. These include:
§ hand hygiene
§ respiratory hygiene and cough
etiquette
§ use of personal protective equipment
(PPE) based on risk assessment
§ safe injection practices

©WHO2020 8
 IPC measures to prevent transmission in
health care settings – 3

Standard precautions continued:

§ environmental cleaning
§ waste management
§ linen management
§ patient care equipment

©WHO2020 9
 Specific IPC measures for COVID-19 – 1

At triage:
§ early recognition of patient with
COVID-19; have a high level of clinical
suspicion of COVID-19
§ give the patient with suspected COVID-19
a medical mask
§ place the patient in separate area
• this will contribute to source control
and diminish potential for
environmental contamination

©WHO2020 10
 Specific IPC measures for COVID-19 – 2

At triage:
§ ensure a well-equipped triage station:
• institute screening questionnaire according to
COVID-19 case definition
• organize the space and process to permit
spatial separation of 1–2 metres between each
patient with COVID-19 and other individuals
§ post signs in public areas reminding symptomatic
patients to alert health care workers
§ ensure that triage and waiting areas are
adequately ventilated

©WHO2020 11
 Specific IPC measures for COVID-19 – 3

§ Encourage respiratory hygiene

(i.e. covering the mouth and nose during
coughing or sneezing with a tissue or
flexed elbow), followed by immediate
disposal of the tissue and hand hygiene

§ When admitting patients to wards ensure

that only those with confirmed infection
are placed with other COVID-19
confirmed cases

©WHO2020 12
 IPC measures in health care settings:
Droplet and contact precautions – 1

Health care workers caring for patients with COVID-19 should apply
DROPLET and contact precautions to prevent transmission of the viruses.
These are:
Place patients in single
rooms, or when not
available, group together
those with the same or
similar diagnosis. Single rooms or
Keep patients spatially wards should be
separated by at least adequately ventilated
one metre.

©WHO2020 13
 IPC measures in health care settings:
Droplet and contact precautions – 2

Health care workers caring for patients with COVID-19 should apply
DROPLET and contact precautions to prevent transmission of the viruses.
When in close contact with patients use:

§ a medical mask
§ face shield or goggles § gloves
§ gown

©WHO2020 14
 IPC measures in health care settings:
Droplet and contact precautions – 3

After patient care,

appropriate doffing and
disposal of PPE and
hand hygiene should be Limit patient movement
carried out. A new set within the institution and
of PPEs is needed, ensure that patients wear
when care is given to a medical masks when
different patient. outside their rooms.

©WHO2020 15
 Droplet and contact precautions – 4

§ If possible, use either disposable

or dedicated equipment (e.g.
stethoscopes, blood pressure
cuffs and thermometers)
§ If equipment needs to be shared
among patients, clean and disinfect
it between each patient use

©WHO2020 16
 Droplet and contact precautions – 5

§ Ensure that health care workers refrain

from touching their eyes, nose, or mouth
with potentially contaminated gloved or
ungloved hands
§ Avoid contaminating environmental
surfaces that are not directly related
to patient care (e.g. door handles and
light switches)
§ Routinely clean and disinfect surfaces
which the patient is in contact

©WHO2020 17
 Droplet and contact precautions – 6

§ Ensure adequate room ventilation

§ Use single rooms, or cohort patients with
the same diagnosis
§ Minimize movement or transport of
patients
§ Perform hand hygiene

©WHO2020 18
 Airborne precautions – 1

Some procedures such as aspiration or open

suctioning of respiratory tract specimens, non-
invasive ventilation, high flow oxygen therapy,
delivery of nebulizers, intubation, cardiopulmonary
resuscitation, and bronchoscopy can generate
aerosols (called aerosol-generating procedures).
These are associated with increased risk of
transmission of COVID-19. Health care workers
need to take the following airborne precautions
when performing these.

©WHO2020 19
 Airborne precautions – 2

§ Use PPE, including gloves, long-sleeved gowns,

eye protection, and particulate respirators
(N95 or equivalent, or higher level of protection)
§ Use adequately ventilated single rooms when
performing aerosol-generating procedures
• this means negative pressure rooms with a
minimum of 12 air changes per hour or at
least 160 litres/second/patient in facilities
with natural ventilation.
§ Ask all people not required for the task to leave
the room.

©WHO2020 20
 Signs and symptoms – 1

As with other coronavirus infections, early signs and

symptoms in more severe infections are likely:
§ fever
§ chills
§ cough
§ shortness of breath

Rapid progression to severe pneumonia and respiratory

failure usually happens within the first week

©WHO2020 21
Life threatening manifestations of
respiratory infection

Life-threatening manifestations of
respiratory infection include:
§ severe pneumonia
§ acute respiratory distress syndrome
Early recognition of these clinical
syndromes allows for timely initiation
of infection prevention and control
(IPC) as well as supportive
therapeutics.

©WHO2020 22
 Supportive therapy – 1

Although there is often no specific cure for

emerging respiratory virus infection, the following
three supportive therapies may counteract the
symptoms and increase chances of survival.
1. Antimicrobials: suitable for likely pathogens,
including community-acquired pneumonia or
health care-associated pneumonia (if infection
was acquired in a health care setting) and sepsis

©WHO2020 23
 Supportive therapy – 2

2. Oxygen: people with severe COVID-19 with

signs of respiratory distress, reduced blood
oxygen levels (hypoxaemia), or shock should be
given supplemental oxygen therapy
immediately
3. Specific treatment for underlying conditions
such as diabetes, kidney failure
• with coronavirus infections, many people
with severe cases of infection have
underlying conditions and this group are at
greatest risk of dying

©WHO2020 24
Intensive supportive care – 1

Severe respiratory distress:

§ not responding to escalating supplemental
oxygen therapy requires advanced respiratory
interventions including:
• high flow oxygen
• non-invasive ventilation
• invasive ventilation

©WHO2020 25
Intensive supportive care – 2

Septic shock: treat with intravenous

fluid therapy and vasopressors to
improve targets of perfusion

§ these approaches generate aerosols

so the airborne precautions outlined
in this unit must be followed

©WHO2020 26
 Therapeutics research – 1

Compounds already licensed

or in development for other
diseases may need to be
repurposed for emerging
respiratory virus infection.

©WHO2020 27
 Management of people with
asymptomatic infection – 1

Contacts of confirmed cases may identify

people who test positive but have no
symptoms. Until more is known, people
who are found to be positive on RT-PCR
testing, should be:
§ isolated,
§ followed up daily for symptoms, and
§ tested at least weekly – or earlier,
if symptoms develop.

©WHO2020 28
 Management of people with
asymptomatic infection – 2

Isolation should continue until two

consecutive upper respiratory tract
samples (e.g. nasopharyngeal and/or
oropharyngeal swabs) taken at least
24 hours apart test negative on RT-PCR

©WHO2020 29
 Resources

Contact:
IPC: Dr April Baller ballera@who.int
Clinical management: Dr Janet Diaz diazj@who.int

Guidance documents and tools:

Infection prevention and control during health care when COVID-19 is suspected:
https://www.who.int/publications-detail/infection-prevention-and-control-during-
health-care-when-novel-coronavirus-(COVID-19)-infection-is-suspected-20200125
Clinical management of acute respiratory infection when COVID-19 is suspected:
https://www.who.int/publications-detail/clinical-management-of-severe-acute-
respiratory-infection-when-novel-coronavirus-(COVID-19)-infection-is-suspected

©WHO2020 30