WHO 2019 NCoV IPC Guideline 2023.4 Eng

Infection prevention and
control in the context of

COVID-19: a guideline
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21 December 2023 t•� Organization
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WHO/2019-nCoV/IPC/guideline/2023.4
© World Health Organization 2023
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Sections
1. Executive summary ..................................................................................................................................................................................... 6
1.1 Definitions .......................................................................................................................................................................................... 6
1.2 Abbreviations ................................................................................................................................................................................... 12
1.3 Background ....................................................................................................................................................................................... 13
1.3.1 Summary of recommendations and good practice statements for the health-care settings ................................................... 15
1.3.2 Summary of recommendations and good practice statements for mitigation measures in the community ........................... 18
2. Methodology .............................................................................................................................................................................................. 21
3. Part 1: Health-care settings ....................................................................................................................................................................... 26
3.1 Background ....................................................................................................................................................................................... 26
3.1.1 What is an IPC programme? ................................................................................................................................................. 26
3.1.2 IPC principles ........................................................................................................................................................................ 26
3.1.3 Standard precautions ............................................................................................................................................................ 29
3.1.4 Transmission-based precautions ........................................................................................................................................... 29
3.2 IPC measures for patients with suspected or confirmed COVID-19 ................................................................................................. 30
3.2.1 Screening and patient placement ........................................................................................................................................... 30
3.2.2 Ventilation ............................................................................................................................................................................... 31
3.2.3 Physical barriers ..................................................................................................................................................................... 34
3.2.4 Physical distancing ................................................................................................................................................................ 37
3.2.5 Mask use for source control .................................................................................................................................................. 38
3.2.6 PPE selection and use .......................................................................................................................................................... 50
3.2.6.1 PPE technical specifications ....................................................................................................................................... 57
3.2.7 Aerosol-generating procedures (AGPs) ................................................................................................................................. 60
3.3 Water, sanitation, hygiene, and waste management ....................................................................................................................... 65
3.3.1 Environmental cleaning ......................................................................................................................................................... 66
3.3.2 Waste management .............................................................................................................................................................. 70
3.3.3 Handling of linens and laundry ............................................................................................................................................... 73
3.4 Safe dead body management .......................................................................................................................................................... 75
3.5 Special settings ................................................................................................................................................................................. 77
3.5.1 IPC principles and procedures for COVID-19 vaccination activities ....................................................................................... 77
3.5.2 Operating theatres .................................................................................................................................................................. 78
3.5.3 Home-care settings ............................................................................................................................................................... 83
3.5.4 Long-term care facilities ........................................................................................................................................................ 85
3.6 Prevention, identification and management of SARS-CoV-2 infections in health and care workers ............................................... 87
3.6.1 Identification of health and care workers infections in the health care setting ....................................................................... 88
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Infection prevention and control in the context of coronavirus disease (COVID-19): A guideline - World Health Organization (WHO)
3.6.2 Duration of isolation for COVID-19 cases in health and care workers ................................................................................... 95
3.6.3 Risk assessment and management of exposure ................................................................................................................ 100
3.7 IPC outbreak preparedness, readiness, response and recovery .................................................................................................... 100
3.7.1 Key activities to strengthen IPC during heath emergencies ................................................................................................. 100
3.8 Lessons learned from COVID-19 and potential future strategies for overburdened health systems .............................................. 101
4. Part 2: Mitigation measures in the community ....................................................................................................................................... 103
4.1 Introduction to public health and social measures .......................................................................................................................... 103
4.2 Mask use......................................................................................................................................................................................... 104
4.2.1 Mask use in the community ................................................................................................................................................. 104
4.2.1.1 Type of mask used by the general public .................................................................................................................... 113
4.2.1.2 Mask use during physical activity ................................................................................................................................ 119
4.2.2 Mask use by children ............................................................................................................................................................ 122
4.2.2.1 Introduction .............................................................................................................................................................. . 123
4.2.2.2 Age-specific recommendations ................................................................................................................................ 126
4.2.2.3 Special populations ................................................................................................................................................... 134
4.2.2.4 Implementation considerations for use of masks in schools ..................................................................................... 136
4.3 Glove use ....................................................................................................................................................................................... 136
4.4 Caring for persons with COVID-19 in the home.............................................................................................................................. 139
4.5 Water, sanitation, hygiene, and waste management ...................................................................................................................... 140
4.5.1 Environmental Cleaning ...................................................................................................................................................... 141
4.5.2 Waste Management ............................................................................................................................................................ 143
4.5.3 Handling of linens and laundry ............................................................................................................................................. 144
4.6 Safe dead body management ........................................................................................................................................................ 145
5. Acknowledgements .................................................................................................................................................................................. 147
5.1 Part 1: Health care setting authorship, acknowledgements and contributions ............................................................................. 147
5.2 Part 2: Mitigation measures in the community authorship, acknowledgements and contributions ................................................ 148
5.2.1 Mitigation measures in the community authorship, acknowledgements and contributors .................................................... 148
5.2.2 Mask use by children authorship, acknowledgements and contributors .............................................................................. 150
5.3 Systematic review teams ............................................................................................................................................................... 151
6. Annexes ................................................................................................................................................................................................... 152
6.1 Annex 1: Research Gaps ............................................................................................................................................................... 152
6.2 Annex 2. Evidence tables for mask use in the community.............................................................................................................. 153
6.3 Annex 3. Evidence tables for mask use by children ...................................................................................................................... 154
6.4 Annex 4. Systematic review for prevention, identification, management of COVID-19 in health and care workers ....................... 155
6.5 Annex 5: Results of rapid qualitative evidence synthesis ............................................................................................................... 167
6.6 Annex 6: Search Strategies ........................................................................................................................................................... 169
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6.6.1 Airborne Precautions ............................................................................................................................................................ 169
6.6.2 Cleaning in the community .................................................................................................................................................. 169
6.6.3 Cleaning in the health-care facility ....................................................................................................................................... 173
6.6.4 UV......................................................................................................................................................................................... 179
6.6.5 Dead body management ..................................................................................................................................................... 180
6.6.6 Glove use in community ...................................................................................................................................................... 181
6.6.7 Laundry ................................................................................................................................................................................ 182
6.6.8 Mask use during physical activity ........................................................................................................................................ 183
6.6.9 Mask fit .............................................................................................................................................................................. .. 185
6.6.10 Physical distancing ............................................................................................................................................................ 185
6.6.11 Operating Rooms ............................................................................................................................................................... 190
6.6.12 Waste Management .......................................................................................................................................................... 191
6.6.13 Ventilation .......................................................................................................................................................................... 192
6.6.14 HEPA Filter ........................................................................................................................................................................ 193
References ................................................................................................................................................................................................... 196
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1. Executive summary
The Infection prevention and control guideline for coronavirus disease 2019 (COVID-19) consolidates IPC technical guidance
developed and published during the COVID-19 pandemic, with evidence-informed recommendations for health-care and community
settings.
COVID-19 is the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Health-care facilities remain high-
risk settings for SARS-CoV-2 transmission as they admit and care for patients with a risk of Consistent application of IPC measures is
essential to preventing transmission of SARS-CoV-2 in health-care settings.
This update (version 7) considers the current context of COVID-19, epidemiological trends, the emergence of variants of concern and
factors including specific considerations for populations at-risk of severe disease outcomes, availability and uptake of vaccines, immunity
levels and indoor environmental conditions.
The target audience for this guideline comprises policy-makers and decision-makers; public health professionals; IPC professionals and
focal points for IPC and occupational health and safety of health workers at national, subnational and facility levels; health-care facility
administrators and managers; and other health and care workers.
The guideline incudes two sections: Part 1 provides an overview of IPC principles and practices, and IPC measures in health-care facilities
for patients with suspected or confirmed COVID-19. Part 2 pertains to mitigation measures for COVID-19 in community settings.
The methodology section describes the methodological approach used to develop technical guidance for COVID-19 based on ongoing
assessment of evidence. The guideline development process followed WHO methodology, including use of Grading of Recommendations,
Assessment, Development and Evaluation (GRADE) to determine the certainty of the evidence and the strength of the recommendations.
Several updates to the IPC COVID-19 guidelines were completed during the period of the pandemic response that were informed by
emerging evidence and consultation with the Guideline Development Group (GDG). The current context considers the transition from
critical emergency-response activities to longer-term, sustained COVID-19 disease prevention, control and management, and a shift
towards integration of IPC activities into routine systems and practices (i.e. a return to standard and transmission-based precautions in
health-care settings, and public health practices for community settings) [1][2].
Recommendations in this guideline should be viewed in their entirety to understand the evidence-to-decision processes, nuances and
contextual factors that have been considered to ensure the guideline can apply to different countries and settings where health care is
delivered.
The guideline is written, disseminated and updated on an online platform (MAGICapp) and can be found on the WHO website.
1.1 Definitions
A child Any person under the age of 18 years [3].
Actively looking for signs or symptoms either by asking the health and care worker questions
regarding their symptoms through a questionnaire, electronic format or verbally. It involves actively
asking about or assessing health workers' health status (through temperature checks, testing) to
identify signs and symptoms of infection.
This mode of screening could be considered, if human resources and logistics permit, when the
health-care facility finds itself in an active outbreak or when there is heightened transmission in the
Active screening
health-care facility or in the community where the health facility is located. Health workers should
be screened after any potential exposure risk before or on arrival for their shift – either through
questionnaires (online or in-person) or through testing (antigen detection rapid diagnostic tests (Ag-
RDT) or real-time reverse-transcription polymerase chain reaction (rt-PCR)) tests [4]. The signs or
symptoms to be monitored should include fever, cough, general weakness, fatigue, headache,
myalgia, sore throat, coryza, dyspnoea, nausea, diarrhoea and anorexia) [5].
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Adequate ventilation in health facilities can be assessed where a natural or mechanical ventilation
system is available [6][7]. The ventilation rate should be 6-12 air changes per hour (e.g. equivalent
Adequately ventilated patient
to 40-80 L/s/patient for a 4x2x3 m3 room) and ideally 12 air changes per hour for new
room or area
constructions, with a recommended negative pressure differential of ≥2.5Pa (0.01-inch water
gauge) to ensure that air flows from the corridor into patient rooms [7].
Aerosol-generating procedures (AGPs) are defined as any medical procedures that can induce the
production of aerosols of various sizes (e.g. tracheal intubation, non-invasive ventilation [e.g.
bilevel positive airway pressure, continuous positive airway pressure], tracheostomy,
cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy, dental
procedures, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation,
Aerosol generating procedures
sputum induction by using nebulized hypertonic saline, dentistry and autopsy procedures. In oral
(AGP)
health care, the following are considered AGPs: all clinical procedures that use spray-generating
equipment such as three-way air/water spray, dental cleaning with ultrasonic scaler and polishing;
periodontal treatment with ultrasonic scaler; any kind of dental preparation with high- or low-speed
hand pieces; direct and indirect restoration and polishing; definitive cementation of crown or bridge;
mechanical endodontic treatment; surgical tooth extraction and implant placement [8].
Airborne transmission refers to the spread of an infectious agent caused by the dissemination of
droplet nuclei that remain infectious when suspended in air over long distances and long periods of
time. Airborne transmission can be further categorized into obligate or preferential airborne
transmission [8].
• Obligate airborne transmission refers to pathogens that are transmitted only by deposition of
Airborne transmission1
droplet nuclei under natural conditions (e.g. pulmonary tuberculosis) [8].
• Preferential airborne transmission refers to pathogens that can initiate infection by multiple
routes but are predominantly transmitted by droplet nuclei (e.g. measles and chickenpox) [8].
• Opportunistic airborne transmission refers to agents that naturally cause disease through other
routes, but under special circumstances may be transmitted via fine-particle aerosols [8].
Airborne precautions prevent the spread of an infectious agent caused by the dissemination of
droplet nuclei that remain infectious when suspended in air over long distances and long periods of
Airborne precautions time. Health workers should wear a respirator (e.g. N95, FFP2, etc.) before entering the patient's
room and remove it after exiting the room. The patient should be placed in an airborne-infection
isolation room (AIIR) [9].
Caregivers refers to parents, spouses and other family members or friends providing informal care
Caregivers
as opposed to the care provided by health-care providers [10].
Cleaning is the physical removal of foreign material, including dust, soil and organic material such
as blood, secretions, excretions and microorganisms. It physically removes rather than kills
microorganisms with water, detergents and mechanical action. Cleaning is always essential prior to
Cleaning
disinfection or sterilization. A surface that has not been cleaned effectively cannot be properly
disinfected or sterilized. Organic material left on a surface or medical device can protect
microorganisms or neutralize the action of disinfectants [11][12].
Clinical triage is a system by which patients are screened for specific signs, symptoms and
Clinical triage epidemiological clues upon initial contact with the health-care system for the purpose of
determining further diagnostic tests, isolation precautions, treatment and reporting [8].
Cohorting is the act of grouping patients who are colonized or infected with the same organism with
the aim to confine their care to one area and prevent them from coming into contact with other
susceptible patients. Cohorts are created based on clinical diagnosis, microbiological confirmation
Cohorting with available epidemiology and the mode of transmission of the infectious agent. Cohorting is
reserved for situations where there are insufficient single rooms or where patients colonized or
infected with the same pathogen can be grouped together – and away from other patients.
Dedicated equipment, toilets and staff should be used for patients within the cohorted area for the
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required time [13].
Contact transmission is the spread of an infectious agent caused by physical contact of a

susceptible host with people or objects [8].
• Direct contact transmission involves both a direct body-surface-to-body-surface contact and

physical transfer of microorganisms between an infected or colonized person and a susceptible
Contact transmission
host [8].
• Indirect contact transmission involves contact of a susceptible host with a contaminated
intermediate object (e.g. contaminated hands) that carries and transfers the
microorganisms [8].
Contact precautions prevent the spread of an infectious agent caused by physical contact of a
susceptible host with people or objects. Health workers should wear a gown and put on gloves
Contact precautions before entering a patient's room and remove them prior to exit. The patient should be placed in a
single room; if a single room is not available, cohort patients with similar symptoms and diagnosis.
Avoid having patients share a toilet if they are in a shared room [9].
A community is a group of people who may or may not be geographically connected but who share
Community common interests, concerns or identities. These communities could be local, national or
international, with shared interests of a specific or broad nature [10].
Disinfection is a thermal or chemical process for inactivating microorganisms on inanimate

Disinfection
objects [11][12].
Droplet transmission is the spread of an infectious agent caused by the dissemination of droplets.
Droplets are primarily generated from an infected (source) person during coughing, sneezing and
talking. Transmission occurs when these droplets that contain microorganisms are propelled
Droplet transmission (usually < 1 metre) through the air and deposited on the conjunctivae, mouth, nasal, throat or
pharynx mucosa of another person. Most of the volume (>99%) comprises large droplets that travel
short distances (< 1 metre) and do not remain suspended in the air. Thus, special air handling and
ventilation are not required to prevent droplet transmission [8].
Droplet precautions prevent the spread of infectious agents caused by the dissemination of
droplets. Health workers should put on a medical mask and wear additional personal protective
equipment (PPE) if indicated (based on a risk assessment) before entering the patient's room. The
patient should be placed in a single room. Consider the following when single-patient rooms are not
Droplet precautions
available: 1) prioritize any single-patient rooms for patients with excessive cough and sputum
production; 2) cohort patients with the same symptoms; 3) physically separate patients by at least 1
metre and draw privacy curtains [9].
Filtering facepiece respirators (FFRs or respirators) offer a balance of filtration, breathability and fit.
Whereas medical masks filter 3-micrometre droplets, N95-rated and FFP2-rated FFRs must filter
more challenging 0.075-micrometre particles or particulates and must do so across the entire
surface of the respirator as a result of the fitted design. European FFP2 FFRs, according to the EN
149 standard, filter at least 94% sodium chloride (NaCl) salt particles and paraffin oil droplets. The
United States of America's N95 FFRs, according to the National Institute for Occupational Safety
and Health (NIOSH) NIOSH 42 CFR Part 84, filter at least 95% NaCl salt particles. Certified FFRs
Filtering facepiece respirators
must ensure unhindered breathing by meeting inhalation and exhalation breathing resistance
(FFR or respirators)
standards below the maximum thresholds. Another important difference between FFRs and other
masks lies in the way filtration is tested. Medical-mask filtration is assessed by testing filtration over
a cross-section of the masks. In contrast, FFRs are tested for filtration across the entire surface.
Most importantly, FFP2 FFRs are fit-tested on a sample of human participants and the FFRs are
measured for leaks as part of product certification. Similarly, for N95 FFRs, individual workers are
typically fit tested each year for specific FFRs at the workplace. Therefore, in both cases, by
ensuring the outer edges of the FFR seal around the wearer’s face, the FFRs' filtration is closer to
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the actual filtration of inhaled air. Other FFR performance requirements include being within
specified parameters for maximum CO2 build-up [14].
Grading of Recommendations
GRADE is an approach used to assess the quality of a body of evidence and to develop and report
Assessment, Development
recommendations.
and Evaluation (GRADE)
Hand hygiene is a general term referring to any action of hand cleansing. Antiseptic hand
rubbing refers to applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
Hand hygiene without the need for an exogenous source of water and requiring no rinsing or drying with towels or
other devices. Handwashing refers to washing hands with plain or antimicrobial soap and
water [15].
Health-care facilities include primary-, secondary-, tertiary-care levels, outpatient care and long-
Health-care facility
term care facilities.
Hazardous waste can harm people and the environment. The types of hazardous waste in a facility
vary according to the size of the facility and the services offered. Examples of hazardous waste are
listed below [16].
Examples of infectious waste:

• Sharps waste is any used or unused sharp item that could cause a cut or puncture wound that
could lead to infection. Examples include instruments (such as scalpels and blades), needles,
syringes and broken glass or ampoules.
• Pathological waste (anatomical waste). Examples include human tissues or fluids (such as
blood and body fluids), organs (body parts), placentas and fetuses and unused blood
products.
• Other infectious waste. Examples include soiled gloves, gauze or bandages contaminated with
blood, body fluids, viruses or parasites [16].
Hazardous waste Examples of other hazardous waste:

• Pharmaceutical waste is used, expired or no-longer-needed pharmaceutical products (such as
vaccines and drugs).
• Chemical waste. Examples include chemical substances (such as laboratory reagents or film
developer), disinfectants, solvents, and waste with high heavy-metal content (such as
batteries, broken thermometers, and blood pressure gauges).
• Genotoxic (harmful to human genes) and cytotoxic (harmful to human cells) waste isn’t common
unless the facility treats cancer patients. It includes some drugs used in cancer treatment, body
fluids from patients exposed to chemotherapy or cytotoxic drugs and other material
contaminated by these agents.
• Radioactive waste: radioactive substances (such as unused liquids from radiotherapy or
laboratory research), glassware, packages, or absorbent paper contaminated with radioactive
substance, urine and excreta from patients treated or tested with radionuclides and sealed
sources (containers in which radioactive substances are stored and sealed) [16].
Health and care workers are all people from in the community to hospitals who are primarily
engaged in actions with the primary intent of enhancing health. This group includes health-service
providers, such as doctors, nursing and midwifery professionals, public health professionals,
Health workers/health and technicians (laboratory, health, medical and non-medical), personal care workers, healers and
care workers practitioners of traditional medicine. It also includes health management and support workers, such
as cleaners, drivers, hospital administrators, district health managers, social workers, and other
occupational groups in health-related activities. This group also includes those who work in acute-
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care facilities and long-term care, public health, community-based care and other occupations in
the health and social care sectors.
Health and care workers may provide direct personal care services in the home, in health-care and
residential settings, while assisting with routine tasks of daily life and while performing a variety of
other tasks of a simple and routine nature [17].
High-risk exposures in the health-care facility occur when a health and care worker without any
PPE or with inappropriate PPE provides direct care to a patient with an infectious disease. They
also occur when a health and care worker experiences a breach in PPE integrity or a lapse in IPC
measures (i.e. hand hygiene not performed as per the WHO 5 moments, lack of cleaning and
High-risk exposures
disinfection of surface/environment); or when a health and care worker present during an AGP is
wearing inappropriate PPE, when there is a breach in PPE integrity, when other IPC measures are
not followed, or when an exposure occurs due to a splash or spray of body fluids/blood and/or a
puncture/sharp injury [18].
Hierarchy of controls A hierarchy of controls provides a means of determining ways to implement systems or controls
(from most effective to least effective) that protect workers from injuries, illnesses and fatalities [19].
High-risk exposures in the health-care facility occur when health and care workers provide direct
care to a patient with an infectious disease without any PPE, or with inappropriate PPE, or
experience a breach in PPE integrity or a lapse in IPC measures (i.e. hand hygiene not performed
High-risk exposures as per the WHO 5 moments, lack of cleaning and disinfection of surface/environment); or when a
health and care worker present during an AGP is wearing inappropriate PPE or when there is a
breach in PPE integrity or other IPC measures are not followed; or when an exposure occurs due to
a splash or spray of body fluids/blood and/or a puncture/sharp injury [20].
Infection prevention and control (IPC) is a unique field of patient safety and quality of care, a
Infection prevention and practical, evidence-based approach to preventing patients and health workers from being harmed
control by avoidable infections. IPC affects all aspects of health care, including the way hospitals operate
during and outside of emergencies [21].
Isolation is the separation of those infected with a contagious disease from those who are not
Isolation
infected.
Medical masks are surgical or procedure masks that are flat or pleated and are affixed to the head
with straps around the ears, the head or both. Their performance standards are tested according to
Medical masks a set of standardized test methods (American Society for Testing Materials (ASTM) F2100, EN
14683, or equivalent) that aim to balance high filtration, adequate breathability and, optionally, fluid-
penetration resistance [14].
Non-hazardous waste does not pose biological, chemical, radioactive or physical risk to people or
the environment, and can be disposed of as municipal waste*. Examples include paper, boxes,
bottles, plastic containers and PPE that have not been contaminated with body fluids or used in an
isolation area [12].
Non-hazardous waste
*Municipal waste is general waste generated mainly by households and commercial activities, and
ideally collected by municipalities (e.g. local villages or cities) for disposal. Municipal waste should
not contain untreated health-care waste [12].
Non-medical masks are a type of facial covering of the mouth and nose of the wearer that are used
to mitigate the spread of respiratory infections but do not meet the performance standards of
medical or surgical masks. Their primary purpose is for source control and to provide a degree of
Non-medical masks particulate filtration to reduce the amount of inhaled particulate matter.
Essential parameters for the performance and safety of non-medical masks have been advocated
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during the COVID-19 public health emergency of international concern (PHEIC) through several
existing international guidelines and one international standard for non-medical masks (ASTM
F3502-21) [14][22][23][24]. Non-medical masks that are self-made or commercially produced and
do not meet guideline-supported essential parameters are permitted in areas that have not
mandated minimum performance requirements for non-medical masks prior to sale and for use by
the general public.
Occupational health and safety is a multidisciplinary area of work aiming at the promotion and
maintenance of the highest degree of physical, mental and social well-being of workers in all
Occupational health and occupations; the prevention among workers of effects on health from their working conditions; the
safety protection of workers in their employment from risks resulting from factors adverse to health; and
the placement and maintenance of the workers in an occupational environment adapted to their
physiological and psychological capabilities [18].
In contrast to active surveillance, passive screening (self-reporting) entails the self-reporting by

health and care workers of symptoms of illness to an appropriate occupational health and safety or
Passive screening (self-
other designated officer in the facility before, during or after their shift. This may be the most
reporting)
suitable option in countries where human, financial and technical resources are limited. It is the
most common type of surveillance in humanitarian emergencies [25][26][27].
The stage that includes the development of public health emergency response plans for relevant
hazards: the mapping of potential hazards and hazard sites, the identification of available
resources, the development of appropriate national stockpiles of resources, and the capacity to
Preparedness
support operations at the intermediate and community and/or primary response levels during a
public health emergency. These activities may take 6 months to 2 years in order to be fully prepared
for an emerging infectious disease or public health threat [129].
The stage that links effective preparedness to efficient response, a statement of the capacity and
Readiness capability of a relief agency or service. These activities may take up to 6 months in order to ensure
readiness for a specific defined threat [129].
The stage in which emergency actions exceed the usual level of activities, in response to a defined
Response
public health threat [129].
The stage after the public heatlh threat has been mitigated or protected. This phase ensure that
Recovery health systems continue to function, but also to identify and digest the lessons learnt through After
Action Reviews (AAR) and ultimately to “build back better” [129].
Standard precautions aim to protect health and care workers and patients by reducing the risk of
transmission of microorganisms from both recognized and unrecognized sources. They are the
minimum standard of IPC practices that should be used by all health and care workers during the
care of all patients, at all times, in all settings. When applied consistently, standard precautions can
prevent the transmission of microorganisms among patients, health and care workers and the
Standard precautions
environment. Key elements of standard precautions include: 1) risk assessment, 2) hand hygiene,
3) respiratory hygiene and cough etiquette, 4) patient placement, 5) personal protective equipment,
6) aseptic technique, 7) safe injections and sharps-injury prevention, 8) environmental cleaning, 9)
handling of laundry and linen, 10) waste management, and 11) decontamination and reprocessing
of reusable patient-care items and equipment [11].
Syndromic screening is the near real-time collection, analysis, interpretation and dissemination of
Syndromic screening health-related data to enable the early identification of the impact (or absence of impact) of potential
health threats that may require public health action [25][26][27].
Spray is the projection of product onto or into a surface, item, or a device (such as an atomizer
Spray
or sprayer) by which a spray is dispersed or applied.
Targeted continuous medical Targeted continuous medical mask use is the practice of wearing a medical mask by all health
mask use workers and caregivers working in clinical areas during all routine activities throughout the entire
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shift.
Transmission-based precautions are used in addition to standard precautions for patients with
known or suspected infection or colonization with transmissible and/or epidemiologically significant
Transmission based pathogens. The type of transmission-based precautions assigned to a patient depends on the
precautions transmission route of the microorganism: contact, droplet or airborne. Transmission-based
precautions must be started as soon as a patient presents with symptoms (e.g. fever, new cough,
vomiting, diarrhoea). There is no need to wait for test results [9].
To wipe is to clean or dry by rubbing with a cloth/paper towel. In health-care facilities, surfaces are
Wipe wiped with cloths soaked with water/detergent, then rinsed and wiped again in a systematic manner
with an approved disinfectant.
Universal masking is the requirement for all persons (staff, patients, visitors, service providers and
Universal masking
others) in health facilities to wear a mask at all times except when eating or drinking.
Ventilation is the process of supplying outdoor air to and removing indoor air from a space, for the
Ventilation purpose of controlling air contaminant levels, potentially accompanied by humidity and/or
temperature, by natural or mechanical means [7].
1
Definition from the WHO Guidelines on "Infection prevention and control of epidemic-and pandemic-prone acute respiratory infections
in health care" (2014) [8]. WHO has hosted expert global consultations in 2022 and in 2023 to further review and plans to update the
definition of airborne transmission. For the latest information on how COVID-19 is transmitted, please see “Coronavirus disease
(COVID-19): How is it transmitted?".
1.2 Abbreviations
ARO Antibiotic-resistant organism
AIIR Airborne infection isolation room
AGP Aerosol generating procedure
Ag-RDT Antigen-detection rapid diagnostic test
ASTM American Society for Testing Materials
aOR Adjusted odds ratio
CASP Critical appraisal skills programme
COVID-19 Coronavirus disease 2019
CI Confidence interval
CT Community transmission
DOI Declaration of interest
EtD Evidence to decision
FFR Filtering facepiece respirator
GDG Guideline Development Group
GPS Good practice statement
GRADE Grading of recommendations, assessment, development and evaluation
GRADE-CERQual Confidence in the evidence from reviews of qualitative research
HAI Health-care-associated infection
HEPA High-efficiency particulate air (filter)
HR Hazards ratio
HVAC Heating, ventilation and air conditioning
ICU Intensive care unit
ILI Influenza-like illness
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IPA International Pediatric Association

IPC Infection prevention and control
NAAT Nucleic acid amplification test
NIOSH National Institute for Occupational Safety and Health
NPI Non-pharmaceutical intervention
MDRO Multidrug-resistant organism
MMAT Mixed-methods appraisal tool
OHS Occupational health and safety
OR Odds ratio
PICO Population, Intervention, Comparator, Outcome
PHEIC Public health emergency of international concern
PHSM Public health and social measure
PPE Personal protective equipment
ROBINS-I Risk of bias in non-randomized studies - of interventions
RCT Randomized controlled trial
rRT-PCR Real-time reverse-transcription polymerase chain reaction
SARS-CoV-1 Severe acute respiratory syndrome coronavirus
SARS-CoV-2 Severe acute respiratory syndrome coronavirus 2
SPICE Setting, Perspective, Intervention, Comparison, Evaluation
UNICEF United Nations Children's Fund
US CDC United States Centers for Disease Control and Prevention
UVGI Ultraviolet germicidal irradiation
WHO World Health Organization
VE Vaccine effectiveness
VoC Variant of concern
1.3 Background
The Infection prevention and control in the context of coronavirus disease 2019 (COVID-19) guideline consolidates infection prevention
and control (IPC) technical guidance developed and published during the COVID-19 pandemic into evidence-informed
recommendations for IPC. Consistent application of IPC measures is essential to preventing transmission of SARS-CoV-2 in health-
care settings, and to establishing relevant mitigation measures in community settings.
The objective of this technical guideline is to provide the most up-to-date recommendations for IPC measures to be implemented when
caring for people with or managing outbreaks of COVID-19. The focus of the guideline is infection prevention and control principles and
practices, with reference to other relevant WHO COVID-19 guidance and resources. In the context of health-care and community
settings, there are areas of overlap with recommendations from other WHO guidelines relevant to IPC measures and implementation
considerations (e.g. clinical management, surveillance, contact tracing and quarantine, laboratory and diagnostic testing, risk
communications and community engagement, public health and social measures, preparedness, readiness and response actions for
COVID-19).
Intended audiences
The target audiences of these guidelines are policy-makers and decision-makers, public health professionals, response incident
managers, IPC professionals, IPC focal points, occupational health and safety for health and care workers at the national, subnational
and facility levels, health-care facility administrators, managers and other health and care workers.
Current context of COVID-19

Health-care facilities remain high-risk settings for SARS-CoV-2 transmission and amplification of healthcare associated infections.
They are locations where patients at risk of severe COVID-19 are admitted and cared for. Maintaining and improving IPC measures
remain critical to ensuring the well-being of patients, staff and visitors.
As the pandemic is in its fourth year, COVID-19 is now an established and ongoing health issue, and is no longer considered a public
health emergency of international concern (PHEIC) [28].
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The updated recommendations consider the current context of COVID-19, including the 2023-2025 COVID-19 Strategic Preparedness
and Response Plan (SPRP) From emergency response to long-term COVID-19 disease management: sustaining gains made during
the COVID-19 pandemic [1][2], which assists countries as they are working to transition their critical emergency response activities to
longer-term, sustained COVID-19 disease prevention, control and management practices. Strategic priorities include strengthening
integrated surveillance and achieving vaccination targets for at-risk groups; continuing to develop strategies to increase access to
affordable therapeutics; and strengthening pandemic preparedness planning while continuing to protect vulnerable groups. To support
emerging needs, especially in fragile, conflict-affected, and vulnerable contexts, countries need to align coordination, planning,
financing and monitoring for the COVID-19 response with broader emergency coordination mechanisms [2].
The primary objective is to ensure the long-term management and sustainability of COVID-19 response efforts in the context of other
concurrent health crises, and integration into broader prevention and control programmes, as well as respiratory disease management.
It remains critical to address the key factors that drive the transmission and impact of SARS-CoV-2, thereby reducing the risk of
emerging SARS-CoV-2 variants of concern and mitigating the direct and indirect consequences of COVID-19 disease. This approach
is vital for strengthening the public health foundation for future epidemic and pandemic responses.
At the time of writing this version of the guideline, although weekly reported cases and deaths are at lower levels, millions continue to
be infected or re-infected with SARS-CoV-2 and thousands of people are dying each week [1]. The global public health risk associated
with COVID-19 remains high. There is evidence of reducing risks to human health driven mainly by high population-level immunity from
infection, vaccination, or both; same levels of virulence of currently circulating SARS-CoV-2 Omicron sublineages compared to
previously circulating Omicron sublineages; implementing public health and social measures; and improving clinical case
management. These factors have contributed to a progressive global decline in the weekly number of COVID-19-related deaths,
hospitalizations, and admissions to intensive care units (ICU). However, available information on hospitalizations and ICU admissions
is provided from a limited number of countries, most of which are high-income countries (HICs). The decline in COVID-19-related
hospitalizations and ICU admissions are expected to increase the capacity of health systems to cope with potential COVID-19
resurgences and the burden of cases of post-COVID-19 condition (PCC), however, uncertainty remains. While the risk of SARS-CoV-2
variants is certain and the risk of more virulent variants emerging exists, the currently circulating variants do not appear to be
associated with increased severity.
COVID-19 transmission remains varied, with evidence suggesting a reduced risk to human health driven mainly by the following
factors: high population-level immunity from infection, vaccination and/or hybrid immunity; variants with consistently lower virulence;
increased availability of countermeasures; and improved clinical care. While SARS-CoV-2 continues to evolve, WHO monitors variants
for severity and impact on health systems [28].
The updated IPC recommendations consider the current context of COVID-19, evolving epidemiological trends, the emergence of new
variants of concern (VoCs), and other factors such as populations and settings at risk, immunity, availability and uptake of vaccines,
and other contextual factors.
Guideline development
This guideline was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process
and the Evidence to Decision framework and in accordance with WHO norms and standards for guideline development [29][30].
To develop the guideline, WHO convened a Guideline Development Group (GDG) to consider current scientific evidence while
assessing factors such as the relative benefits and harms, values and preferences, resource implications, availability and feasibility
issues. The GDG members had expertise in IPC, epidemiology, infectious diseases, microbiology, pediatrics, water, sanitation and
hygiene (WASH), engineering and aerobiology. Balance was sought on the GDG with regard to geographical and gender
representation.
WHO convened the GDG to address specific settings and populations. A methodologist with expertise in guideline development
assisted the GDG in formulating the recommendations. While the GDG takes into account the individual patient perspective when
making recommendations, it also considers resource implications, acceptability, feasibility, equity and human rights. Although
systematic reviews were conducted, there were limited studies to address the questions related to human rights and the overall quality
of evidence was low. The GDG carefully considered the available evidence, contextual factors, and implementation considerations in
its deliberations.
The WHO Quality Assurance for Norms and Standards Department helped to identify rapid reviews of the evidence. Where required,
WHO staff or commissioned external review teams conducted systematic reviews to address specific questions to inform
recommendations. Additional details are described in the methodology section.
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Updates and access

Several updates to the IPC COVID-19 guidelines were completed during the period of the pandemic response, informed by emerging
evidence and consultation with the GDG. This update (version 7) considers the context of the transition from critical emergency-
response activities to longer-term, sustained COVID-19 disease prevention, control and management, and a shift towards integration
of IPC activities into routine systems and practices (i.e. a return to standard and transmission-based precautions in health-care
settings, and public health and social measures for community settings) [1][2].
The first version was published 22 December 2021 using a living guideline format, driven by what was then the urgent need for global
collaboration to provide trustworthy and evolving COVID-19 guidance informing policy and practice worldwide. This update (version 7)
is considered a standard guideline, subject to review in accordance with WHO methodology for guideline development, and depending
on how fast the evidence in a topic area is expected to change.
The guideline is written, disseminated and updated on an online platform (MAGICapp) and can be found on the WHO website.
1.3.1 Summary of recommendations and good practice statements for the health-care
settings
Table 1. Summary of recommendations and good practice states in the health-care setting.
Recommendation or good practice statement Strength/type Date Published
Ventilation
1. WHO recommends adhering to the ventilation rate Strong recommendation for, 09 October 2023
requirements for health-care facilities in the context of very low certainty of
COVID-19: evidence
160 l/s/patient for airborne precaution rooms
60 l/s/patient for general wards and outpatient departments
Physical barriers
2. WHO suggests considering the use of physical barriers such Conditional recommendation 09 October 2023
as glass or plastic windows for areas where patients first for, very low certainty of
present, such as screening and triage areas, the registration evidence
desk at the emergency department and the pharmacy
window.
Physical distancing
3. Maintain a physical distance of at least 1 metre between and Good Practice Statement 09 October 2023
among patients, staff and all other persons in health-care
settings, when feasible. When possible, increase this
distance.
Mask use for source control
4. WHO suggests targeted continuous medical mask use in Conditional recommendation 09 October 2023
health-care facilities in situations with minimum to moderate for, very low certainty of
impact of COVID-19 on the health system. evidence
Remarks:
• Targeted continuous masking is the practice of wearing a

well-fitting medical mask by all health and care workers
and caregivers in clinical areas during all routine
activities throughout the entire shift.
• In non-patient areas, staff who have no patient contact
are not required to wear a medical mask during routine
activities.
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• If caring for a suspected or confirmed COVID-19 patient,

please see the recommendation on mask type for health
and care workers.
5. WHO recommends universal masking in health-care facilities Strong recommendation for, 09 October 2023
when there is a significant impact of COVID-19 on the health very low certainty of
system. evidence
Remarks:
• Universal masking is the practice of all health and care

workers and other staff, caregivers, visitors, outpatients
and service providers wearing a well-fitting medical
mask at all times within the health facility and in any
common area (e.g. cafeteria, staff rooms).
• Inpatients are not required to wear a medical mask
unless physical distancing of at least 1 metre cannot be
maintained (e.g. during examinations or bedside visits)
or when outside of their care area (e.g. when being
transported), provided the patient is able to tolerate the
mask and there are no other contraindications.
• If caring for suspected or confirmed COVID-19 patients,
please see the recommendation on mask type for health
and care workers.
PPE section and use

6. Appropriate mask fitting should always be ensured (for Good Practice Statement 09 October 2023
respirators, through fit testing and a user seal check when a
filtering facepiece respirator is put on; and for medical masks,
through methods to reduce air leakage around the mask) as
well as compliance with appropriate use of PPE and other
standard and transmission-based precautions.
7. A respirator or a medical mask should be worn along with Strong recommendation, low 09 October 2023
other PPE – a gown, gloves and eye protection – by health certainty of evidence
and care workers providing care to a patient with suspected
or confirmed COVID-19.
8. Suggested factors for informing the choice of the type of Conditional 09 October 2023
mask include a risk assessment and health and care workers’ recommendation, low
values and preferences. certainty of evidence
WHO suggests respirators be used in care settings where

ventilation is known to be poor or cannot be assessed, or the
ventilation system is not properly maintained.
Aerosol-generating procedures
9. WHO suggests using airborne precautions while performing Conditional recommendation 09 October 2023
aerosol-generating procedures (AGPs) and, based on a risk for, very low certainty of
assessment, when caring for patients with suspected or evidence
confirmed COVID-19.
10. A respirator should always be worn along with other PPE by Strong recommendation for, 09 October 2023
health and care workers performing aerosol-generating very low certainty of
procedures (AGPs) and by health and care workers on duty evidence
in settings where AGPs are regularly performed on patients
with suspected or confirmed COVID-19, such as intensive
care units (ICU), semi-intensive care units or emergency
departments.
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Environmental cleaning
11. For COVID-19, health-care settings should use standard Good Practice Statement 21 December
precautions for the cleaning and disinfection of the 2023
environment and other frequently touched surfaces.
Waste management
12. Health-care waste generated from care provided to Good Practice Statement 21 December
suspected or confirmed COVID-19 patients should be 2023
segregated according to existing guidelines (e.g. non-
infectious, infectious) for disposal and, where necessary,
treated per national/subnational/local regulations and
policies.
Handling linens and laundry
13. Health-care facilities should follow standard processes for Good Practice Statement 21 December
handling, transporting, sorting and laundering of linens for 2023
patients with suspected or confirmed COVID-19.
Remark: This process should adhere to national/subnational/

local policies as well as ensure the implementation of
standard precautions.
Safe dead body management

14. Health and care workers and other persons involved in Good Practice Statement 21 December
handling the deceased should follow standard precautions 2023
according to risk-assessment and existing national/
subnational/local protocols for managing and handling the
bodies of deceased persons infected with COVID-19.
Operating theatres
15. WHO suggests that the designation of a specific Conditional recommendation 21 December
operating theatre for patients with suspected or confirmed against, very low certainty of 2023
COVID-19 infection is not needed. evidence
Terminal cleaning of operating theatre after surgical Good Practice Statement 21 December
intervention/procedures for patients with suspected or 2023
16. confirmed COVID-19 should be performed according to
national/subnational and local policies for transmission-based
precautions.
Identification of health and care workers infections in the health care setting
17. Countries should have national and subnational testing Good Practice Statement 10 August 2023
strategies for the detection of SARS-CoV-2 infections in
health and care workers.
18. Passive screening of symptoms for SARS-CoV-2 and other Good Practice Statement 10 August 2023
respiratory infections should be performed based on self-
monitoring and reporting of symptoms by health and care
workers.
19. Health and care workers should be prioritized for SARS- Good Practice Statement 10 August 2023
CoV-2 testing in the context of COVID-19 testing policies for
both the community and health-care facilities.
20. Health-care facilities should have protocols for reporting and Good Practice Statement 10 August 2023
managing health and care workers’ occupational and non-
occupational high-risk exposures to COVID-19.
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21. Any health and care worker who has signs or symptoms of Good Practice Statement 10 August 2023
SARS-CoV-2 infection should be excluded from their
activities at work that require providing in-person care to
patients or other activities in the health-care facility where
they are in contact with other health and care
personnel. They should furthermore consult with their
occupational health and safety department and plan for
isolation in a designated setting for the duration of the
required period of isolation outlined by their local policy.
Duration of isolation for COVID-19 cases in health and care workers
22. We suggest 10 days of isolation for individuals who are Conditional recommendation Published in IPC
symptomatic due to SARS-CoV-2 infection (very low certainty for, very low certainty of guidelines: 10
of evidence). evidence August 2023
Published in
Clinical
Management
guidelines: 13
January 2023
23. We suggest 5 days of isolation for individuals who are Conditional recommendation Published in IPC
asymptomatic with SARS-CoV-2 infection (very low certainty for, very low certainty of guidelines: 10
of evidence). evidence August 2023
Published in
Clinical
Management
guidelines: 13
January 2023
24. We suggest the use of rapid antigen testing to reduce the Conditional recommendation Published in IPC
period of isolation (very low certainty of evidence). for, very low certainty of guidelines: 10
evidence August 2023
Published in
Clinical
Management
guidelines: 13
January 2023
1.3.2 Summary of recommendations and good practice statements for mitigation

measures in the community
Table 2. Summary of recommendations and good practice statements for mitigation measures in the community.
Recommendation or good practice statement Strength/type Date published

Mask use in the community
1. WHO recommends the use of a mask for the Strong recommendation for, low- 13 January 2023
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prevention of SARS-CoV-2 transmission in the to-moderate certainty of evidence

community in the following situations:
• when in crowded, enclosed, or poorly ventilated

spaces;
• following recent exposure to COVID-19 (according
to the WHO definition) when sharing a space with
others;
• when sharing a space with a person who displays
signs or symptoms of COVID-19 or is
COVID-19-positive;
• for individuals at high risk of severe complications
from COVID-19.
2. In situations not addressed by the strong Conditional recommendation for, 13 January 2023
recommendation, WHO suggests a risk-based low-to-moderate certainty of
approach to inform the decision to use a mask for the evidence
prevention of SARS-CoV-2 transmission in the
community.
Factors that favour mask use:
• COVID-19 epidemiological trends at the

community level indicating high or rising
transmission or hospitalizations;
• low coverage of COVID-19 vaccination;
• low levels of population immunity to SARS-CoV-2;
• a greater degree of crowding, poorer indoor
ventilation, and/or the presence of individual risk
factors.
3. Individuals with any signs or symptoms suggestive of Good Practice Statement 13 January 2023
COVID-19 or who test positive for COVID-19 should
wear a medical mask when sharing a space with
others until they are resolved or the isolation period is
complete.
4. Policies aimed at reducing the transmission of SARS- Good Practice Statement 13 January 2023
CoV-2 in the community should be revisited,
strengthened and updated according to the most
recent scientific evidence.
5. When wearing a mask in community settings, Good Practice Statement 10 October 2023
individuals should use a well-fitting mask with full
coverage of the nose and mouth.
• Ensure a snug fit at the nose bridge, cheeks, chin

and lateral sides of the face
• The “knot-and-tuck” and “linking-ear-loops-behind-
the-head” techniques improve medical mask fit by
reducing gaps on the sides of medical masks with
ear loops
Mask use during physical activity

6. WHO suggests that people do not wear masks during Conditional recommendation 21 December 2023
vigorous-intensity physical activity. against, low certainty evidence
Mask use by children
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7. Masks are not required for children 5 years of age and Conditional recommendation 07 March 2022
under. against, very low certainty of
evidence
8. In areas where there is known or suspected community Conditional recommendation for, 07 March 2022
transmission of SARS-CoV-2, masks are low certainty of evidence
recommended for use in children ages 6-11 years in
the following settings:
• in indoor settings where ventilation is known to be

poor or cannot be assessed, or the ventilation
system is not properly maintained, regardless of
whether physical distancing of at least 1 metre
can be maintained;
• in indoor settings that have adequate ventilation if
physical distancing of at least 1 metre cannot be
maintained.
9. Adolescents 12 years or older should follow the same Strong recommendation for, low 07 March 2022
WHO recommendations for mask use as adults. certainty of evidence
10. Children with cognitive or respiratory impairments, Good Practice Statement 07 March 2022
developmental disorders, disabilities or other specific
health conditions who experience difficulties wearing a
mask or have health conditions that interfere with
mask-wearing should not be required to wear a mask.
11. The use of a medical mask is recommended for Good Practice Statement 07 March 2022
children with a higher risk of severe complications from
COVID-19 but should be assessed in consultation with
the child’s medical provider.
Glove use
12. WHO suggests that the general public not wear gloves Conditional recommendation 21 December 2023
for routine activities in community settings in the against, very low certainty of
context of COVID-19. evidence
Remarks: Hand hygiene should be performed

frequently.
Environmental cleaning
13. In the context of COVID-19, households and Good Practice Statement 21 December 2023
community settings should follow routine
environmental cleaning and disinfection practices.
Waste management
14. Waste generated in the community from persons with Good Practice Statement 21 December 2023
suspected or confirmed COVID-19 should be handled
and disposed of according to national/subnational/local
regulations for waste management.
Handling of linens and laundry

15. Regular household processes should be used for Good Practice Statement 21 December 2023
laundering items for persons with suspected or
confirmed COVID-19.
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2. Methodology
Guideline Development Groups (GDGs) and External Review Groups
The IPC recommendations, good practice statements (GPSs) and implementation considerations included in this document were
developed in accordance with WHO methodology, including a review of available evidence by the Guideline Development Group (GDG).
The establishment of the GDG considered representation of members with a broad expertise spanning multiple specialties, across all
WHO regions, and was gender-balanced. A consensus was sought for recommendations and GPSs. When consensus was not achieved,
approval of a recommendation or GPS required a supermajority (≥ 70%) of the GDG voting members.
The technical officer responsible for the collection and review of the required declaration of interest (DOI) from GDG members assessed
the DOIs for any potential conflicts. If a conflict of interest was identified, appropriate management actions were taken in accordance with
the WHO Handbook for guideline development and WHO Guidelines for DOI (for WHO Experts) [29][31].
External review group members were also identified for specific technical areas and provided additional review of the guidelines. External
review groups do not change the recommendations made by the GDG; however, any major concerns are brought back to the GDG for
additional discussion. For more information on authorship, contributions and DOI, please refer to the acknowledgement section.
Evidence synthesis and assessment

As noted in the Executive Summary, with support from the WHO Quality Assurance for Norms and Standards Department, rapid
systematic reviews of published literature were commissioned. The literature for each identified topic was assessed using Grading of
Recommendations, Assessment, Development and Evaluation (GRADE) to determine the certainty of the evidence (Table 1) based on the
presence of risk of bias/study limitations, inconsistency, imprecision, indirectness and publication/reporting biases.
Table 3. Determining the Quality of Evidence in Grading of Recommendations, Assessment, Development and Evaluation
(GRADE)
Quality level Definition
The Group is very confident in the estimate of effect and considers that further research is
High
very unlikely to change this confidence.
The Group has moderate confidence in the estimate of effect and considers that further
Moderate research is likely to have an important impact on that confidence and may change the
estimate.
The Group has low confidence in the estimate of effect and considers that further research is
Low very likely to have an important impact on that confidence and is likely to change the
estimate.
Very low The Group is very uncertain about the estimate of the effect.
Rapid reviews
To provide timely, evidence-informed recommendations, the GDG needed to review multiple questions within a limited time frame. Rapid
reviews of the evidence were commissioned to external groups (e.g. clinical effectiveness of mask use in health care and use of airborne
precautions in the context of COVID-19) or conducted by WHO staff (e.g. ecological studies on mask effectiveness). Reviews were
conducted using standardized methods for systematic reviews, which included searches of multiple electronic databases, use of pre-
defined inclusion/exclusion criteria, risk-of-bias assessments and syntheses (using GRADE); noting that some used rapid-review methods
and some were living reviews. Furthermore, non-commissioned and previously published reviews supplemented the decision-making
process. Some of the reviews have been published and updated to identify emerging evidence that informed deliberations by the
GDG [32][33]. Some of the rapid reviews have been published to identify any emerging evidence that may inform deliberations by the
GDG [32][33]; details about search strategies can be found within these reviews. Evidence from randomized, controlled trials (RCTs) has
been limited; therefore, the reviews included non-randomized studies, cohort, case-control and ecological studies.
Airborne precautions, ventilation, dead body management, waste management, physical barriers, laundry, operating rooms and
glove use in the community rapid review
The rapid reviews of airborne precautions, physical barriers, ventilation, dead body management, waste management, physical barriers,
laundry, operating rooms and glove use in the community were informed by the approach for rapid reviews developed by Tricco et al.,[34].
Search strategies were tested and designed in conjunction with the WHO Secretariat. Final searches were conducted in Medline, Elsevier
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Embase, medRxiv preprint server, and Google Scholar. Documents were selected through pre-set inclusion and exclusion criteria. The
study design, population, setting and methodology were extracted from the included articles for synthesis. All data were analysed using
framework analysis [35] and assessed for quality using the Mixed Methods Appraisal Tool (MMAT). When the search yielded studies
answering the PICO (Population, Intervention, Comparator, Outcome) question, a summary of findings or GRADE tables was presented to
the GDG.
Universal masking and targeted continuous masking rapid review

The rapid review for universal masking was conducted through a rapid, living review approach. A medical librarian searched PubMed,
MEDLINE, and Elsevier Embase, WHO COVID-19 database and the medRxiv preprint server. Studies were selected by using predefined
criteria. One investigator extracted study data (e.g. study author, year, population characteristics and results) and a second investigator
verified data; odds ratios were calculated as needed. A formal risk-of-bias assessment was not done, though key limitations were
narratively noted. Results were synthesized, though quantitative synthesis was not possible due to methodological limitations; study
design variability; and heterogeneity in populations, comparisons, and analytic methods. The results and the certainty of evidence were
presented to the GDG using GRADE, including GRADE Evidence Profiles and Summary of Findings tables. Contextual data on cost-
effectiveness, equity, acceptability, resources required and feasibility were captured and summarized narratively. Since the completion of
the published rapid review [36][37], the WHO Secretariat has been receiving quarterly updates from the author group on the topic to inform
evidence-based recommendations.
Mask type rapid review

Evidence for mask effectiveness and type is continuously reviewed through a rapid, living review approach [32][33]. A medical librarian
searched PubMed, MEDLINE, and Elsevier Embase, WHO COVID-19 database and the medRxiv preprint server. Studies were selected
by using predefined criteria. The population was health and care workers with interventions of disposable N95 filtering facepiece
respirators, surgical masks and cloth masks. One investigator extracted study data (e.g. study author, year, setting, population
characteristics, mask intervention, and results) into standardized tables, and a second investigator verified data. Relative risks were
calculated for randomized trials and odds ratios were calculated for observational studies. For observational studies, key limitations of
each study, such as potential recall, selection, or participation bias, were noted and results were synthesized narratively. Unadjusted and
adjusted risk estimates were presented for observational studies. For cluster randomized trials, risk estimates adjusted for cluster effects
were utilized. The results and the certainty of evidence were presented using GRADE, including GRADE Evidence Profiles and Summary
of Findings tables. Contextual data on cost-effectiveness, equity, acceptability, resources required, and feasibility were captured and
summarized narratively. Additional details on the study methodology can be found in the published article or its frequent updates [32][33].
Cleaning and disinfection, spraying versus wiping, physical distance, and mask use during physical activity rapid review
The rapid reviews on cleaning and disinfection, spraying versus wiping, physical distance and mask use during physical activity were
performed by an external team. Search strategies were tested and designed in conjunction with the WHO Secretariat. Final searches were
conducted in Cochrane Library, Cochrane Database for Systematic Reviews, Central, Elsevier Embase, and PubMed. Documents were
selected through pre-set inclusion and exclusion criteria. The study design, population, setting and methodology were extracted from the
included articles for synthesis. Three authors independently screened the search output (for both title and abstract and full-text eligibility
screening) using Distiller SR and MS Excel. Any discrepancies were resolved by discussion within the review team. Assessment of the
risk of bias in included studies was with ROBINS-I (Risk of bias in non-randomized studies - of interventions). GRADE profile was
prepared by one author and cross-checked by other members of the review team, and a summary of findings or GRADE tables was
presented to the GDG.
Evidence review for the chapter on management, identification and prevention of infections in health and care workers
The WHO Quality Assurance for Norms and Standards Department conducted a systematic review to assess the latest evidence on the
prevention, identification, testing and management of infected health and care workers. The librarian and members of the IPC team
designed the search strategy. The PICOs were developed in conjunction with the GDG chairs, methodologists and Secretariat to examine
research that had not previously been evaluated to provide the basis for an evidence-based decision. The WHO COVID-19 Research
Database, which includes results from several other databases, was searched from January 2020 to June 2022. Full details can be found
in Annex 3.
Evidence from RCTs has been limited during the pandemic. Therefore, the reviews included mostly non-randomized studies, cohort, case-
control and ecological studies. The systematic reviews were presented in GDG meetings and were supplemented by other (non-
systematically reviewed) data presented by WHO staff. Such presentations informed considerations regarding contextual factors on testing
health and care workers; their recommended isolation period; when to return to work after an infection; and under what conditions. The
GDG also received regular updates on SARS-CoV-2 epidemiology and transmission from the WHO epidemiology team. In addition, the
WHO clinical management team for COVID-19 presented a systematic review on the period of infectiousness, which influenced the GDG’s
recommendations on the duration of isolation needed for a positive COVID-19 case. Some members of the IPC GDG participated in the
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development of this recommendation by the Clinical Management GDG, and the recommendation was also adopted for health and care
workers.
Qualitative reviews and grey literature searches

In addition to the rapid reviews, other data were presented by WHO staff, Member States and partner organizations. Such presentations
were used to inform considerations regarding contextual factors on mask use, physical barriers and distancing, and cleaning and
disinfection. These presentations included desk reviews of other prominent guidelines, information on mask filtration properties, technical
specifications on ventilation and periodic updates on the ever-changing epidemiology of COVID-19.
WHO also commissioned a qualitative review of the literature (reports, qualitative studies and related systematic reviews) to understand
the perceptions of health and care workers on mask use and other PPE and to better inform the GDG in the evidence-to-decision-making
process. The review question was articulated using the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) framework and
the protocol was registered on PROSPERO, an international prospective register of systematic reviews. The review utilized a structured
database search on MEDLINE (Ovid) and study selection and data extraction were conducted using pre-piloted tools. Methodological
quality was assessed using the modified CASP (Critical appraisal skills programme) tool and data were synthesized using the thematic
synthesis approach. Such an approach generated descriptive and analytical themes, using the GRADE-CERQual (Confidence in the
evidence from reviews of qualitative research) tool to assess confidence in the review finding. Findings were presented to the GDG to help
inform the evidence-to-decision framework.
Rapid reviews of the evidence for mask use in the community

Systematic reviews were commissioned to external groups [32][33] or conducted by WHO staff [38].
The evidence review for mask use in the community was continuously reviewed through a rapid, living review approach. A medical
librarian searched PubMed, MEDLINE, and Elsevier Embase, the WHO COVID-19 Research Database and the medRxiv preprint server.
Studies were selected by using predefined criteria. One investigator extracted study data (e.g. study author, year, population
characteristics, setting) into standardized tables, and a second investigator verified data (study author, year, setting, mask interventions
and results). Relative risks were calculated for randomized trials and odds ratios for observational studies. Available data on RCTs were
assessed by using criteria adapted from the U.S. Preventive Services Task Force. For observational studies, key limitations of each study,
such as potential recall, selection or participation bias were noted and results were synthesized narratively. Risk estimates adjusted for
cluster effects and unadjusted and adjusted risk estimates were presented for RCTs and observational studies, respectively. The results
and the certainty of evidence were presented using GRADE, including GRADE Evidence Profiles and Summary of Findings tables.
Contextual data on cost-effectiveness, equity, acceptability, resources required and feasibility were captured and summarized narratively.
This review has been published and is regularly updated to include any emerging evidence that may inform deliberations by the GDG.
The systematic review on mask fit was informed by guidance for rapid evidence reviews developed by Tricco et al. [34]. Search
strategies were tested and designed in conjunction with the WHO Secretariat. Final searches were conducted in Medline, Elsevier
Embase, medRxiv preprint server, and Google Scholar. Documents were selected through pre-set inclusion and exclusion criteria. The
study design, study population, study setting and study methodology were extracted from the included articles for synthesis. All data were
analysed using framework analyses [35] and assessed for quality using the MMAT. The results and the certainty of evidence were
presented using GRADE, including GRADE Evidence Profiles and Summary of Findings tables. Due to a lack of data that would enable
pooling, a descriptive summary of the patient characteristics, study characteristics, and risk of bias/methodological quality results was
presented.
Process for developing recommendations

Once the balance of benefits to harms and certainty of the evidence was determined (based on the systematic reviews described above),
the GDG, with the guidance of the methodologist, determined if a recommendation (strong or conditional) or a GPS was warranted.
GRADE evidence profiles describe the GDG’s assessment of the balance of benefits to harms, the certainty of the evidence, and a
summary of findings for each critical outcome and each key question. The GDG used these summaries as the basis for discussions and
formulation of recommendations.
The evidence-to-decision (EtD) framework was used by the GDG to support the formulation of the recommendation or GPS. In addition to
the magnitude of benefits relative to harms and the certainty of the evidence, the strength of recommendations (strong or conditional) was
informed by values and preferences, resource allocation (costs), equity, feasibility and acceptability (Table 2).
Table 4. Evidence-to-decision-making domains
Domain Favours strong recommendations Favours conditional
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recommendations
Benefits and harms more closely

Balance of benefits and harms Benefits highly outweigh harms
balanced
Quality of evidence Higher certainty Lower certainty
Benefits-to-harms assessment not

Values/preferences regarding Variability in values/preferences would
afected by variability in values/
outcomes affect benefits to harms assessment
preferences
Acceptability Highly acceptable Low or variable acceptability
Costs/resources Cost saving/cost effective Costly/cost ineffective
Unfeasible or feasibility varies in intended

Feasibility Feasible in intended settings
settings
Decreased equity or effect on equity

Equity Increased equity
variable
For mask use in children, these additional EtD domains were informed by five consultation sessions conducted by the United Nations
Children's Fund (UNICEF) with members of the International Pediatric Association (IPA), and members from different geographical
regions, in multiple languages, regarding paediatric health professionals' children's field experiences (including acceptability and feasibility)
with the implementation of previous WHO guidance on masks.
For recommendations on mask use in health and care workers, the EtD domains were informed by presentations from stakeholders from
individual countries regarding acceptability and feasibility, mask availability and costs globally. The GDG also received regular updates on
SARS-CoV-2 epidemiology and transmission from the WHO epidemiology team. Otherwise, the EtD domain assessments (including
values/preferences and equity) were based on the collective input and experience of the GDG, which comprised members (including
persons in the community, clinicians and policymakers) who represented all WHO regions and ranged from low- to very high-income
countries, supplemented by key studies suggested by GDG members when available. Results from the qualitative review on PPE and
masks were also used to inform the evidence to decision tables for mask use by health and care workers.
The GDG graded recommendations as strong or conditional. Strong recommendations are supported when benefits clearly outweigh
harms with at least moderate certainty; other factors that support strong recommendations are non-sensitivity to variability in preferences/
values regarding outcomes, wide feasibility and acceptability, cost savings or cost-effectiveness, and likely positive impacts on improving
equity. When certainty is low or very low, strong recommendations require a strong rationale for potential net benefits despite important
uncertainty and strong support from the other EtD domains. Alternatively, a GPS may be considered if the certainty of benefits is high
based on indirect evidence, despite no direct evidence or low/very low certainty based on direct evidence (see the section on GPS). In
some cases, after determining that the benefits of intervention do not outweigh the harms and considering EtD domains (Table 2), the
GDG may make a recommendation against an intervention. The GRADE tables used in this guideline can be found in the evidence
section.
Good practice statements and implementation considerations

GPSs are most suitable when direct evidence is lacking, but benefits are determined to be large and harms very small; the certainty of
benefits and harms is great; the decision to use the recommended intervention is not sensitive to values/preferences regarding outcomes;
the intervention is cost saving; and the intervention is clearly acceptable, feasible and promotes equity [39][40][41][42]. GPSs
characteristically represent situations in which a large and compelling body of indirect evidence, made up of linked evidence including
several indirect comparisons, strongly supports the net benefit of the recommended action [39][40][41][42]. GPSs generally indicate
interventions that would be considered the standard practice that obviously would result in net benefit. GPSs are not GRADEd
statements [39][40][41][42].
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On multiple occasions, the GDG elected for a GPS instead of a strong or conditional recommendation. These GPSs are part of an overall
evidence-based process, and often a systematic review was commissioned to determine whether direct evidence was available. The GDG
issued a GPS if it judged that an assessment of the use of indirect evidence provided high certainty of benefit despite the fact that the
evidence was either insufficient or of such low quality that it did not qualify as a recommendation.
Implementation considerations are critical elements that facilitate the appropriate use of recommendations and GPSs. When applying IPC
measures, it is important to consider factors that can affect successful implementation, potential barriers and strategies to adapt to the
specific setting and situational needs.
Implementation considerations refer to the factors that need to be taken into account when putting guidelines or recommendations into
practice. These include practical, logistical and organizational aspects that can affect the application of measures to be followed by health-
care providers and organizations. Examples include factors such as resource allocation, training and education, the physical environment
and layout of the health-care facility, integration into existing systems, application at the point of care, cultural and contextual
considerations.
Implementation considerations are not assessed using the GRADE methodology. However, considerations for application of
recommendations into practice are guided by existing WHO guidelines and established IPC practices (standard and transmission-based
precautions). They may be actionable and relevant to implementing one of the intervention options and may include information to
enhance implementation [39][40][41][42].
Readership cues for statements

Table 3 presents the readership cues used for the statements in this guideline, which is subject to review as a normative product. The
green checkmarks and red X symbols reflect statements that are developed using the GRADE evidence-assessment methodology and the
evidence-to-decision framework to inform a recommendation or a GPS. The grey bar refers to implementation considerations that support
statements through practical advice and are the product of expert consensus.
Table 5. Readership cues used for statements in the guideline
The GREEN checkmark symbol denotes a recommendation or a good practice statement in favour of an
intervention.
The RED X denotes a recommendation or good practice statement against an intervention.
The GREY bar denotes an implementation consideration supporting the practical implementation of the
statement.
Periodicity of the guideline revision and updates

In accordance with WHO methodology, several updates to the IPC COVID guideline were completed during the period of the pandemic
response, informed by emerging evidence and consultation with the GDG. Considering the current context of COVID-19, with the transition
from emergency status (PHEIC) with a return to normative IPC practices, this update (version 7) transitions the format from a living
guideline to a guideline.
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3. Part 1: Health-care settings

This section provides an overview of infection prevention and control (IPC) principles and practices, and IPC measures for patients with
suspected or confirmed COVID-19 in health-care settings.
3.1 Background
Infection prevention and control (IPC) is a practical, evidence-informed approach to preventing patients and health and care workers
from being harmed by avoidable infections [43]. Implementation of IPC measures is based on a risk-assessment approach and
established practices (i.e. standard and transmission-based precautions). This section provides an overview of IPC programmes,
principles and precautions.
3.1.1 What is an IPC programme?

What is an infection prevention and control programme?
IPC is a practical, evidence-informed approach to preventing patients and health and care workers from being harmed by
avoidable infections. Health-care-associated infections (HAIs) are among the most common adverse events in care delivery and a
major public health problem affecting morbidity, mortality and quality of life. On average, 7% of patients in developed countries and
15% of patients in developing countries will acquire at least one HAI [44]. These infections also impose a significant economic
burden on society. A large proportion of them are preventable through effective IPC measures.
Establishing an infection prevention and control programme at national and acute health-care facility levels
The WHO Guidelines on core components of infection prevention and control programmes at national and acute health-care facility
levels [43] include strategies to prevent current and future threats from infectious agents and antimicrobial resistance in health-
care.
The core components constitute a framework of recommendations and good practice statements distributed into eight areas: 1)
infection prevention and control programmes, 2) national and facility-level infection prevention and control guidelines, 3) IPC
education and training, 4) health-care-associated infections surveillance, 5) multimodal strategies for implementing infection
prevention and control activities, 6) monitoring and evaluation and feedback, 7) workload, staffing and bed occupancy at the facility
level and 8) built environment, materials and equipment for IPC at the facility level. Ensuring adequate clinical staffing levels is
recommended as a core component to prevent the transmission of HAIs and multidrug-resistant organisms (MDROs); limit human-
to-human transmission; reduce secondary infections; and prevent transmission through amplification and super-spreading events.
Implementation of an IPC programme requires a stepwise approach to achieve its full potential [43]. Minimum requirements as
identified by WHO support the strengthening of IPC in countries where IPC is limited or nonexistent [45][46]. In this regard, a
facility-level IPC programme with a dedicated and trained IPC team, or at minimum, an IPC focal point, should be in place and
supported by national-level and facility-level senior management. Achieving the IPC minimum requirements (and more robust and
comprehensive IPC programmes in all countries) is essential to being able to control the COVID-19 pandemic, other emerging and
re-emerging pathogens and MDROs. Finally, WHO has also developed guidance on the core competencies [47] required for
infection prevention and control professional staff, which can be used to develop curricula for IPC specialists.
3.1.2 IPC principles

The following section outlines the core elements of IPC principles and practices for implementation in health-care facilities,
including 1) the chain of transmission, 2) the hierarchy of control measures and 3) the implementation of standard and
transmission-based precautions.
Standard precautions are the core practices that are to be applied in all health-care settings, for all patients, at all times [11].
Transmission-based precautions are additional measures implemented according to a risk assessment, where standard
precautions are not sufficient [9]. For COVID-19, this includes the rapid identification and implementation of control measures, such
as isolation of suspect or confirmed cases. See the respective subsections on standard and transmission-based precautions for
more information.
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Understanding the chain of infection
Epidemiology aids in the understanding of infectious diseases; the distribution of illness; and the identification of modifiable factors
that affect occurrence and outcomes. The spread of microorganisms occurs within a community or health-care setting through a
sequence of events described as a chain of infection [48].
Transmission of microorganisms may result in a transient carriage or long-term colonization, asymptomatic infection or clinical
disease. The presence of microorganisms in or on a host, with growth and multiplication but without tissue invasion or cellular
injury, is referred to as colonization [9]. Infection is the condition in which microorganisms multiply within the body and respond to
the host’s immune defenses. Infection may or may not lead to clinical disease (symptomatic infection) [9].
Certain conditions must be met for an infectious agent to be spread from person to person. The establishment of infection involves
a set of complex interrelationships among the source of the infectious agent, the susceptible host and the environment, and
requires the transmission of infectious agents from the source to a susceptible host [49].
The chain of infection includes six links: the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry and
susceptible host. If this chain is broken at any of the links, the process is interrupted and the infection is prevented from
occurring [48]. IPC measures can interrupt each link of this chain, and thus can control the spread of infectious disease. For
example, by properly applying cleaning and disinfection practices, one may disrupt the reservoir (i.e. contaminated surfaces) and
thereby reduce or limit the spread of disease.
Figure 1. Chain of infection
Infection prevention and control practices are informed by a risk-assessment approach that assesses and analyses the potential for
exposure to infectious agents. When applied consistently, IPC precautions (i.e. standard and transmission-based precautions) can
prevent or reduce the risk of exposure and transmission of health-care-associated and occupational infections [48].
Hierarchy of occupational safety and health-control measures
The hierarchy of controls describes measures that can be taken to minimize exposure and subsequent transmission of infectious
diseases [19]. These principles can be applied in health-care settings to reduce or mitigate the hazard, a key component of IPC
efforts.
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The hierarchy of occupational safety and health control framework includes five levels of actions to reduce or remove hazards:
• Elimination
• Substitution
• Engineering controls
• Administrative controls
• Personal protective equipment (PPE)
Figure 2. Hierarchy of occupational safety and health controls [50]
Principles can be applied in health-care settings to reduce or mitigate the hazard. Control measures listed at the top of the
hierarchy are more protective than those at the bottom. If a combination of measures is implemented at each level, the risk of
transmission is reduced. The hierarchy applies to a broad range of work environments and potential hazards, including pathogens,
other particles and chemicals [19][50].
In the framework above, the two first tiers, elimination and substitution, are more challenging actions to reduce or remove hazards
in health-care settings, as it may not be feasible to eliminate or substitute the hazard. Infection prevention and control measures
focus on three of these tiers: engineering controls, administrative controls, and the selection and use of personal protective
equipment (PPE) for health and care workers to mitigate the risk of potential infectious hazards in the workplace [19][50].
Engineering controls
Engineering controls are measures taken to reduce the risk of transmission of infections to health and care workers and patients
through health-care-facility design. These measures can include modifying the ventilation, the equipment or the workspace; making
available an airborne infection isolation room (AIIR) or other designated isolation room; installing protective and physical barriers;
designating handwashing sinks for use by health and care workers; and creating signage to direct patients.
Engineering controls do not depend on an individual's compliance with exposure-prevention strategies. These controls are usually
established and controlled within the building structure, thereby eliminating choice about their application and reducing the
opportunity for individual error. As such, they provide more effective protection [19][50].
Administrative controls
Administrative controls are measures taken to reduce the risk of transmission of infections to health and care workers and patients
through the implementation of policies, procedures, training, monitoring and support of IPC practices. Examples include support for
effective IPC programmes, IPC policies, procedures and resources (i.e. patient placement, symptom screening, visitor
management, sick-leave policies); occupational health and safety policies, including preplacement assessment, work restrictions,
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respiratory protection programmes, sharps safety and other practices that prevent exposure to bloodborne pathogens; vaccination
programs; training and education of workers; monitoring of IPC practices, HAIs and occupational infections [19][50].
To be effective in preventing the transmission of microorganisms and/or detecting cases of infection, administrative controls are
best implemented at the point of first encounter with an infected source and are continued until the infected source leaves the
health-care setting or is no longer infectious. Inherent in the development of administrative controls to prevent transmission of
infection is the commitment by the health-care organization to provide the resources needed to implement the controls [19][50].
Personal protective equipment
PPE controls are considered the lowest level of the control measures and should not be relied on as the primary or stand-alone
prevention intervention. A singular focus on the availability and use of various PPE to the exclusion of other tiers in the hierarchy of
controls will result in suboptimal protection of all people in the health-care setting. The effective and appropriate use of PPE is the
measure that is most reliant on the user's adherence and competence and, therefore, the control level most easily compromised
(resulting in ineffective protection from an infectious agent/infected source) [19][50].
The PPE tier refers to the availability and appropriate use of equipment that provides a barrier to protect from an infectious agent/
infected source. This includes the use of gloves, gowns, masks, facial protection, eye protection (face shields or goggles) and FFP/
respirators, when indicated. The health-care organization plays a critical role in ensuring the availability of appropriate PPE for use
by health and care workers to prevent exposure to an infectious agent/infected source. Staff should perform proper fit testing and
receive PPE training on use. Selection of PPE is based on the route of transmission of the pathogen, the level of exposure
anticipated, the appropriateness for the task, and fit [19][50].
3.1.3 Standard precautions

Standard precautions aim to reduce the risk of transmission of pathogens in the health-care setting from recognized and
unrecognized sources and are the basic level of IPC precautions that should always be followed in the care of all patients [11].
• Standard precautions include, but are not limited to:

◦ risk assessment
◦ hand hygiene
◦ respiratory hygiene and cough etiquette
◦ patient placement
◦ personal protective equipment
◦ aseptic technique
◦ safe injections and sharps injury prevention
◦ environmental cleaning
◦ handling of laundry and linen
◦ waste management
◦ decontamination and reprocessing of reusable patient-care items and equipment [11].
For additional information on standard precautions see Standard precautions for the prevention and control of infections: aide-
memoire [11].
3.1.4 Transmission-based precautions

Transmission-based precautions are used in addition to standard precautions for patients with known or suspected infection or
colonization with transmissible and/or epidemiologically significant pathogens. The type of transmission-based precautions
assigned to a patient depends on the transmission route of the microorganism: contact, droplet or airborne.
Screening and application of transmission-based precautions are to be started as soon as a patient presents at a health facilty with
symptoms (e.g. fever, new cough, vomiting, diarrhoea). For additional information on transmission precautions see Transmission-
based precautions for the prevention and control of infections: aide-memoire [9].
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3.2 IPC measures for patients with suspected or confirmed COVID-19

Early recognition of SARS-CoV-2 infections and timely application of IPC measures reduce the risk of transmission of COVID-19 for
patients and for health and care workers. The following section outlines well-established infection prevention and control practices that
are to be implemented at the point of care, based on a risk assessment, for patients with suspected or confirmed COVID-19 [51][52].
Basic IPC principles and practices provide the foundation for health-care facilities to prevent and manage outbreaks.
3.2.1 Screening and patient placement

The following section describes IPC measures that should be implemented in the health-care facility for patients presenting with
suspected or confirmed COVID-19.
Identify and manage individuals with suspected or confirmed COVID-19
Prompt identification of patients with signs and symptoms of acute respiratory infections reduces transmission in health-care
facilities. This section provides an overview of IPC measures for individuals presenting with suspected or confirmed COVID-19.
These practices are consistent with precautions for ARIs, such as respiratory and hand-hygiene best practices; isolation of patients
where applicable; appropriate selection and use of PPE; environmental cleaning and disinfection; and, where possible, maintaining
a physical distance of at least 1 metre. Additional measures (transmission-based precautions) are applied when standard
precautions alone are insufficient.
For patients with suspected or confirmed COVID-19, the following IPC practices mitigate the risk of transmission in healthcare
facilities:
1. Apply standard precautions for all patients at all times [11]
• Apply standard precautions for all patients when providing diagnostic and care services.
2. Screen for early recognition of suspected or confirmed COVID-19 patients and rapid implementation of source control
measures
• Use clinical triage1 to assess patients for signs and symptoms2,3 of acute respiratory infections, including COVID-19, to
prevent transmission to health and care workers [8].
• Promptly isolate/separate patients when appropriate [52].
• Use source-control measures, which prevent infections from spreading by stopping them at the source, to reduce the
transmission of COVID-19 and other respiratory infections.
• Note that, after being screened, a person enters the COVID-19 care pathway4, which includes an assessment of symptoms
that meet the standardized case definition [5]. WHO recommends that COVID-19 care pathways be established at local,
subnational and national levels. COVID-19 care pathways are for persons with suspected or confirmed COVID-19 and are a
tool to support health and care workers in visualizing the current clinical and therapeutic recommendations to be considered in
the care plan for patients with COVID-19.
3. Apply transmission-based precautions [9]
Additional measures are focused on the mode of transmission of the microorganism and are always used in addition to standard
precautions, grouped into categories according to the route of transmission of the infectious agent (i.e. contact, droplet and/or
airborne precautions). Transmission-based precautions are applied when caring for patients with known infection, patients who are
colonized with an infectious organism, and asymptomatic patients who are suspected of or are under investigation for colonization
or infection with an infectious microorganism. In addition to standard precautions, additional measures are applied according to risk
assessment, including the appropriate selection and use of PPE, when providing direct care for patients with suspected or
confirmed COVID-19 [9][53].
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4. Patient placement for those with suspected or confirmed COVID-19
• Isolation is used to separate people with confirmed or suspected COVID-19 from those without COVID-19.
◦ A patient with suspected or confirmed COVID-19 should be cared for in a separate, well-ventilated area, preferably in an
isolation room or single-patient room, if available.
◦ WHO recommendations for the duration of isolation can be found here [52].
• Maintain a physical distance of at least 1 metre between patients, increasing that distance where possible.
• When making decisions about patient placement, health and care workers may consider factors such as the availability of
single rooms, and anticipated requirements for procedures or situations that may increase the risk and/or likelihood of
transmission.
• Cohorting patients confirmed to have COVID-19 in the same room is a consideration when other options are not available.
Patients should stay in their rooms, with restrictions to movement or transport to essential activities.
• Use source-control measures, such as mask use for patients with COVID-19 who require (and are able to tolerate) transport,
when the patient leaves the room and when is it not possible to maintain a distance of 1 metre.
• In areas with increased community transmission of COVID-19, consider limiting visitors to those who are essential and instruct
them to wear a mask (as per facility policy).
1
Clinical triage is a system by which patients are screened for specific signs, symptoms and epidemiological clues upon initial
contact with the health-care system for the purpose of determining further diagnostic tests, isolation precautions, treatment and
reporting
2
Signs or symptoms: fever, cough, general weakness/fatigue, headache, myalgia, sore throat, coryza, dyspnoea, nausea/
diarrhoea/anorexia [18]
3
For information on laboratory diagnosis of SARS-CoV-2, see clinical management of COVID-19: living guideline [52], Antigen-
detection in the diagnosis of SARS-CoV-2 infection [54], Use of SARS-CoV-2 antigen-detection rapid diagnostic tests for
COVID-19 self-testing [17] and Diagnostic testing for SARS-CoV-2 interim guidance [55] regarding specimen collection, processing
and laboratory testing and the diagnostic algorithm
4
For more information on COVID-19 care pathways, refer to https://www.who.int/tools/covid-19-clinical-care-pathway [51]
3.2.2 Ventilation
Background
The risk of getting COVID-19 is higher in crowded and inadequately ventilated spaces where infected people are in close proximity
to one another. Understanding and controlling building ventilation can improve the quality of the air we breathe and reduce indoor
health risks by preventing the indoor spread of the virus that causes COVID-19 [7].
Ventilation is the process of supplying outdoor air to and removing indoor air from a space, for the purpose of controlling air
contaminant levels, potentially accompanied by humidity and/or temperature, by natural or mechanical means [7]. The purpose of
ventilation in buildings is to ensure that the air is healthy for breathing. At present, this is achieved mainly by diluting pollutants
originating in the building with clean air, and by changing this air (at a specified rate) with the goal of removing any pollutants.
Ventilation can also be a control measure used for odour control and containment of infectious agents; it is often combined with
climatic control (temperature and relative humidity).
There are three methods that may be used to ventilate a building: natural, mechanical and hybrid (mixed-mode) ventilation.
Adequate ventilation in all patient-care areas plays a key role in helping prevent infections and in reducing their incidence. For
additional ventilation requirements and strategies, see WHO Roadmap to improve and ensure good indoor ventilation in the
context of COVID-19 [7].
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Strong recommendation for , Very low certainty evidence
WHO recommends adhering to the ventilation rate requirements for health-care facilities in the context of
COVID-19:
• 160 l/s/patient for airborne precaution rooms

• 60 l/s/patient for general wards and outpatient departments
Published 09 October 2023
Practical info
Implementation considerations
To provide maximum utility of a ventilation system and greater general dilution of air contaminants throughout any given space,
mechanical and natural systems can be used independent of the settings. However, each setting has specific ventilation
requirements, defined by national and international regulatory bodies, which differ according to the ventilation objectives. For
instance, ventilation systems in health-care facilities are in place as an environmental and engineering control for infection
prevention while, in residential buildings, they are mainly intended to create a thermally comfortable indoor environment with
acceptable indoor air quality [7].
Adequate ventilation in all patient-care areas plays a key role in helping to prevent and reduce infections.
Ventilation has three basic elements: ventilation rate (m³/hr, l/s or air changes per hour [ACH]), which is the volume of outdoor
air that is provided into the space; airflow direction, which is the overall airflow direction in a building and spaces; and air
distribution or airflow pattern, which is where the external air should be delivered to each part of the space in an effective and
efficient manner.
There are three methods that may be used to ventilate a building: natural, mechanical and hybrid (mixed-mode) ventilation.
• The ventilation rate minimum requirements are 160 L/s/patient or 12 air changes per hour (ACH) where aerosol-generating
procedures (AGPs) are performed;
• The ventilation rate minimum requirement is 60 L/s/patient or 6 ACH for other patient-care areas;
• The airflow direction should be from clean zones to dirty zones;
• Air should be exhausted directly to the outside, away from air-intake vents, people and animals;
• Heating, Ventilation and Air Conditioning (HVAC) systems should be operated continuously when people are in the
building and should be regularly inspected, maintained and cleaned;
• AGPs should be performed in rooms equipped with negative-pressure ventilation systems, in keeping with airborne
precautions;
• If no other strategy can be adopted to meet the ventilation rate minimum requirements, consider using a stand-alone air
cleaner equipped with a high-efficiency particulate air (HEPA) filter;
• For additional information on implementing ventilation standards and strategies to improve a health-care facility's
ventilation, see Roadmap to improve and ensure good indoor ventilation in the context of COVID-19 [7].
Evidence to decision
Benefits and harms Small net benefit, or little difference between alternatives
No studies investigated ventilation standards versus suboptimal compliance with existing standards. Although there was no
direct evidence on the harms of adherence to ventilation standards, the GDG judged any harms to be trivial or none.
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Certainty of the Evidence Very low
The quality of evidence is indirect and very low.
Values and preferences Substantial variability is expected or uncertain
It was not possible to assess values and preferences as there was a lack of evidence on the effects that adherence to
ventilation standards may have on SARS-CoV-2 infection.
Resources Important issues, or potential issues not investigated
Current ventilation standards are the standard of care, though not all facilities comply with ventilation standards and costs
to implement likely vary.
Equity Important issues, or potential issues not investigated
Given the lack of evidence on benefits and harms, the GDG judged no negative impacts on equity if ventilatory standards
are adhered to.
Acceptability No important issues with the recommended alternative
Ventilation standards already exist and are widely accepted.
Feasibility No important issues with the recommended alternative
GDG members noted that existing ventilation standards have been enforced for many years without issue. However, GDG
members also noted that harm may occur when ventilation systems are not up to standard, as there is a correlation
between non-compliance and HAIs other than SARS-CoV-2.
The feasibility of implementing airborne current ventilation standards likely varies in different countries and settings and is
dependent on whether standards are being followed properly.
Justification
No studies compared the effects of non-compliance with existing ventilation standards to compliance with ventilation standards
and risk of SARS-CoV-2 infection. However, health-care facilities are subject to national, subnational and local regulations for
ventilation requirements; ventilation standards are necessary for control of infections other than SARS-CoV-2, and laboratory
and epidemiological studies demonstrate the association between inadequate ventilation and increased risk of respiratory
infections. The above-mentioned standards are pre-existing WHO recommendations for ventilation requirements [7][8].
Therefore, the GDG members agreed that these existing standards should also be utilized in the context of COVID-19.
Clinical question/ PICO

Population: Health care settings
Intervention: Ventilation standards for health care (all health care spaces have variations of their own ventilation
standards, but specifically ANSI/ASHRAE/ASHE Standard 170-2017 Ventilation of Health Care Facilities - Addendum,
vol. 2017)
Comparator: Ventilation standards for healthcare settings are not met (non-compliance with all requirements)
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Summary
No studies evaluated impacts on risk of SARS-CoV-2 infection.
Comparator Intervention
Ventilation Ventilation Certainty of
Outcome Study results and standards for standards for the Evidence
Summary
Timeframe measurements healthcare health care (all (Quality of
settings are not health care evidence)
met (non- spaces h
SARS-CoV-2
Infection No studies were found
Very low that looked at SARS-
CoV-2 infection
3.2.3 Physical barriers

Background
Transmission of SARS-CoV-2 can occur when one or more individuals is in close contact with an infected person. Health-care
facilities may consider installing physical barriers in places where patients first present as an additional mitigation measure to
protect health and care workers as well as patients. Consider consulting with a heating, ventilation, and air-conditioning
(HVAC) professional to ensure the use of barriers is protective and does not adversely affect the ventilation patterns.
Conditional recommendation for , Very low certainty evidence
WHO suggests considering the use of physical barriers such as glass or plastic windows for areas where
patients first present, such as screening and triage areas, the registration desk at the emergency department
and the pharmacy window.
Practical info
• Physical barriers are thought to provide some level of protection for individuals sharing a space, first by preventing people
from getting too close, and as a partition to potentially prevent or decrease respiratory particle movements.
• Physical barriers are used with other infection prevention and control measures, including environmental cleaning, hand
hygiene, respiratory hygiene, and mask use (source control).
• Physical barriers in health-care settings should be installed according to facility requirements and as part of engineering
control measures, including ventilation standards.
• Those installing and using partitions should consider best practices in the design, installation and maintenance of physical
barriers, in consultation with public health and industry standards, to ensure they are most protective.
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◦ Consider the dimensions of the physical space, the intended use of barriers, types of activities, occupancy and
ventilation.
◦ The dimensions should not exceed the breathing zone of users; the height should consider the tallest user and the
breathing zone of a seated person.
◦ Transparent barriers often need openings; these slots should be as small as possible, depending on the activity. There
should be adequate space to pass any required documents, cash, etc., without touching the barrier; otherwise, cross-
contamination can occur through the barrier. A sliding door or flap is considered a high-touch surface for cleaning and
disinfection purposes.
◦ With regard to safety, a surface-mounted barrier or free-standing partition is preferable to a hanging partition.
◦ It is unknown what material (e.g. plexiglass) and what design (i.e. shape, size) are best suited for the construction of
physical barriers [57].
Benefits and harms Important harms
One before-after study found the implementation of universal masking and physical barriers was associated with
decreased SARS-CoV-2 infection incidence in most facilities [56]. GDG members noted potential harms associated with
barriers and their effect on ventilation systems.
As the evidence base is a single before-after study in which it is impossible to separate the effects of universal masking
and physical barriers, the certainty of evidence has been assessed as very low.
Values and preferences No substantial variability expected
Physical barriers are probably not associated with significant individual harms; therefore, the decision to use physical
barriers is probably not preference-sensitive.
Research evidence
The cost and resource considerations likely vary depending on the setting, type of barrier, existing infrastructure and other
factors.
Equity No important issues with the recommended alternative
The GDG did not identify negative impacts on equity, assuming that implementation is consistent across different settings.
Acceptability Important issues, or potential issues not investigated
The acceptability of physical barriers may vary depending on costs and other factors (e.g. convenience, etc.) as well as the
size, layout and type of barrier.
Feasibility Important issues, or potential issues not investigated
The feasibility of implementing physical barriers likely varies in different settings. GDG members noted the importance of
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consulting with HVAC professionals and/or engineers prior to installation. There may be factors affecting feasibility, such as
size, layout, design and type of barrier.
Justification
The evidence is very low since it was only one study; it used a before-after design; and it wasn't possible to separate the effects
of barriers from those of masking. Despite the limitations in the evidence, the GDG judged that physical barriers could
potentially reduce risk of infection in high-traffic areas with trivial or no harms, without specifying optimal barrier type and design
(i.e. materials, shape, dimensions).
After reviewing the evidence, GDG members elected a conditional recommendation on physical barriers. GDG members noted
that the location of these barriers was imperative, as improperly placed glass or plastic screens can disrupt the flow of air and
reduce the effectiveness of the ventilation system.
GDG members felt these barriers would be most useful in triage and reception areas, pharmacies, and other locations that
have patient contact but that are not considered clinical areas. GDG members also noted that physical barriers are not a
substitute for public health and social measures (PHSMs) or IPC practices.

Population: Health-care
Intervention: Physical barriers
Comparator: No physical barriers
Summary
One study compared the use of physical barriers to no use of physical barriers; however, this study was an
observational study out of a meat-processing facility in the United States of America [56]. The purpose of this study was
to detail the demographics and outcomes of SARS-CoV-2 infections among workers in Nebraska meat processing
facilities and determine the effects of initiating universal mask policies and installing physical barriers at thirteen meat-
processing facilities. This was a pre-post comparative study, dating from April to July 2020 with 2600 participants.
Results showed that ten days after interventions, eight of the thirteen facilities saw a statistically significant reduction in
cases [56]. Three of the thirteen facilities saw a nonsignificant reduction; however, one facility saw a statistically
significant increase and another one saw a nonsignificant increase. The use of physical barriers can reduce SARS-
CoV-2 transmission, but this study did not separate the effect from other interventions [56].
Certainty of
Outcome Study results and the Evidence
No physical Physical Summary
Timeframe measurements (Quality of
barriers barriers
evidence)
SARS-CoV-2 There were too few who

experienced the SARS-
infection CoV-2 infection, to
Very low determine whether
physical barriers made a
difference
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3.2.4 Physical distancing
Background
Transmission of SARS-CoV-2 can occur when one or more individuals is in close contact with an infected person. Health facilities
should adhere to recommended IPC measures, particularly to respiratory etiquette and hand hygiene best practices; with
application of standard precautions and transmission-based precautions (as per risk assessment); adequate environmental
cleaning and disinfection; ensuring adequate ventilation; and use of isolation facilities for COVID-19 patients. In addition, where
possible, a physical distance of at least 1 metre (and more, whenever feasible) should be maintained between any two individuals
in health facilities, especially in indoor settings.
Good practice statement
Maintain a physical distance of at least 1 metre between and among patients1, staff and all other persons in
health-care settings, when feasible. When possible, increase this distance.
1
Health and care workers providing direct patient care should wear appropriate PPE.
Justification
WHO previously advised to maintain a physical distance of at least 1 metre in health-care settings. This recommendation was
based on a review that primarily included studies of other infections and that had methodological limitations. For this update,
the GDG commissioned a review to determine whether there was evidence to support increasing physical distance to >1 metre.
Only one study compared distances (1 metre vs 2 metres) and reported similar rates [58]. Therefore, the GDG found
insufficient evidence to support increasing the recommended minimum physical distance.
The GDG elected to keep the minimum distance of 1 metre based on indirect evidence showing high certainty of benefit and
trivial harms. However, based on data indicating that transmission can occur at distances of 1 metre or greater, the GDG
suggested increasing the minimum physical distance, when possible, to potentially reduce risk.
After extensive deliberation, the GDG decided to maintain its previous guidance on physical distancing. As only one study
addressed the PICO question [58], the GDG elected for a good practice statement. The lone study had few events and
estimates were imprecise.
The WHO commissioned a qualitative review of the literature (reports, qualitative studies, and related systematic reviews) to
better understand the perceptions of health and care workers on physical distance and to better inform the GDG in the
evidence to the decision-making process, which highlighted compliance and feasibility issues.
Many GDG members noted that maintaining a physical distance of 1 metre or more is not feasible for health and care workers
when they are providing direct care to patients with suspected or confirmed COVID-19. When unable to maintain a distance of
at least 1 metre, health and care workers should ensure the proper use of PPE (a mask, gown, gloves, and eye protection)
considering the risk when in close proximity. This good practice statement is informed by established IPC principles and
practices.
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Population: Health and care workers
Intervention: 1 metre of physical distance
Comparator: More than 1 metre of physical distance; less than 1 metre
Summary
One study addressed the PICO question, in which SARS-CoV-2 cases were similar irrespective of the physical distance
(1 metre vs 2 metres) between participants [58]. Importantly, this study had estimates that were very imprecise due to
very few events. The environment in which this study was performed had concurrent policies for universal masking and
influenza vaccination, thus potentially affecting the outcome [58]. Further studies are required to increase the certainty
of the evidence around the effectiveness of a physical distance of 1 metre compared to distances greater or less than 1
metre, in reducing and mitigating the transmission of SARS-CoV-2.
A qualitative synthesis was also performed on this topic; for results, see the Annex.
Comparator
More than 1 Intervention Certainty of
Outcome Study results and metre of 1 metre of the Evidence
Summary
Timeframe measurements physical physical (Quality of
distance; less distance evidence)
than 1 metre
There were too few who

SARS-CoV-2 experienced SARS-
infection CoV-2 infection to
determine whether 1
metre of physical
distance made a
difference
3.2.5 Mask use for source control

Background
Source-control measures prevent infections from spreading by stopping them at the source; they are important tools to reduce the
transmission of COVID-19 and other respiratory infections [59].
Source control refers to engineering, environmental and administrative-control measures such as screening for early identification
of COVID-19; use of protective barriers; and placement of patients, aimed at reducing and preventing the dissemination of
infectious agents. In health-care settings, this protects those in the facility, including the health and care worker and those at
increased risk of becoming severely ill.
Source control also includes wearing well-fitting medical masks to cover a person's nose and mouth to prevent respiratory
secretions from spreading when breathing, talking, singing, sneezing or coughing.
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Targeted continuous masking
WHO suggests targeted continuous medical masking in health-care facilities when there is a minimum to
moderate impact of COVID-191 on the health system.
Remarks:
• Targeted continuous masking is the practice of wearing a medical mask by all health and care workers and caregivers in
clinical areas during all routine activities throughout the entire shift2.
• In non-patient areas, staff who have no patient contact are not required to wear a medical mask during routine activities.
• If caring for a suspected or confirmed COVID-19 patient, please see the recommendation on mask type for health and
care workers.
1
Situational level up to 2 (as defined in the latest PHSM document [60]):
• Situational Level 0 corresponds to a situation with no known transmission of SARS-CoV-2 in the preceding 28 days. The
health system and public health authorities are ready to respond, but there are no restrictions needed on daily activities,
and only core PHSMs (e.g. respiratory etiquette) are needed.
• Situational Level 1 is a situation with minimal transmission, morbidity, and health system impact of SARS-CoV-2, with only
basic ongoing PHSMs needed.
• Situational Level 2 represents a situation where there is moderate impact of COVID-19, although there may be higher
impact in specific sub-populations. Additional measures may be required to reduce transmission; however, disruptions to
social and economic activities can still be limited, particularly if PHSMs can be targeted strategically to more affected
settings.
2
unless otherwise specified (e.g. when performing AGP).
Practical info
Targeted continuous masking is the practice of wearing a medical mask by all health and care workers and caregivers in clinical
areas during all routine activities throughout the entire shift.
When adopting targeted, continuous masking within a health facility, it is essential for health and care workers to follow proper
mask-wearing procedures and practices. For additional information, review the implementation considerations
on mask management for health and care workers.
The WHO recommendation on mask fitting should be followed, including the related considerations on this critical aspect.
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Benefits and harms Substantial net benefits of the recommended alternative
No studies were identified on targeted, continuous mask use/universal masking compared to no mask use in low- to
moderate-impact settings. However, several studies found that implementation of universal masking is associated with
decreased risk of acquiring SARS-CoV-2 infection among health and care workers. Although studies suggest benefits of
universal masking, they were all conducted in settings experiencing significant impact of COVID-19 [61][62][63][64][65].
Studies of universal masking in settings experiencing mild to moderate impact of COVID-19 were not available. However,
the GDG determined that the benefits of universal masking did not support universal masking in these mild- to moderate-
impact settings; rather, targeted continuous masking was suggested [62][63][64][65].
If caring for COVID-19 patients, please see the recommendation on mask type for health and care workers caring for a
patient with suspected or confirmed COVID-19.
No studies compared targeted continuous masking/universal masking in settings with mild or moderate impact of SARS-
CoV-2. The evidence is indirect and based on evidence on universal masking in settings experiencing high impact of
SARS-CoV-2; therefore, the certainty of the evidence is rated as very low.
Other indirect evidence on medical mask use in the community supports benefits of mask use in preventing SARS-CoV-2
infection but is also indirect [32][33].
Given the protective effects of mask use, health and care workers, including community health and care workers and
caregivers, would likely favour targeted continuous masking in health facilities. The qualitative review suggests health and
care workers value the protection PPE provides to them and to their patients. Furthermore, health and care workers were
reported to be anxious about the level of risk associated with COVID-19; the review noted that PPE associated with higher
levels of protection relieved anxiety and insecurities, in particular when health and care workers were providing patient
care [67][68][69][70][71][73].
Resources No important issues with the recommended alternative
The GDG considered the potential issues with supply availability, particularly medical masks for both low-resource and
higher-resource areas. The GDG noted that supply chains have improved since the beginning of the COVID-19 pandemic,
and therefore judged that implementation of targeted, continuous masking is likely to have a low-to-moderate impact on
resources.
The GDG judged that implementing targeted continuous masking will likely have no adverse impact on equity, as long as
masks are provided in health-care settings and are readily available to those for whom they are indicated.
Targeted, continuous masking is less burdensome than universal masking and was judged by the GDG to be generally
acceptable.
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Some health and care workers expressed concerns about the quality of the PPE, including masks, provided throughout the
COVID-19 pandemic [67][70][71].
Many health-care facilities have transitioned from universal masking to targeted, continuous mask use, indicating general
feasibility, though the GDG noted that clear policies and training may be required.
Justification
In response to the shift in epidemiology and WHO terminology classifying community transmission levels, the GDG re-
assessed the recommendation within the current context of COVID-19, previously published in April 2022.
No studies were identified on targeted, continuous mask use/universal masking compared to no mask use in low- to moderate-
impact settings. Studies of universal masking were conducted only in settings experiencing significant COVID-19 impact. The
GDG judged that, in settings experiencing mild or moderate COVID-19 impact, the benefits of universal masking were unclear,
but likely smaller than in settings experiencing significant COVID-19 impact.
Given the potential discomfort and other harms of universal masking, such as impact on communication and resource costs,
the GDG judged that evidence was insufficient to support universal masking in this setting. However, the GDG felt that
targeted, continuous mask based on the degree of exposure to SARS-CoV-2 was warranted to reduce the risk of infection.
The GDG judged that targeted, continuous mask use would be feasible and more acceptable than universal masking and
would require fewer resources. The recommendation is conditional because of very limited evidence with high uncertainty.

Intervention: Targeted continuous masking/universal masking
Comparator: No mask use
Summary
No studies have been conducted of targeted continuous mask use vs other strategies, or universal mask use in settings
experiencing low or moderate COVID-19 impact (see universal masking PICO question for with summary of evidence
on universal masking in high COVID-19 impact settings.) The universal use of masks probably decreases the risk of
SARS-CoV-2 infection slightly.
Intervention
Targeted Certainty of
Outcome Study results and Comparator continuous the Evidence
Summary
Timeframe measurements No mask use masking/ (Quality of
universal evidence)
masking

Very low experienced the SARS-
infection CoV-2 infection, to
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Intervention
Targeted Certainty of
Outcome Study results and Comparator continuous the Evidence
Summary
Timeframe measurements No mask use masking/ (Quality of
universal evidence)
masking
determine whether
targeted continuous
masking/universal
masking in low-impact
settings made a
difference.
Universal masking
WHO recommends universal masking in health-care facilities when there is a significant impact of COVID-19 on
the health system1.
Remarks:
• Universal masking is the practice of all health and care workers and other staff, caregivers, visitors, outpatients and
service providers wearing a well-fitting medical mask2 at all times within the health facility and in any common area (e.g.
cafeteria, staff rooms).
• Inpatients are not required to wear a medical mask unless physical distancing of at least 1 metre cannot be maintained
(e.g. during examinations or bedside visits) or when outside of their care area (e.g. when being transported), provided the
patient is able to tolerate the mask and there are no other contraindications.
• If caring for suspected or confirmed COVID-19 patients, please see the recommendation on mask type for health and care
workers.
1
Situational levels 3 and 4 (as defined in the latest PHSM document [60]):
• Situational Level 3 is a situation with significant impact on the health system and a risk of health services becoming
overwhelmed, or resulting in unacceptably high morbidity and mortality, even in cases where the health system capacity is
sufficient. In these situations, a larger combination of PHSMs may need to be put in place to limit transmission, manage
morbidity and avoid overwhelming the health system.
• Situational Level 4 corresponds to an uncontrolled epidemic with very high morbidity/mortality and limited or no additional
health system response capacity available, thus requiring extensive PHSMs to avoid overwhelming health services and to
limit substantial excess morbidity and mortality.
2
Unless otherwise specified, (e.g. when performing AGPs).
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Practical info
When implementing universal masking, health facilities should:
• Ensure well-fitting medical masks are available for all health and care workers, caregivers, visitors, service providers,
outpatients and inpatients.
◦ See the WHO recommendation on mask fitting, including the related considerations on this critical aspect.
• Ensure there are areas equipped with waste bins for disposal of medical masks after use, including at the entrances/exits
to the facility.
• Ensure sufficient hand-hygiene stations are located where masks are provided for use and where masks are removed
(e.g. entrance and exit areas).
• Health and care workers, patients, family and visitors should follow proper mask-wearing procedures and practices as per
facility policy. For additional information, review the implementation considerations on mask management for health and
care workers.
• As the use of PPE, in particular the use of masks, during care activities increased throughout the COVID-19 pandemic,
awareness of unintended consequences, such as increases in health-care waste and impact on the environment,had to be
taken into consideration. For additional information on the environmental impact of the use of masks (and other PPE),
please see WHO's Global analysis of health care waste in the context of COVID-19 [74].
Implementation of universal masking is associated with decreased risk of acquiring SARS-CoV-2 infection among health
and care workers in several studies conducted in settings significantly affected by SARS-CoV-2. However, these studies
had methodological limitations, including utilization of before-after study design and lacking or limited controls for
confounders such as the use of other personal protective equipment and exposures; in addition, most studies were
conducted in the United States of America [61][62][63][64][65], a fact that could reduce their applicability to other countries/
settings.
In areas where there is community transmission of COVID-19, universal masking reduces the risk of transmission among
health and care workers and other staff, patients and visitors to the facility. Literature provides limited insight into the harms
of universal masking; however, evidence on mask use, in general, indicates bothersome but non-serious harms [32][33].
A qualitative review suggests that mask use may be associated with constraints on communication (both verbal and facial
communication), as the mask covers the face. Health and care workers also report issues related to hearing, such as
muffled words and the inability to read others' lips. This potentially affects communication, and groups such as the elderly –
who are at higher risk of experiencing hearing problems -- may be more affected.
Despite the limitations in the evidence, the GDG judged that the available evidence suggests that the benefits of
implementing universal mask use in health-care facilities outweigh the potential harm in settings experiencing a significant
impact of COVID-19.
If caring for COVID-19 patients, please see the recommendation on mask type for health and care workers when caring for
a patient with suspected or confirmed COVID-19.
Given the limited number and type of evidence available (i.e. before-after studies) investigating the implementation of
universal masking to prevent transmission or infection, the certainty of the evidence is rated as very low.
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In the context of universal masking, some health and care workers may prefer to wear a respirator instead of a medical
mask, based on their perception of what offers the better protection against COVID-19.
A qualitative review of the literature reports that health and care workers often feel that masks and other PPE provide them
with peace of mind and thereby create a climate of safety [66][67]. Furthermore, health and care workers were reported to
be anxious about the level of risk associated with COVID-19 and to feel that PPE that they believed offered higher levels of
protection relieved their anxiety and insecurity [68]. In many settings with low impact of COVID-19, in contrast, PPE has
been shown to make health and care workers feel uncomfortable and to add to their feelings of stress and discomfort,
especially if worn for prolonged periods [69][70][71][72][73].
The COVID-19 pandemic increased the need for PPE, which led toPPE shortages and use of optimization strategies when
supplies were low. These strategies included measures that were used temporarily during periods of anticipated PPE
shortages. While current supply may be adequate, there may be uncertainty about the adequacy of future supplies, which
may pose clinical and operational challenges, particularly in low- and middle-income countries. The use of PPE requires an
additional investment of financial and logistical resources to provide the best protection possible to health and care
workers.
As supply chains have improved in the current context of COVID-19, the GDG has judged that implementing universal
masking is likely to have a low-to-moderate impact on resources, assuming facilities use medical masks. This does not
take into consideration the availability of respirators, when indicated, and resources required for fit testing.
The GDG determined no adverse impacts on equity when universal masking is implemented in both low- and higher-
resource settings, and where there is availability of medical masks for all heath and care workers, staff, visitors and
patients.
The qualitative review found that some health and care workers indicated that the use of masks gave them peace of mind
and created a safe climate in which to deliver optimal care [66][67].
But the qualitative review of the evidence also noted some health and care workers reporting drawbacks that they
asssociated with mask use, such as headaches, feelings of being hot or overheating, and excessive
sweat [67][68][70][71][73].
In the context of universal masking, some health and care workers may prefer to wear a respirator instead of a medical
mask, based on their perception of which intervention offers better protection against SARS-CoV-2 infection.
Overall, the GDG judged that universal masking was probably acceptable in health-care facilities, given the protective
effects for health and care workers, other staff, visitors and patients.
The universal use of masks in health-care facilities as an intervention was widely implemented in many high-resource
settings throughout the COVID-19 pandemic, indicating that it is feasible in those settings.
Many reports suggest that universal masking is likely feasible in health-care facilities, as long as PPE is available and
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health and care workers have proper institutional support and training [66]. Therefore, the GDG judged that universal
masking was probably feasible.
Supply chain and availability of PPE such as masks may also be an issue [72].
Justification
In response to the shift in epidemiology and WHO terminology classifying community transmission, the GDG re-examined this
recommendation, which was first published in April 2022. Since that time, WHO commissioned a qualitative review of the
literature (reports, qualitative studies and related systematic reviews) to examine the perceptions of health and care workers on
mask use and other PPE use in health-care settings. The GDG agreed that the wording of this recommendation would be
amended to reflect the institutional change in terminology and classification of situational levels; the GDG did not make other
changes to the content of this recommendation.
Despite the very low certainty of the evidence for the implementation of universal masking, the GDG judged that the evidence
indicates benefits without significant harm in settings experiencing significant impact from COVID-19; in addition, the GDG
members judged that universal masking could prevent health and care worker infections and further transmission within the
health-care setting. Members also felt that, based on their own professional experience or that of colleagues, universal masking
in health-care settings was routinely implemented in most countries; therefore, the acceptability and feasibility favoured a
strong recommendation, as well.
Additionally, the GDG reviewed the mask type to be used universally in health-care facilities; considering variants of interest
and variants of concern and the subsequent need to protect health and care workers and their patients, GDG members felt the
use of medical masks was justified. If caring for suspected or confirmed COVID-19 patients, please see the recommendation
on mask type for health and care workers.
Given the available evidence on the effectiveness of medical masks and established industry standards for production, a
majority of GDG members felt the universal use of medical masks in the health-care setting would provide better protection for
staff, caregivers, patients and visitors.

Intervention: Universal masking
Comparator: No universal masking
Summary
A systematic review included four studies on the effects of hospital universal masking policies on risk of SARS-CoV-2
infections in HCWs. The studies were conducted in the United States, used a before-after design and had other
methodological limitations, including failure to control for other factors (e.g. other PPE use or infection-control measures
or exposures) that could result in changes in SARS-CoV-2 infection, and failure to measure mask use or
adherence [61][62][63][65].
Studies found a decline in health-care-acquired SARS-CoV-2 infections during and after the intervention. Hospitals
continued to see a decrease in SARS-CoV-2 infections within the hospital when there was an increased rate of
infection within the community. While universal masking was the main intervention, hospitals also implemented other
IPC measures such as physical distancing, increased access to hand-hygiene stations and strict adherence to a
quarantine regime for those health and care workers who were exposed. All of the studies were conducted in settings
experiencing significant SARS-CoV-2 impact.
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Certainty of
No universal Universal Summary
masking masking
evidence)
4 before-after studies Very low

All studies used
experienced the SARS-
infection before-after
CoV-2 infection to
design and had
determine whether
serious
universal masking made
methodological
a difference
limitations.
Appropriate mask fitting should always be ensured (for respirators, through fit testing and a user seal check
when a filtering facepiece respirator is put on; and for medical masks, through methods to reduce air leakage
around the mask) as well as compliance with appropriate use of PPE and other standard and transmission-
based precautions.
Practical info
• When adopting a mask policy, it is essential that health and care workers follow proper mask-wearing procedures and
practices.
• Health and care workers should also comply with appropriate use of PPE and other standard and transmission-based
precautions.
• For additional information, review the implementation considerations on mask management for health and care workers.
Methods to improve the fit of respirators or medical masks
Respirators
• Filtering facepiece respirators (FFRs) vary for their measurement of fit, either through maximum allowable leak tightness or
minimum fit factor. For European certified FFRs, the maximum leakage varies:
◦ FFP1 (maximum 22% leakage)
• FFRs (EN 149) are subject to testing for leakage with human participants as part of the product's certification (Europe)
• For NIOSH, N-type FFRs (minimum fit factor of 100) are certified according to OSHA 29 CFR 1910.134 for each wearer
prior to use [75].
• At a minimum, FFRs that meet FFP2 and N95 performance levels are recommended to be worn by health workers in
areas where AGPs are performed [25].
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• Ensure a range of FFR sizes are available to accommodate different face shapes and sizes, especially for those with small
faces.
• Qualitative or quantitative fit testing should be performed annually and for new staff at the employer's expense to ensure
that the respirator model fits each health worker's unique facial features and provides a consistent seal [76].
• A seal check should be performed on an FFR whenever a health worker puts it on to determine if it fits adequately. See
WHO guidance on how to perform a particulate respirator seal check for additional details.
Two methods can be used for fit testing FFRs

1) qualitative fit test (health worker reports taste of an ambient aerosol) and 2) quantitative fit test [76]
Table 6. FFRs fit testing parameters
Qualitative Fit Testing Quantitative Fit Testing
OSHA 29 CFR 1910.134 Appendix A EN 149, Clause 7.9.1 (EN-type, e.g. FFP2)
Standard test methods
(for N95) OSHA 29 CFR 1910.134 Appendix A (e.g. N95)
Equipment Hood and sweet/bitter aerosol Ambient aerosol condensation nuclei counter
>8% leakage (for FFP2)
Pass/Fail Criteria Wearer reports tasting aerosol
<100 fit factor (for N95)
Medical masks
Improving the fit of medical masks with techniques such as the “knot-and-tuck” and “linking-ear-loops-behind-the-head” uses
ear loops to reduce gaps on the sides of medical masks. Such gaps allow air leakage (potentially containing infectious
particles) to bypass the filtration layers of the medical mask when the wearer inhales or exhales.
Considerations on the use of linking-ear-loops-behind-the-head techniques to improve medical mask fit
• Always use a clean, unused, rectangular, pleated medical mask meeting the minimum performance standards (or
equivalent) [25].
• Always clean hands thoroughly (per WHO guidance) prior to putting on, taking off and/or manipulating a mask [15].
• Where connectors are used to link ear loops behind the head, ensure that these connectors are clean for use upon putting
them on (either new, cleaned and disinfected or laundered, depending on the connector and local implementation
strategy). When connectors are removed, they should be treated as potentially contaminated. A local strategy should be in
place to manage used connectors through cleaning and disinfection processes, laundering or discarding used connectors
through standard waste management.
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Figure 3. How to improve medical mask fit in health-care settings
Justification
GDG members agreed that having practical advice on improving medical mask fit would be useful. After reviewing many
methods to improve mask fit, the GDG decided to retain the use of the ear loops-linked-behind-the-head method and the tie-
and-tuck method as advisable methods to improve the fit of masks; additional details can be found in the practical information
section.
GDG members reported that the evidence available on improving the fit of medical masks to reduce the transmission risk of
SARS-CoV-2 is in the form of laboratory-based studies with limited field and clinical investigations [77][78][79][80].

Intervention: Methods to improve mask fitting
Comparator: An ill-fitting mask (does not fit snugly, has gaps)
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Summary
The research of the included studies had been conducted over a large range of countries, with the most frequent
research coming from the USA [77][78][79][80].
Studies aimed to evaluate:
• modifications to improve the mask fit to reduce the number of expelled particles
• amount of leakage associated with double masking
• fitted filtration efficiency of consumer-grade masks
• aerosol particle leaking/leakage and standard surgical mask fitting with three elastomeric harness designs.
Studies found that crossing ear loops or using mask brackets made no significant improvement. However, modifications
such as knot-and-tuck methods did improve the fit, blocking particles from the wearer and reducing exposure.
Furthermore, increasing the tension through a brace, connector, “ear-guards”, etc., did improve fit and protection.
Lastly, an elastomeric harness may improve the fit and protection of a standard surgical mask.
Comparator
Intervention Certainty of
An ill-fitting
Outcome Study results and Methods to the Evidence
mask (does not Summary
Timeframe measurements improve mask (Quality of
fit snugly, has
fitting evidence)
gaps)

SARS-CoV-2 Evidence was not experienced SARS-
infection GRADE’d as all CoV-2 infection to
studies were determine whether
performed in the methods to improve
laboratory setting mask fitting made a
difference.
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Health and care workers should comply with the following procedures and practices when wearing a mask for an extended
period in health-care settings:
• Medical masks should be combined with other measures, including frequent hand hygiene and physical distancing of at
least 1 metre among health workers in shared and crowded places such as cafeterias, break rooms and dressing rooms.
• Medical masks must be changed when wet, soiled or damaged or if the health worker or caregiver removes the mask for
any reason (e.g. for eating or drinking or caring for a patient who requires droplet/contact precautions for reasons other
than COVID-19).
• Used medical masks should be disposed of properly.
• The medical mask should not be touched to adjust it or if it is displaced from the face for any reason. If this happens, the
mask should be safely removed and replaced and hand hygiene performed.
• The medical mask (as well as other PPE) should be discarded and replaced after caring for any patient who requires
contact/droplet precautions for other pathogens, followed by hand hygiene.
• Under no circumstances should a medical mask be shared.
• During extended use, medical masks can become displaced from their optimal placement, over the mouth and nose,
which creates gaps for respiratory particles to bypass the filtration layers on inhalation and exhalation. The WHO
recommendation on mask fitting should be followed, including the related considerations on this critical aspect.
3.2.6 PPE selection and use

Background
Personal protective equipment (PPE) is one component of the hierarchy-of-control measures and should always be used in
conjunction with engineering and administrative controls. For information on the types of PPE, technical specifications and
certification, see Section 3.2.6.1
PPE worn by health and care workers should fit properly, be worn appropriately and provide adequate coverage. Staff should be
trained and monitored for compliance with procedures for selecting, putting on and removing PPE [53]. This includes performing
hand hygiene with PPE use and between patient encounters [15].
Strong recommendation for , Low certainty evidence
A respirator or a medical mask should be worn along with other PPE – a gown, gloves and eye protection – by
health and care workers providing care to a patient with suspected or confirmed COVID-19.
Note: This recommendation applies to any setting where regular care is provided to patients with suspected or confirmed
COVID-19, including home care, long-term care facilities and community care settings. For settings where AGPs are
performed on patients with suspected or confirmed COVID-19, see the AGP recommendation.
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Practical info
Within any health facility, health and care workers must follow appropriate mask-wearing procedures and practices. For
additional information, review the implementation considerations on mask management for health and care workers.
Health and care workers should follow the WHO recommendation on mask fitting, including the related considerations, such as
the type of FFR that they should use.
Implementation considerations and contextual factors that may influence the overall risk of transmission, including general PPE
use, PPE training, fit testing, ventilation and behavioural factors (including compliance) and transmission of SARS-CoV-2
among health and care workers, appear to occur mostly in community settings [32][33].
Evidence comparing the effectiveness of respirators versus medical masks for SARS-CoV-2 in health-care settings is
limited to five observational studies [81][82][83][84][85], and one randomized controlled trial [86]. The five observational
studies were conducted prior to the emergence of the Delta, Omicron and other variants and before widespread
vaccination in health-care settings. These five observational studies reported inconsistent findings regarding the risk of
SARS-CoV-2 infection between the use of respirators versus medical masks and had methodological limitations (for
example, recall bias, low participation, and limited measurement of exposures). One study showed a reduction of risk with
respirator use [83], while two other studies found no significant risk reduction [82][85]. One study showed no
association [85], and another found respirators were associated with increased risk (OR 7.1), likely related to confounding
factors [82]. In the intention-to-treat analysis, the randomized controlled trial found that RT-PCR-confirmed COVID-19
occurred in 52 of 497 (10.46%) participants in the medical mask group versus 47 of 507 (9.27%) in the N95 respirator
group (hazard ratio [HR], 1.14 [95% CI, 0.77 to 1.69]) [86]. Results were within the pre-specified, non-inferiority threshold
(HR <2.00), but do not rule out a protective effect of N95 respirators. Furthermore, the length of the RCT transcended
across various VoCs (Delta and Omicron).
The following side effects have been reported with respirators: discomfort, headaches, possible development of facial skin
lesions and irritant dermatitis or worsening acne when used frequently for long hours [32][33].
Medical masks are typically associated with fewer discomforts and side effects than respirators, given their reduced seal,
although this has not been quantified. Undesirable outcomes from the prolonged use of respirators were noted, including
general discomfort, headaches and the development of facial skin lesions, irritant dermatitis, and worsening acne [32][33].
The fitting process for respirators is burdensome, and issues with achieving it have been well described.
Certainty of the Evidence Low
The certainty of the evidence is low, primarily based on a single RCT with some imprecision and methodological limitations.
The observational studies were inconsistent and had important methodological limitations. Most studies were conducted
before the emergence of the Delta variant and few were conducted in the Omicron era; studies included other respiratory
infections but were not specific to the outcome for SARS-CoV-2 transmission [32][33] and the certainty of the evidence for
particulate respirators compared to medical masks was rated as low.
Given similar effects of respirators vs medical masks when providing routine patient care, decisions about whether to use a
respirator or medical mask could be sensitive to variability in preferences regarding perceptions of the potential increased
prevention of SARS-CoV-2 infection with respirators versus increased discomfort or other harms.
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Given similar effects of respirators vs medical masks when providing routine patient care, decisions about whether to use a
respirator or medical mask could be sensitive to variability in preferences regarding potential increased prevention of
SARS-CoV-2 infection with respirators vs increased bothersome and other harms.
The use of respirators for the care of all patients with suspected or confirmed COVID-19 in health-care facilities requires
additional investment of financial and logistical resources (including fit testing), particularly in low- and middle-income
countries. However, scaling up the market for respirators could lead to cost reduction.
Given the limited global supply of respirators and their higher cost compared to medical masks, recommending the use of
respirators for all COVID-19 cases in health-care settings could result in inequity in resource-limited settings. However, it is
also expected that the widespread use of respirators (if available) would reduce inequities related to COVID-19 exposure
risk. There is an additional equity issue around medical masks, which may not be available in sufficient quantities and of
adequate quality in low-resource settings.
The current recommendation provides the option of using either respirators or medical masks, except for specific
circumstances when a respirator is required. Those specific circumstances are covered by other recommendations. Given
this flexibility, the GDG judged that the recommendation would be acceptable to stakeholders and policymakers.
The current recommendation provides the option of using either respirators or medical masks, except for specific
circumstances when a respirator is required. Those specific circumstances are covered by other recommendations. Given
this flexibility and, based on current availability of respirators and medical masks, the GDG judged that the
recommendation would be feasible for implementation in various settings.
Justification
The GDG considered the evidence for particulate respirators versus medical masks and agreed that the strength of this
evidence was insufficient to recommend one type of mask over another, except in some specific conditions (see conditional
recommendation).
The only RCT of medical masks vs respirators indicated similar effects with regard to the risk of SARS-CoV-2 infection when
providing routine care. Therefore, the GDG recommended use of either respirators or medical masks when providing routine
care.
Decisions to use respirators or masks may be based in part on one's values and preferences, especially in regard to the weight
placed on the potential benefits of respirators in preventing SARS-CoV-2 infection. Furthermore, GDG members noted that the
perceived discomfort caused by respirators may also play a critical role in a health and care worker's choice to wear a medical
mask or a respirator.
Given the potential protective effects of respirators, some GDG members felt that respirators may be superior to medical masks
in preventing SARS-CoV-2 infection and their use should be encouraged when the health-care worker delivers care while in
close contact with the patient and/or when ventilation is inadequate. If respirators are used, there needs to be appropriate fit
testing and training on use.
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The GDG members advised that, irrespective of the mask type (medical mask or respirator), health and care workers should
wear a mask along with other PPE when caring for those with suspected or confirmed COVID-19 infection. The GDG noted that
the core elements of IPC include the implementation of standard and transmission-based precautions.
The GDG considered serious concerns about the limited availability of respirators in low-resource settings and the resource
implications associated with more widespread use of respirators.

Intervention: disposable filtering facepiece respirators
Comparator: surgical masks, and cloth masks
Summary
limited to five observational studies [81][82][83][84][85] and one randomized controlled trial [86]. The five observational
example, recall bias, low participation, and limited measurement of exposures). One study showed a reduction of risk
with respirator use [83], while in two other studies the use of respirators was not significantly associated with risk
reduction [82][85]. One study showed no association [85] and another found respirators were associated with increased
risk (OR 7.1), likely related to confounding factors [82]. In the intention-to-treat analysis, the randomized controlled trial
found that RT-PCR-confirmed COVID-19 occurred in 52 of 497 (10.46%) participants in the medical-mask group versus
47 of 507 (9.27%) in the N95 respirator group (hazard ratio [HR], 1.14 [95% CI, 0.77 to 1.69]) [86]. Results were within
the pre-specified, non-inferiority threshold (HR <2.00), but do not rule out a protective effect of N95 respirators.
Furthermore, the length of RCT transcends across various VoCs (Delta and Omicron). Overall, the findings for N95 vs
surgical masks and risk of SARS-CoV-2 infection in health and care workers were inconsistent.
Intervention
Comparator Certainty of
disposable
Outcome Study results and surgical masks the Evidence
filtering Summary
Timeframe measurements and cloth (Quality of
facepiece
masks evidence)
respirators
SARS-CoV-2 Inconsistent findings for

infection N95 vs surgical masks
Low and risk of SARS-CoV-2
infection in health and
care workers.
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Conditional recommendation for , Low certainty evidence
Suggested factors for informing the choice of the type of mask include a risk assessment1 and health and care
workers’ values and preferences.
WHO suggests respirators be used in care settings where ventilation is known to be poor2 or cannot be
assessed, or where the ventilation system is not properly maintained.
1
The risk assessment should consider the following factors: the activity (procedure), the setting (patient care environment) and
the patient.
2
Ventilation in a health-care setting is considered to be poor when the requirements established for these settings are not in
place (see ”Definitions” section).
Note: This recommendation applies to any setting where regular care is provided to patients with suspected or confirmed
COVID-19, including home care, long-term care facilities and community care settings. For settings where AGPs are regularly
performed on patients with suspected or confirmed COVID-19, see the AGP recommendation.
Practical info
When adopting a mask policy within a health facility, it is essential that health and care workers follow proper mask-wearing
procedures and practices. For additional information, review the implementation considerations on mask management for
The WHO recommendation on mask fitting should be followed, as should the related considerations on this critical aspect, such
as the type of FFR that health and care workers should use.
limited to five observational studies [81][82][83][84][85], and one randomized controlled trial [86]. The five observational
example, recall bias, low participation, limited measurement of exposures). One study showed a reduction of risk with
respirator use [83], while in another two studies the use of respirators was not significantly associated with risk
reduction [82][85]. One study showed no association [85], and another found respirators were associated with increased
found that RT-PCR-confirmed COVID-19 occurred in 52 of 497 (10.46%) participants in the medical mask group versus 47
of 507 (9.27%) in the N95 respirator group (hazard ratio [HR], 1.14 [95% CI, 0.77 to 1.69]) [86]. Results were within the
pre-specified, non-inferiority threshold (HR <2.00), but do not rule out a protective effect of N95 respirators. Furthermore,
the length of RCT transcends across various VoCs (Delta and Omicron). The following side effects have been reported with
respirators: discomfort, headaches, possible development of facial skin lesions, irritant dermatitis and worsening acne
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when used frequently for long hours [32][33].
Medical masks are typically associated with fewer discomforts and side effects than respirators, given the medical masks'
decreased thickness and reduced seal, although this has not been quantified. Undesirable outcomes from the prolonged
use of respirators included general discomfort, headaches and the development of facial skin lesions, irritant dermatitis,
and worsening acne [32][33]. The fitting process for respirators is burdensome, and issues with achieving it have been well
described.
Given the methodological limitations of the evidence, notably inconsistency and indirectness (e.g. most studies were
conducted before the emergence of the Delta variant and few in the Omicron era), evaluation of non-SARS-CoV-2
infections or assessment of non-clinical outcomes [32][33], the certainty of the evidence for particulate respirators versus
medical masks was rated as low.
There is substantial variability in preferences related to the use of respirators in preventing HAIs. In the context of the
increased transmissibility of variants of concern, some health and care workers may value the wider use of respirators to
potentially reduce their risk, despite the limited evidence. Others may prefer not to wear a respirator for the duration of their
shift because of discomfort or potential side effects.
Local values, preferences and practicalities should play an important role in directing choices on respirators. Furthermore,
other factors may influence the overall risk of transmission, including general PPE use, PPE training, fit testing, ventilation
and behavioural factors (including compliance) as well as the fact that transmission of SARS-CoV-2 among health and care
workers appears to occur primarily in community settings.
The use of respirators for the care of all patients with suspected or confirmed COVID-19 in health-care facilities requires an
additional investment of financial and logistical resources, which could be challenging, particularly in low-resource settings.
There is also the need for fit testing for all staff, requiring additional investments and expertise; however, scaling up the
market for respirators could lead to cost reduction.
Given the limited global supply of respirators and their higher cost compared to medical masks, a recommendation to use
respirators for all COVID-19 cases in health-care settings could result in inequity in resource-limited settings. There is an
additional equity issue around medical masks, which may not be available in sufficient quantities and of adequate quality in
low-resource settings.
Discussion with the GDG suggests that this recommendation is likely acceptable for health and care workers, policymakers
and hospital administrators.
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Although WHO unpublished modelling data indicated an inadequate supply of respirators to replace medical masks in all
COVID-19 health-care settings, policies advising respirators in all COVID-19 settings would likely lead to increased
investments and production. Furthermore, a strong supply distribution and logistics system is needed to ensure efficient
procurement and reach across the whole health system. However, inefficiencies in the distribution of supplies and supply
chain problems have been reported. The adequate fit of the device is correlated with the effectiveness of the respirators,
but fit testing may not be feasible in all regions.
Justification
The GDG considered the evidence for particulate respirators versus medical masks and agreed that the strength of this
evidence was insufficient to recommend one type of mask versus the other, except in some specific conditions.
Given the protective effects of respirators, several GDG members felt that respirators may be superior to medical masks in
preventing SARS-CoV-2 infection and their use should be encouraged when the health and care worker delivers care in close
contact with the patient and when ventilation is inadequate.
The previous recommendation considered serious concerns about the limited availability of respirators in low-resource settings
and the resource implications of more widespread use of respirators. The GDG voting on this recommendation considering
Omicron was based on the very low certainty of the evidence for particulate respirators versus medical masks, given the
methodological limitations of the evidence, as well as the previously noted concerns about respirators’ availability.
Given the limitations described, the deliberations of the GDG and its decision-making process were also informed by the
perspectives and experiences of experts who were on the panel.
Research needs
More research is needed to investigate the risks associated with medical masks and respirators and adverse events (including
self-contamination) during extended and repeated use. Other gaps include studies on simpler, faster and less costly methods,
or alternative methods, to determine respirator fit and seal. Further data are needed regarding compliance with appropriate use
of PPE, including masks, and appropriate techniques for putting on and taking off PPE in COVID-19 and non-COVID-19 units.

Intervention: disposable filtering facepiece respirators
Comparator: surgical masks, and cloth masks
Summary
limited to five observational studies [81][82][83][84][85] and one randomized controlled trial [86]. The five observational
example, recall bias, low participation, and limited measurement of exposures). One study showed a reduction of risk
with respirator use [83], while in two other studies the use of respirators was not significantly associated with risk
reduction [82][85]. One study showed no association [85] and another found respirators were associated with increased
found that RT-PCR-confirmed COVID-19 occurred in 52 of 497 (10.46%) participants in the medical-mask group versus
47 of 507 (9.27%) in the N95 respirator group (hazard ratio [HR], 1.14 [95% CI, 0.77 to 1.69]) [86]. Results were within
the pre-specified, non-inferiority threshold (HR <2.00), but do not rule out a protective effect of N95 respirators.
Furthermore, the length of RCT transcends across various VoCs (Delta and Omicron). Overall, the findings for N95 vs
surgical masks and risk of SARS-CoV-2 infection in health and care workers were inconsistent.
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Intervention
Comparator Certainty of
disposable
Outcome Study results and surgical masks the Evidence
filtering Summary
Timeframe measurements and cloth (Quality of
facepiece
masks evidence)
respirators
SARS-CoV-2 Inconsistent findings for

infection N95 vs surgical masks
Low and risk of SARS-CoV-2
infection in health and
care workers.
3.2.6.1 PPE technical specifications

Background
Personal protective equipment (PPE) is considered a medical device for COVID-19 [87]. Regulatory agencies require
technical specifications for types of PPE that define the minimum requirements for the product to ensure that they are of good
quality, safety and efficacy.
The methods used to develop the following technical specifications involved a review of infection prevention and control (IPC)
COVID-19 guidelines; a review of PPE products available in the market and PPE products approved by stringent regulatory
agencies; and an analysis of international, regional and country standards on PPE. The specifications were reviewed by
members of the Technical Advisory Group of Experts on Personal Protective Equipment (TAG PPE), who also provided
technical input; and by WHO staff and consultants from WHO regional offices. All experts and consultants provided conflict-of-
interest declarations and no conflicts were found.
This section includes information published in “Technical specifications of personal protective equipment for COVID-19” [14].
This section also includes basic technical characteristics of PPE that have been considered and incorporated into this
guideline. The decisions as to the appropriate clinical use of each of these devices were made in accordance with
recommended IPC practices, national and subnational policies and regulations, and considerations for procurement and
intended use.
Regulatory approvals and certification

For PPE and related IPC supplies, the following regulatory approvals and certifications apply. It should be noted that, in some
economic regions, some PPE is considered a medical device and therefore the relevant regulations are to be followed. In other
regions, some PPE may be considered an industrial protection garment and not tagged for medical use.
During COVID-19, some regions experienced limited manufacturing capacity, where some products from other economic
regions might have been granted “emergency use authorizations” from regulatory agencies. Therefore, the requirements listed
below for PPE use apply to the COVID-19 period, subject to review and updating by regulatory agencies.
Table 7. PPE regulatory requirements.
Requirements Names, synonyms
General technical
See technical specifications for PPE specific for COVID-19 (below).
requirement
Labeling on the primary packaging needs to include:
Packaging • Name and/or trademark of the manufacturer.

• Model or product reference.
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• Information for storage conditions (temperature, pressure, light, humidity).
Certified quality management system for medical devices (e.g. ISO 13485) and application of risk
Quality management management to medical devices (e.g. ISO 14971), if applicable.
system from the
manufacturer, for the General quality management (e.g. ISO 9001) (for non-medical devices). European Union (EU)
PPE types Module C2 or D conformity to type certificate (Category III CE certified PPE only).
Free sales certificate (FSC) of medical device and related IPC products.
Certificate for exportation of medical device and related IPC products, provided by the authority in
the country of manufacture (in the case of imported goods).
National local regulatory approval (of recipient country, as applicable). Proof of regulatory
compliance, as appropriate, per the product’s risk classification. For example:
• Europe: Conformité Européenne [CE] certification and declaration of conformity and/or EU type
examination certificate as applicable, e.g. PPE cat. III for respirators;
Regulatory approval / • USA: Food and Drug Administration [FDA] approval or emergency use authorization;
Certification • China: National Medical Products Administration [NMPA] listed.
Ability for purchaser to check authenticity directly with the issuing regulatory authority (e.g. online
database of active licences).
Category I PPE, may accept self-declaration with declaration of conformity (COVID-19 context).
Authorized representative must be identified and document expiration date supplied (valid until).
Official test reports (all pages, in English) must either originate from accredited test labs, whereby
the accreditation authority is preferably a member of International Laboratory Accreditation
Cooperation (ILAC), or from an EU-notified body. Accredited facilities should be ISO
17025-certified.
Test reports should clearly indicate the accredited laboratory name and accreditation (for regulator
or procurer, to be able to check authenticity of test reports).
Test reports
Test standard must be within the scope of the accreditation of the laboratory. CE certificates (EU
type examination certificates) for category III PPE should mention the notified body name/number.
Instructions for authentication of test report(s) and certificates should be provided.
Ability for purchaser to check authenticity directly with the accredited test laboratory (e.g. online
uploading of test report and automatic version check, or emailing test facility).
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Table 8. Technical specifications for Personal Protective Equipment (PPE) [14]
Performance standards (or

Item Characteristics*
alternative equivalent)
Always use a clean, unused,

rectangular, pleated medical mask
meeting the following minimum
performance standards (or
equivalent):
Medical mask, good breathability, internal
Medical mask for a health and and external faces should be clearly • EN 14683 (Type II or Type
care worker identified, 98% droplet filtration, preferably IIR);
fluid-resistant. • ASTM F2100 (Level 1, 2 or 3);
or
• YY 0469 OR YY/T 0969 (with
at least 98% bacterial filtration
efficiency).
EN 14683 Type I YY 0469 or YY/T

Medical mask, good breathability, internal
0969, if bacterial droplet filtration is
Medical mask for patient and external faces should be clearly
below 98% or alternative
identified.
equivalent standard.
To evaluate effectiveness of seal
To evaluate effectiveness of seal for tight-
Fit test kit for tight-fitting respiratory
fitting respiratory protection devices.
protection devices.
Fluid-resistant respirator:
• Minimum NIOSH-approved
(42 CFR Part 84) and FDA-
cleared “surgical N95”
• EN 149, minimum “FFP2“ and
EN 14683 Type IIR
• GB 19083, minimum “Grade/
Good particle filtration (minimum 94% or Level 1”
95%), good breathability with design that • Or alternative equivalent
does not collapse against the mouth (e.g. standard
Particulate respirator duckbill, cup-shaped). May be tested for
fluid resistance (NIOSH/FDA surgical N95,
EN 149 FFP2+Type IIR, GB 19083 Grade/ Non-fluid resistant respirator:
Level 1).
• Minimum NIOSH-approved
N95 according to 42 CFR Part
84
• EN 149, minimum FFP2
• GB 2626, minimum KN95
• Or alternative equivalent
standard
Gloves, examination, nitrile (preferable),

EN 455 ASTM D6319, D3578,
latex, polychloroprene or PVC, powder-free,
Gloves, medical examination D5250, or D6977 EN 374, optional
non-sterile (e.g. minimum 230 mm total
(nonsterile) additional. Or alternative
length). Minimum thickness 0.05 mm. Sizes
equivalent set of standards
S, M, L.
Gloves, surgical (sterile) Gloves, surgical, nitrile (preferable), latex, Gloves, surgical, nitrile
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(preferable), latex, polyisoprene or

polyisoprene or polychloroprene, sterile, polychloroprene, sterile, powder-
powder-free, single-use. Gloves should free, single-use. Gloves should
have long cuffs, reaching well above the have long cuffs, reaching well
wrist, ideally to mid-forearm. Minimum above the wrist, ideally to mid-
thickness 0.10 mm. Sizes ranging 5.0–9.0. forearm. Minimum thickness 0.10
mm. Sizes ranging 5.0–9.0.
Good seal with the skin of the face, flexible
PVC frame to easily fit with all face contours
with even pressure; enclose eyes and the
surrounding areas; accommodate wearers
with prescription glasses, clear plastic EN 166
lenses with fog- and scratch-resistant
Goggles, glasses protective ANSI/ISEA Z87.1. Or alternative
treatments. Adjustable band to secure firmly
equivalent set of standards
so as not to become loose during clinical
activity. Indirect venting to avoid fogging.
May be reusable (provided appropriate
arrangements for decontamination are in
place) or disposable.
Made of clear plastic and providing good
visibility to both the wearer and the patient.
EN 166 (if reusable)
Adjustable band to attach firmly around the
head and fit snugly against the forehead, ANSI/ISEA Z87.1 (if reusable)
Face shield fog-resistant (preferable). Completely cover
the sides and length of the face. May be Or alternative equivalent set of
reusable (made of robust material, which standards
can be cleaned and disinfected) or
disposable.
*Characteristics / Performance standards (or alternative equivalent standard)
Extracted from “Technical specifications of personal protective equipment for COVID-19” [14]
3.2.7 Aerosol-generating procedures (AGPs)

Background
An aerosol-generating procedure is defined as any medical procedure that can induce the production of aerosols of various sizes,
including droplet nuclei [8]. Evidence suggests that proximity to AGPs increases a person's risk of SARS-CoV-2
infection [8][36][37]; therefore, WHO recommends adhering to the below IPC practices in the context of AGPs and COVID-19.
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Airborne precautions during AGPs
WHO suggests using airborne precautions while performing aerosol-generating procedures (AGPs) and, based
on a risk assessment1, when caring for patients with suspected or confirmed COVID-19.
1
The risk assessment should consider the following factors: the activity (procedure), the setting (patient care environment) and
the patient.
Practical info
• When caring for someone on airborne precautions, health and care workers should:
◦ Place the patient in an AIIR;
◦ Wear a respirator (e.g. N95, FFP2, etc.) before entering the patient's room and remove it after exiting the room;
▪ Perform a respirator seal-check;
▪ Perform hand hygiene before and after the use of respirators;
◦ Use disposable or dedicated patient-care equipment (e.g. stethoscopes) and clean and disinfect equipment before use
on other patients;
◦ Instruct the patient to wear a medical mask and follow respiratory hygiene and cough etiquette when transport is
necessary.
• For airborne precautions, place the patient in an AIIR.

◦ An AIIR includes a ventilation rate of 6-12 air changes/hour (i.e. equivalent to 40-80 L/second/patient for a 4x2x3 m3
room) and ideally 12 air changes per hour for new constructions, with a recommended negative pressure differential of
≥2.5Pa (0.01-inch water gauge);
◦ Direct exhaust of air to the outside, away from places where people walk or congregate, and away from any air intake
openings;
◦ Keep door shut when it is not being used for entry or exit;
◦ If an AIIR is not available, use a well-ventilated, single-patient room with doors closed.
• The following actions may be taken to optimize natural ventilation when an AIIR is not available:
◦ Use a room that has good cross-ventilation (two or more windows that open to the outdoors);
◦ Use an exhaust fan in one window to assist in moving room air to the outdoors, making sure the exhaust window is
away from people and any air intake opening;
◦ Turn off air conditioning and open windows to enhance ventilation if an independent air supply is not available;
◦ Keep the door to the hallway closed, except when health and care workers enter or exit the room.
For additional information on transmission-based precautions, including airborne precautions, see Transmission-based
precautions for the prevention and control of infections: aide-memoire [9].
No studies evaluated the effects of airborne precautions compared to droplet or contact precautions. However, the
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evidence does suggest that health and care workers are at higher risk of SARS-CoV-2 exposure when performing
intubations or other AGPs [36][37].
No evidence was found on harms related to the use of airborne precautions vs droplet or contact precautions.
Given the evidence on the increased risk of SARS-CoV-2 infection when performing intubations or other AGPs, the GDG
judged that airborne precautions may reduce the risk of SARS-CoV-2 infection in these situations.
The certainty of evidence was rated as very low given the absence of direct evidence on airborne versus droplet or contact
precautions.
The GDG was unable to determine whether decisions to utilize airborne precautions would be preference-sensitive, due to
the lack of evidence on the benefits and harms of airborne precautions versus droplet or contact precautions.
GDG members judged that implementing airborne precautions is associated with significant cost and resource implications
that are warranted when risk of acquiring airborne infection is increased.
Many GDG members noted that AIIRs (which are preferable for the implementation of airborne precautions) may not be
available in low- and middle-income countries and some facilities may face challenges in trying to accommodate patients
when such rooms are limited or not available. There are, however, strategies available for improving natural ventilation that
countries may be able to implement (see implementation considerations).
The GDG judged that the impact on equity was uncertain, given the lack of evidence.
Acceptability of intervention likely varies.
Given resource limitations, implementation likely varies.
Justification
Airborne precautions are a bundle of measures (see practical info for full details) [9]. No studies were found that investigated
the risk of SARS-CoV-2 infections when implementing airborne precautions compared to droplet and contact precautions.
However, other evidence does suggest that health and care workers are at higher risk of SARS-CoV-2 exposure when
performing intubations or other AGPs [36][37]. Therefore, the GDG judged that implementing airborne precautions in these
situations has potential benefits in reducing the risk of SARS-CoV-2 infection that likely outweigh the harm.
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The GDG discussed the use of airborne precautions within the context of the care environment and resources. For example,
there are practical considerations regarding the availability of airborne infection isolation rooms (AIIRs), which are also referred
to as negative-pressure rooms. It was noted that improving ventilation may be a challenge in some low- and middle-income
countries. There is guidance for health facilities on the use of natural ventilation, although achieving negative pressure may not
be reasonable, or may not meet the definition of an AIIR [6].
WHO published a list of AGPs in 2014, prior to the onset of the COVID-19 pandemic [8]. However, the GDG members noted
that an important challenge in implementing airborne precautions when performing AGPs for patients with suspected or
confirmed COVID-19 is a continued lack of consensus and available evidence for defining AGPs.
Within the context of COVID-19, the GDG considered that some procedures have been found to be associated with an
increased risk of aerosol generation and transmission of respiratory particles, but also noted that these particles can be
produced during other activities such as talking, coughing, sneezing and singing.

Population: Health and Care Workers
Intervention: Airborne Precautions
Comparator: Droplet/Contact precautions
Summary
A systematic review found no studies comparing the use of airborne precautions versus droplet and contact
precautions when conducting intubations or other AGPs.
Certainty of
Droplet/Contact Airborne Summary
precautions Precautions
evidence)
SARS-CoV-2
infection No studies were found
that looked at SARS-
CoV-2 infection.
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PPE use during AGPs
A respirator should always be worn along with other PPE1 by health and care workers performing aerosol-
generating procedures (AGPs) and by health and care workers on duty in settings where AGPs are regularly
performed on patients with suspected or confirmed COVID-19, such as intensive care units (ICU), semi-
intensive care units or emergency departments.
1
PPE includes gown, gloves, eye protection.
Practical info
When adopting a mask policy within a health facility, health and care workers must follow proper mask-wearing procedures and
practices. For additional information, review the section on mask management for health workers.
The WHO recommendation on mask fitting should be followed, including the related considerations on this critical aspect.
No studies have compared respirators vs other masks in health and care workers when performing AGPs or in settings in
which AGPs are regularly performed. However, exposure to an AGP such as tracheal intubation was associated with a
higher risk of infection with SARS-CoV-1, the human coronavirus most closely related to SARS-CoV-2 [88]. Furthermore, a
living rapid review showed that certain exposures, such as involvement in intubations, are significantly associated with
SARS-CoV-2 infections [36][37].
If respirators are appropriately fit tested and worn, they have higher filtration efficiency standards and demonstrate better fit
with fewer air gaps allowing bypass of the filter media than medical masks. The living review on masks found bothersome
but no serious harms of respirators. Therefore, the GDG judged that respirators may be superior in preventing transmission
of SARS-CoV-2 during AGPs [36][37].
Given the absence of direct evidence on the effect of respirators versus medical masks in preventing SARS-CoV-2
infection when performing AGPs or in settings in which AGPs are frequently performed, the certainty of the evidence was
rated as very low.
Given increased risk of SARS-CoV-2 infection when conducting AGPs or in settings in which AGPs are frequently
performed, potential moderate or large benefits of respirators in preventing SARS-CoV-2 infection, and small and trivial
harms, the GDG judged that decisions regarding use of respirators to prevent SARS-CoV-2 would not be preference-
sensitive.
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Research evidence
The use of respirators requires an additional investment of financial and logistical resources, including the need for fit
testing for all staff, requiring additional investments and expertise [76]. Some clinical and operational challenges may be
experienced, particularly in low- and middle-income countries, and investments are needed to provide the best protection
possible during AGPs.
Summary
The use of respirators requires an additional investment of financial and logistical resources, including the need for fit
testing for all staff, requiring additional investments and expertise [76]. Some clinical and operational challenges may be
experienced, particularly in low- and middle-income countries, and investments are needed to provide the best protection
possible during AGPs.
The GDG judged that the recommendation could have negative impacts on equity if the global supply of respirators is
limited and availability is restricted/limited in resource-poor settings.
Stakeholders and policy-makers will likely accept the recommended use of respirators during procedures that produce
aerosols as this is the policy currently in place in most countries and is one that is historically integrated into a conditional
recommendation by the WHO for acute (non-SARS-CoV-2) respiratory infections [8].
The use of respirators during the performance of an AGP is feasible and has been standard practice.
Justification
No trials of respirators vs medical masks have been conducted in this setting. A majority of GDG members noted that, despite
the very low certainty of evidence, a strong recommendation to use respirators when conducting AGPs or in settings in which
AGPs are frequently performed was justified based on increased risk of exposure and acquiring infection; importance of
preventing iatrogenic infections; superior filtration properties of respirators; small or trivial potential harms relative to benefits;
and high acceptability and feasibility of implementation. Other factors informing the strong recommendation were the increased,
widespread transmission of Omicron, its immune escape, and still limited vaccination coverage in health and care workers
worldwide.
Based on these factors, the GDG upgraded this from a conditional recommendation to a strong recommendation [8]. The GDG
acknowledged costs associated with utilizing respirators but judged the costs as being justified and noted the importance of
ensuring an adequate supply of respirators to meet needs globally.
3.3 Water, sanitation, hygiene, and waste management

Background
Fully functioning water, sanitation, hygiene (WASH) and health-care waste management services are critical aspects of infection
prevention and control (IPC) practices and ensuring patient safety and quality of care. WASH is a critical foundation for improving
quality across the health system.
In the context of COVID-19, special WASH precautions. However, health facilities must strengthen, monitor and assess their WASH
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programmes. For information on improving WASH systems in a health-care facility, please see the WASH FIT practical guidance [89].
Like other coronaviruses, SARS-CoV-2 is an enveloped virus with a fragile outer lipid envelope that makes it more susceptible to
disinfectants compared to non-enveloped viruses such as rotavirus, norovirus and poliovirus [90][91].
Following existing recommendations for WASH and waste measures in health-care settings is important for providing adequate care to
patients and protecting patients, staff and caregivers from infection risks. Additional measures are not required to prevent SARS-CoV-2
transmission, but taking the following standard WASH-related actions is particularly important:
• engaging in frequent hand hygiene using appropriate techniques;

• implementing regular environmental cleaning and disinfection practices;
• managing excreta (faeces and urine) safely;
• safely managing health-care waste produced by COVID-19 cases; and
• safely managing dead bodies.
Many other infectious diseases can be prevented and health co-benefits realized by safely managing water and sanitation services,
and by applying good hygiene and waste-management practices.
3.3.1 Environmental cleaning

Background
Cleaning and disinfection of the physical environment in health-care settings is important as it reduces the number of
microorganisms that may potentially be transmitted to other individuals. The determination of environmental cleaning procedures
for patient-care areas, including frequency, method and process, should be based on the risk of pathogen transmission [11].
The immediate environment of an infected individual can serve as a source of transmission, as infectious SARS-CoV-2 has been
found on environmental surfaces [90][91]. The survival time of the virus depends on several factors, including the initial virus
concentration, type and smoothness of the surface, temperature and relative humidity [90][91]. This includes the patient-care
environment, which can be contaminated with SARS-CoV-2 virus in health-care facilities and is where certain medical procedures
are performed. Therefore, areas where patients with COVID-19 are being cared for and items in those areas must be properly
cleaned and disinfected to prevent further transmission. Examples include furniture and other fixed items inside and outside of
patient rooms and bathrooms, such as tables, chairs, walls, light switches and computer peripherals, electronic equipment, sinks,
toilets as well as the surfaces of non-critical medical equipment, such as blood pressure cuffs, stethoscopes, wheelchairs and
incubators.
While the terms “cleaning” and “disinfection” are sometimes used interchangeably, they are not the same.
Cleaning is the physical removal of soil and debris through the mechanical action of wiping with a clean wet cloth or mop to
remove pathogens or significantly reduce their load on contaminated surfaces [11][12][92][93]. Cleaning with water, soap (or a
neutral detergent) and some form of mechanical action (brushing or scrubbing) removes and reduces dirt, debris and other organic
matter such as blood, secretions and excretions, but does not kill microorganisms. Organic matter can impede direct contact of a
disinfectant to a surface and inactivate the germicidal properties or mode of action of several disinfectants.
Disinfection is a thermal, chemical or physical process for inactivating microorganisms on inanimate objects [11][12]. Disinfection
is the inactivation of disease-producing microorganisms through wetting of a surface with a ready-to-use disinfectant wipe or cloth
saturated with a disinfectant solution prepared according to the manufacturer’s instructions for use. To achieve disinfection, the
surface must stay wet for the manufacturer’s recommended contact time.
Surfaces must be cleaned of visible soil before they can be disinfected, as dust, dirt and organic matter interfere with the
effectiveness of the disinfectant. A chemical disinfectant, such as chlorine or alcohol, should be applied after cleaning with soap
and water to kill any remaining microorganisms. Disinfectant solutions must be prepared and used according to the manufacturer’s
recommendations for volume and contact time. Improperly prepared disinfectants (either too dilute or too concentrated) may not be
fully effective. Enough disinfectant solution should be applied to allow surfaces to remain wet and untouched long enough for the
disinfectant to inactivate pathogens, as recommended by the manufacturer. All staff performing cleaning and disinfecting tasks
should be knowledgeable about standard precautions, environmental cleaning principles, cleaning and disinfection products,
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cleaning frequencies and methods so that their cleaning is safe and effective.
Existing recommended cleaning and disinfection procedures for health-care facilities should be followed consistently and
correctly [89]. At a minimum, all patient-care areas should be routinely cleaned once a day, and more often when contamination is
visible. For patients who require additional IPC measures (transmission-based precautions), more frequent cleaning may be
required, especially in multi-bedrooms [92][93].
Many disinfectants – including commonly used hospital disinfectants – are active against enveloped viruses, such as SARS-CoV-2.
The selection of chemical disinfectants should meet local authorities’ requirements for market approval [94].
Routine environmental cleaning processes in health-care settings include (Figure 4):
• daily cleaning of all patient-care areas;

• more frequent cleaning for common areas and high-touch surfaces, and for patients on transmission-based precautions,
especially in shared living spaces and bedrooms;
• terminal cleaning1 (Figure 5) whenever a patient is discharged or transferred, when precautions have been discontinued.
Figure 4. Routine Cleaning [12]
Figure 5. Terminal cleaning process [12]
1
Terminal or discharge cleaning aims to remove organic material and significantly reduce or eliminate microbial contamination to
ensure that there is no transfer of microorganisms to the next patient [12]. It uses the same best practices as routine cleaning, but
is more detailed.
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For COVID-19, health-care settings should follow standard precautions for the cleaning and disinfection of the
environment and other frequently touched surfaces.
Published 21 December 2023
Practical info
• Provide a clean and hygienic environment, including water, sanitation and hygiene infrastructure and adequate ventilation
(natural or mechanical).
• Train cleaning staff on the principles and practices of environmental cleaning, including how to prepare and use cleaning
and disinfection products.
◦ All staff performing cleaning and disinfecting tasks should be knowledgeable about standard precautions, environmental
cleaning principles, cleaning and disinfection products, cleaning frequencies and methods so that their cleaning is safe
and effective.
• Frequency of cleaning and disinfection procedures should follow existing processes for patient-care rooms and shared
areas, for example, at least once a day, paying particular attention to high-touch surfaces. If there is a spill or when
surfaces are contaminated with blood, body fluids or other substances, attend to them promptly, in accordance with local
protocols.
• Use products approved for health-care settings and apply them according to the manufacturer’s instructions.
◦ While wearing the appropriate personal protective equipment (PPE) to avoid chemical exposure, follow the
manufacturer’s instructions to ensure that disinfectants are prepared and handled safely.
▪ In selecting a disinfectant, cleaners should consider the microorganisms targeted, as well as the recommended
concentration and contact time, the compatibility of the chemical disinfectants with surfaces, toxicity, ease of use,
and stability of the product. The selection of chemical disinfectants should meet local authorities’ requirements for
market approval, including any regulations applicable to specific sectors, for example, health-care and food
industries [94].
▪ Provide efficient environmental cleaning and disinfectant products.
• Cleaning (with soap and water or one-step cleaner/disinfection) should be performed first, followed by disinfection.
◦ Cleaning should progress from the least-soiled (cleanest) to the most-soiled (dirtiest) areas, and from the higher to
lower levels so that debris may fall to the floor and be cleaned last in a systematic manner to avoid missing any areas.
When cleaning and disinfecting, concentrate on frequently touched surfaces.
◦ Emphasis for cleaning and disinfection should be placed on surfaces that are most likely to become contaminated with
pathogens, including clinical-contact surfaces and frequently touched surfaces (such as light switches, bracket trays,
switches on dental units, computer equipment) in the patient-care environment.
◦ Surfaces must first be cleaned of visible soil before disinfection, as dust, dirt and organic matter interfere with the
effectiveness of the disinfectant. In addition to the method of application, the disinfectant concentration (or dose) and
contact time are also critical for effective surface disinfection.
• After proper cleaning, disinfection may occur.

◦ Refer to the manufacturer's instructions for the preparation and use of chemical disinfectant solutions.
◦ A chemical disinfectant, such as chlorine or alcohol, should be applied after cleaning with soap and water to kill any
remaining microorganisms.
◦ Wiping is the preferred method for the application of a product. Ensure that the disinfectant is applied liberally so that
the surface is wet.
◦ Spraying may be considered as an alternative but may be associated with potential harm. Appropriate PPE should
be worn. If utilizing a spraying method, ensure it is done away from other persons.
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◦ To achieve chemical disinfection, cleaners must ensure that the surface stays wet for the recommended contact time.
Concentrations with improper dilution during preparation may reduce their effectiveness. The surface must remain wet
and untouched long enough for the disinfectant to inactivate pathogens, as recommended by the manufacturer.
• If considering the use of ultraviolet germicidal irradiation (UVGI) as a supplemental technology, carefully assess benefits
versus harms and ensure that the product is used according to the manufacturer's instructions.
Justification
Rapid reviews exploring cleaning and disinfection found no evidence of impacts on SARS-CoV-2 infection. This included no
difference when comparing wiping vs spraying in the application of products. Therefore, the GDG determined that there was
insufficient evidence to suggest additional precautions are needed for environmental cleaning in the context of COVID-19.
As no data were found on the efficacy of cleaning methods, the GDG based its decision upon accepted standard environmental
cleaning and disinfection practices.
The GDG agreed that health-care facilities should follow existing procedures for cleaning and disinfection and emphasize the
need to follow standard precautions for environmental cleaning. WHO commissioned a qualitative review of the literature
(reports, qualitative studies and related systematic reviews) to further understand the perceptions of health and care workers
on cleaning and disinfection and to better inform the GDG about the evidence to decision-making process. The GDG members
reviewed the outcomes and discussed the need for human resources and clear and consistent guidelines for cleaning and
disinfection in implementing a proper cleaning and disinfection regime. GDG members noted that, in indoor spaces, wiping is
the preferred method; routine application of disinfectants to environmental surfaces by spraying or fogging (also known as
fumigation or misting) is not advised for COVID-19, particularly in situations where people are present.

Population: Health-care settings
Intervention: Differential cleaning measures beyond standard environmental cleaning
Comparator: Standard precautions for environmental cleaning
Summary
No studies compared more intensive cleaning measures vs standard measures and risk of SARS-CoV-2 infection.
Three studies were found and included in the narrative syntheses that compared standard cleaning to differential
cleaning. The evidence was inconclusive, as surface contamination varied greatly by the health-care facility, the
disinfectant used and the cleaning regime.
Intervention
Differential
Comparator
cleaning Certainty of
Standard
Outcome Study results and measures the Evidence
precautions for Summary
Timeframe measurements beyond (Quality of
environmental
standard evidence)
cleaning
environmental
cl
SARS-CoV-2 There were no studies

looking at impact on
infection SARS-CoV-2 infection,
Very low Evidence was insufficient
to determine impacts on
risk of infection.
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Population: Health-care settings
Intervention: Spraying
Comparator: Mechanical cleaning (wiping, brushing, scrubbing)
Summary
No studies evaluated the effects of SARS-CoV-2 infection. Three studies were found and included in the narrative
syntheses that compared spraying versus wiping. The evidence was inconclusive as surface contamination varied
greatly by the health-care facility, the disinfectant used and the cleaning regime.
Comparator
Mechanical Certainty of
Outcome Study results and cleaning Intervention the Evidence
Summary
Timeframe measurements (wiping, Spraying (Quality of
brushing, evidence)
scrubbing)
SARS-CoV-2 Few studies looked at

infection the outcome of SARS-
CoV-2 infection.
Evidence was
inconclusive.
3.3.2 Waste management

Background
Health-care waste is divided into two main categories: hazardous and non-hazardous waste. Hazardous waste can be broken
down into two subcategories: infectious and hazardous [16]. If waste is not segregated correctly, hazardous waste can contaminate
non-hazardous waste, which can complicate its collection, transport, treatment and disposal. Furthermore, treating non-hazardous
waste as though it is hazardous results in wasted resources and effort [16].
The WHO description of hazardous waste in health care is as follows: Hazardous waste can harm people and the environment.
The types of hazardous waste in a facility vary according to the size of the facility and the services offered [16]. Examples of
hazardous waste are listed below.
Examples of infectious waste:

• Sharps waste is used or unused sharp items that could cause cuts or puncture wounds that can lead to infection. Examples
include instruments (such as scalpels and blades), needles, syringes and broken glass or ampoules.
• Pathological waste (anatomical waste) includes human tissues or fluids (such as blood and body fluids), organs (body parts),
placentas and fetuses and unused blood products.
• Other infectious waste includes soiled gloves, gauze or bandages contaminated with blood, body fluids, viruses or
parasites.
• Other hazardous waste includes pharmaceutical waste, chemical waste, genotoxic and radioactive waste.
Examples of hazardous waste:

• Pharmaceutical waste is used, expired or no-longer-needed pharmaceutical products (such as vaccines and drugs);
• Chemical waste includes chemical substances (such as laboratory reagents or film developers), disinfectants, solvents and
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waste with high heavy-metal content (such as batteries, broken thermometers and blood pressure gauges);
• Genotoxic (harmful to human genes) and cytotoxic (harmful to human cells) waste isn’t common unless the facility treats
cancer patients. They include drugs used in cancer treatment, body fluids from patients exposed to chemotherapy or cytotoxic
drugs and other material contaminated by these agents.
• Radioactive waste includes radioactive substances (such as unused liquids from radiotherapy or laboratory research),
glassware, packages, or absorbent paper contaminated with a radioactive substance, urine or excreta from patients treated or
tested with radionuclides and sealed sources (containers in which radioactive substances are stored and sealed).
Figure 6. Waste processing [16]
• Where feasible, minimizing waste produced by a health-care facility is a good waste management practice, which includes the
proper and rational use of PPE and reducing unnecessary glove use and improving hand hygiene practices.
◦ Waste minimization is most commonly applied at the point of generation, but it can also happen before items even enter the
health-care facility [92].
• Waste segregation can substantially reduce the quantity of health-care waste that requires specialized treatment. Health-care
facilities should segregate waste when and where it is generated, such as before leaving a patient’s room, examination room,
operating theatre or laboratory.
◦ Staff should discard waste in the appropriate containers, based on the potential hazard posed by the waste and the
treatment and final disposal methods.
◦ Color-coded or labeled waste containers with clear signs and symbols should be strategically placed for convenient use.
• After waste is segregated, staff should be designated for each ward or unit to collect and transport it for treatment/disposal or
to a dedicated storage area to await treatment/disposal.
◦ Each category of waste is treated onsite or offsite and disposed of using the safest available methods.
• While general, non-hazardous health-care waste (municipal general waste) can be disposed of without treatment, hazardous
waste should be treated prior to final disposal.
◦ Refer to WHO safe management of wastes from health-care activities [95] for more information.
• Health-care facilities should conduct a risk assessment based on the type and quantity of waste and access to resources and
choose the disposal methods that will pose the least risk to the community and the environment.
For additional details on how to properly handle health-care waste, please review the course on WHO entitled: Standard
Precautions: Waste Management [16]
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Health-care waste generated from care provided to suspected or confirmed COVID-19 patients should be
segregated according to existing guidelines (e.g. non-infectious, infectious) for disposal and, where necessary,
treated per national/subnational/local regulations and policies.
Practical info
For proper handling and disposal of waste:
• assign responsibility and adequate human and material resources for the collection, segregation and disposal of waste;
• minimize the amount of waste produced by the health-care facility;
• treat waste, preferably on-site, and then safely dispose of it;
• understand where and how waste moved off-site will be treated and disposed of to ensure that it is handled safely and that
it is properly decontaminated and disposed of;
• prepare for the management of additional waste during an outbreak of SARS-CoV-2 or an increase in cases associated
with the use of PPE and in the context of COVID-19 vaccination delivery;
• ensure that staff use appropriate PPE (boots, long-sleeved gown, heavy-duty gloves, mask and goggles or a face shield)
while managing infectious waste and that they perform hand hygiene during and after the removal of PPE;
• treat waste contaminated with blood, body fluids, secretions and excreta as hazardous infectious waste, in accordance
with local regulations;
• consider environmentally friendly treatment methodologies and solutions to minimize both general and medical waste at
points of use, segregation, disposal and collection; and
• treat human tissue and laboratory waste that is directly associated with specimen processing as hazardous infectious
waste.
As the use of PPE, in particular the use of masks, during care activities increased throughout the COVID-19 pandemic,
awareness of unintended consequences, such as increases in health-care waste and the impact on the environment, had to be
taken into consideration. For additional information on the environmental impact of masks and other PPE, see the WHO global
analysis of health-care waste in the context of COVID-19 [74].
For additional information on waste management, see the OpenWHO course Standard Precautions: Waste management [16].
Justification
A systematic review found no study comparing the handling of COVID-19-related waste as infectious versus non-infectious and
the GDG found no evidence to support handling COVID-19-related waste differently from other health-care-related waste. Upon
review of the evidence, the GDG determined waste produced from SARS-CoV-2 did not require special handling beyond what
was the standard advised through national, subnational or local policies for handling health-care waste. As no data were found
on the differences among various waste-disposal methods, the GDG based its decision on accepted standard waste-
management practices as highlighted in standard precautions. Some GDG members noted varying regional definitions for
infectious waste, which underscores the importance of following one's local, national or subnational policy. Members noted that
there is nothing particularly different about SARS-CoV-2, when compared to other respiratory pathogens, that would require
policies above and beyond standard precautions.
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Population: Personnel handling waste in health-care facilities
Intervention: Infectious waste
Comparator: Noninfectious waste
Summary
Certainty of
Noninfectious Infectious Summary
waste waste
evidence)
SARS-CoV-2
CoV-2 infection.
3.3.3 Handling of linens and laundry

Background
Management of linens in health-care settings includes the collection, transport, handling, washing and drying of soiled linen,
including protection of staff and hand hygiene [11][93]. Laundry in health-care settings may include bed-sheets and blankets,
towels, personal clothing, gowns, uniforms, laundry bags and drapes for surgical procedures. Although contaminated textiles and
fabrics in health-care facilities can be a source of microorganisms, the overall risk of disease transmission during the laundering
process is negligible with control measures and based on principles of hygiene [15]. Staff should be trained in procedures for safe
handling and laundering practices to protect themselves from potential cross-contamination from soiled linen by wearing
appropriate PPE and should have access to hand-hygiene stations.
Health-care facilities should follow standard processes for handling, transporting, sorting and laundering of
linens for patients with suspected or confirmed COVID-19.
Remark: This process should adhere to national/subnational/local policies as well as ensure the implementation
of standard precautions.
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Practical info
Regular laundering of bed linen and patients’ clothing includes the following:
• Handle soiled linen and waste carefully (with minimal manipulation or agitation) to prevent personal contamination and
transfer of any microorganisms.
• After carefully removing any solid excrement and putting it in a covered bucket to be disposed of in either a flush or dry
toilet, place soiled linen in bags or containers.
• While wearing appropriate PPE, remove heavily soiled material (e.g. faeces) from linen before placing the linen in a
laundry bag. PPE selection and use are determined by a risk assessment.
• Machine washing with warm water at 60−90°C and laundry detergent are recommended. The laundry can then be dried
according to routine procedures.
◦ For manual cleaning, items such as cloths and linen should be immersed in a detergent solution and scrubbed to
remove any soiled material anywhere laundry facilities are not available. This should be performed safely, for example,
using PPE. Items should be disinfected by immersing them in boiling water or in a disinfectant solution for the required
contact time, then rinsing them with clean water and (ideally) hanging them out in the sun to dry [96].
• Staff involved in environmental cleaning, laundering and dealing with soiled bedding, towels and clothes from patients with
SARS-CoV-2 infection should wear appropriate PPE during that process and then, after exposure to blood or body fluids
and after removing their PPE, they should perform hand hygiene.
◦ Perform hand hygiene frequently and at critical access points [15] during and after removal of PPE, or after exposure to
blood or body fluids and after removing PPE.
• Store clean linen in a clean area to minimize the chance that they will come into contact with environmental
contaminants [11].
For additional details see Environmental cleaning and infection prevention and control in health care facilities in low- and
middle-income countries [92].
Justification
The GDG found insufficient evidence to support additional measures and precautions in the context of COVID-19 in regard to
handling, transporting, sorting and laundering of linens. The evidence on the effects of SARS-CoV-2 infection was limited to
one study [97].
The GDG advised that health-care facilities follow their existing procedures when partaking in these duties. The GDG members
emphasized the importance of adhering to standard precautions when handling linens and laundry. The GDG elected for a
Good Practice Statement, based on established IPC practices for handling linen.

Population: Personnel handling linens in health-care facilities
Intervention: Above standard
Comparator: Standard precautions for routine handling of linens and laundry
Summary
One study addressed the PICO question, reporting that SARS-CoV-2 RNA was not detected in rinse water after
washing with tap-water, disinfecting with sodium hypochlorite, or disinfecting with 80 °C water [97]. However, SARS-
CoV-2 was detected in one of five samples after washing with laundry detergent and in one of six samples after
washing with fabric softener [97].
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Comparator
Standard
Certainty of
precautions for
Outcome Study results and Intervention the Evidence
routine Summary
Timeframe measurements Above standard (Quality of
handling of
evidence)
linens and
laundry

SARS-CoV-2 experienced the SARS-
infection CoV-2 infection to
determine a difference
between standard
versus above-standard
cleaning.
3.4 Safe dead body management

Background
Deaths from COVID-19 may occur in health-care facilities, at home or in other locations. The safe management of dead bodies
ensures proper dignity for those who have died of COVID-19, and protects their families, health and care workers and funeral home
workers. For safe handling of bodies in the community, recommended practices would follow the same measures as those followed in
cases of death due to other respiratory illnesses (e.g. influenza). The dignity of the dead, their cultural and religious traditions and their
families should be respected and protected throughout, balancing the rights of the family, the need to investigate the cause of death,
and the risks of exposure to infection.
In the health setting, apply standard precautions and follow any additional regulatory requirements for the safe management of dead
bodies in accordance with local, subnational and national guidance for patients who had COVID-19.
Good practice statement Updated
Health and care workers and other persons involved in handling the deceased should follow standard precautions
according to risk-assessment1 and existing national/subnational/local protocols for managing and handling the
bodies of deceased persons infected with COVID-19.
1
The risk assessment should consider the following factors: the activity (procedure), the setting (patient care environment) and the
patient.
Practical info
Health-care facility
Health and care workers who handle the dead body should follow standard precautions, including hand hygiene, environmental
cleaning and appropriate selection and use of PPE.
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• In the context of COVID-19 and the safe management of dead bodies, SARS-CoV-2 does not pose a substantial infectious
risk [98]. Therefore, IPC measures for managing the bodies of deceased persons infected with SARS-CoV-2 should be
consistent with those applied to patients who have died of an infectious disease and in accordance with national, subnational
and local public health guidance. If a risk assessment determines the need for additional measures, apply transmission-based
precautions accordingly.
• The dignity of the dead, their cultural and religious traditions and their families should be respected and protected throughout,
balancing the rights of the family, the need to investigate the cause of death and the risks of exposure to infection.
• Before attending to a dead body, health and care workers should ensure that necessary hand-hygiene supplies, PPE and
cleaning and disinfection supplies are readily available.
• When preparing and packing the body for transfer from a patient room in a health facility to an autopsy unit, mortuary,
crematorium, or burial site, ensure that staff who interact with the body (health-care or mortuary staff, or the team preparing
the body for burial or cremation) apply standard precautions, including hand hygiene, before and after interaction with the
body and the patient environment; and use of the appropriate PPE, based on a risk assessment and considering the level of
interaction.
• Preparing the body for transfer may include removing all lines, catheters and other tubes and ensuring that any body fluids
leaking from orifices are contained and keeping movement and handling of the body to a minimum. Wrap the body in cloth or a
plastic shroud, if culturally appropriate.
• Surfaces used during the care of the dead body should be cleaned and disinfected. Management of waste should be carried
out in accordance with local standards.
• If the body of a person with suspected or confirmed COVID-19 is selected for autopsy, health-care facilities must ensure that
those performing the autopsy are protected by safety measures, including appropriate supplies of PPE, a scrub suit, a long-
sleeved, fluid-resistant gown, gloves (either two pairs or one pair of autopsy gloves), a particulate respirator (N95 or FFP2 or
its equivalent), eye protection (face shield or goggles), and boots/footwear protection.
• Autopsies must be performed in adequately ventilated rooms and in accordance with regulations.
Mortuary staff/Funeral home workers

Mortuary staff or funeral home workers preparing the body (i.e. washing the body, tidying/shaving hair, or trimming nails) should
wear appropriate PPE according to standard IPC precautions and risk assessment, including gloves, impermeable gown or gown
with impermeable apron, medical mask, eye protection (face shield or goggles) and closed footwear or footwear protection.
• To avoid excessive manipulation of the body, embalming is not recommended. However, if embalming is done, it should be
performed by trained, experienced staff following standard IPC precautions.
• If family members wish to view the body, allow them to do so, but instruct them not to touch or kiss the body; to maintain at
least a 1-metre distance from one another and any staff during the viewing; and to perform hand hygiene after the viewing.
• Identify local alternatives to kissing and touching the dead body in settings where such contact is traditionally part of funeral
procedures.
Justification
There was no evidence to support additional precautions; therefore, the GDG unanimously agreed that the use of standard
precautions with a risk assessment and following national, subnational and local protocols is a sufficient protocol for handling dead
bodies infected with COVID-19. Members noted that there is nothing particularly different about COVID-19 when compared to other
respiratory pathogens that would require policies above and beyond the standard. GDG members noted that a health and care
worker's risk assessment may lead one to determine whether adhering to contact and droplet or airborne precautions is necessary.

Population: Health-care workers, mortuary staff, those working with a decedent with a COVID-19 infection
Intervention: PPE (Mask, gown, gloves, face shield), body bag
Comparator: No PPE, Limited PPE, no body bag/covering
Summary
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Certainty of
No PPE, PPE (Mask,
Limited PPE, no gown, gloves, Summary
body bag/ face shield),
evidence)
covering body bag
SARS-CoV-2
CoV-2 infection.
3.5 Special settings

IPC principles and practices are applicable across all settings across the continuum of care where health care is delivered. In the
context of COVID-19, there may be additional challenges for specific settings and additional operational considerations when
implementing established IPC practices. This section describes IPC measures for vaccination, long-term care, home care and
operating theatres, in the current context of COVID-19.
When applying IPC measures, it is important to consider factors that can affect their successful implementation, including potential
barriers, as well as strategies to adapt to the setting and situational needs. These may include practical, logistical and organizational
aspects and contextual factors. For example, special considerations may be appropriate for people living and working in congregate-
living facilities, such as those used for long-term care, or for other populations at risk, or for populations with complex care needs or
whose treatment occurs outside hospital settings.
Specialized-care settings such as operating theatres and areas used for vaccination administration were affected by COVID-19. In
addition to the core IPC practices outlined in the guideline, this section provides additional information for each setting that will be
helpful in the application of IPC principles as well as operational and implementation considerations to reduce SARS-CoV-2
transmission.
3.5.1 IPC principles and procedures for COVID-19 vaccination activities

Background
As with all clinical care and vaccine administration, health and care workers administering COVID-19 vaccines need to take
standard precautions and follow safe injection practices. This section summarizes IPC measures and considerations for the safe
delivery of COVID-19 vaccines.
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Implementation consideration
Health and care workers, policy-makers and decision-makers are encouraged to consider the following when implementing
IPC measures while conducting COVID-19 vaccination activities. These considerations are based on expert opinion, standard
and transmission-based precautions and as per minimum requirements for IPC programmes.
Standard precautions are designed to prevent infections in clinical settings. In the context of vaccination, follow standard
precautions [32] with attention to hand hygiene according to WHO 5 moments of hand hygiene [15], and follow safe-injection
practices[99][100][101].
• Health and care workers use a risk assessment to determine the need for transmission-based precautions, including the
selection and use of appropriate PPE1 when caring for patients with suspected or confirmed COVID-19
◦ Gloves are not indicated for intramuscular or intradermal injections [99][102];

◦ Single-use gloves are indicated if there is any skin breakdown [102];
◦ Perform hand hygiene when putting on and removing PPE;
◦ See WHO’s recommendations on mask use in health-care settings.
• Follow routine processes for environmental cleaning and disinfection.

• For COVID-19 vaccination of health and care workers, see Interim recommendations for the use of mRNA COVID-19
vaccines [103].
1 types of PPE: mask, eye protection, gloves, gowns
3.5.2 Operating theatres

Background
Operating theatres (also known as operating rooms or operating suites) pose a risk of transmission of infectious agents to patients
and to health and care workers due to the nature of the work performed there and the specific infrastructure
requirements [104]. These include procedure rooms and ambulatory care settings, where surgical interventions occur. Health-care
facilities with operating rooms (ORs) need to comply with specific infrastructure requirements such as ventilation systems [7],
cleaning, disinfection and sterilization processes, specialized training and adequate staff, with additional considerations for the
delivery of patient-care services in a sterile environment, scheduling of cases and post-operative recovery. In addition, specific
procedures might generate aerosols that can lead to an increased risk of infectious agents, including SARS-CoV-2 [36][37].
As COVID-19 can easily be transmitted to health-care workers and to other patients during surgery, it is important to establish a set
of infection prevention and control mitigation strategies to prevent COVID-19 from spreading in the OR. Implementation of infection
prevention and control measures helps create a safe environment for clinicians and patients. This includes the implementation of
hierarchy-of-control measures (e.g. engineering, administrative, PPE) to reduce the risk of infection with COVID-19. Practices
include proper scrubbing procedures for both the patient and the operator; protocols to be followed by the operating personnel at
the time of procedures; proper handling of the instruments; and maintenance of an aseptic environment throughout the procedure.
This section presents the current recommendations for IPC measures related to COVID-19 in operating theatre and
implementation recommendations for policy-makers and frontline health and care workers.
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Conditional recommendation against , Very low certainty evidence
WHO suggests that the designation of a specific operating theatre for patients with suspected or confirmed
COVID-19 infection is not needed.
Practical info
• Apply standard and transmission-based precautions.

• Ventilation standards for operating rooms (OR) should be in accordance with national, subnational and local policies [7].
• Health-care facilities should follow any additional requirements or guidance specific to surgical areas, including
recommendations for environmental cleaning of operating rooms and air exchange between cases [105][106].
• PPE is worn :
◦ Follow recommended practices for putting on and removing PPE; there may be additional considerations for the
selection and use of PPE in operating and procedure rooms, based on a risk assessment and maintenance of a sterile
environment
◦ A particulate respirator (i.e. N95, FFP2 or equivalent) should be used if there is potential for an AGP or a surgical
procedure with risk of exposure to infectious agents
• The surgical staff in the operating theatre should be restricted to essential personnel.
• Sterile and clean supplies in patient-care areas should be kept in closed cabinets or closed containers to minimize the risk
of contamination.
All medical devices and surgical instruments should undergo standard decontamination procedures. For additional details, see
Decontamination and reprocessing of medical devices for health care facilities: aide-memoire [108].
One observational study found a COVID-free pathway associated with decreased risk of SARS-CoV-2 infection vs no
COVID-free pathway (adjusted OR 0.53, 95% CI 0.36 to 0.76) [107]. The COVID-free pathway included elements other
than a COVID-free OR (COVID-free wards, ICU).
As the evidence base is a single observational study, the certainty of evidence has been assessed as very low.
Because there wasn't enough evidence to determine benefits or harms, the GDG was unable to determine whether
decisions to have a designated COVID-19 operating room would be preference-sensitive.
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Resources Important negative issues
The cost and resource considerations likely vary, depending on the setting, existing infrastructure and other factors. GDG
members noted that a designated operating room may be associated with significant cost and resource implications.
Equity Intervention likely increases inequity
GDG members noted that a single designated operating theatre may not be available in low- and middle-income countries.
Some health facilities may face challenges in trying to accommodate patients when such rooms are limited or not available.
Therefore, the GDG judged that the intervention likely increases inequity.
Acceptability of intervention likely varies.
Feasibility Intervention is likely difficult to implement
The feasibility of implementing single designated operating rooms for COVID-19 likely varies in different settings and may
be difficult to implement, especially in low- and middle-income countries.
Justification
The GDG found insufficient evidence to determine the benefits and harms of a single designated operating theatre for patients
with COVID-19, based on low-certainty evidence from a single observational study. Because of a lack of evidence showing
benefits, the additional resources that would be required, and feasibility concerns, the GDG agreed on a conditional
recommendation against requiring a single designated operating theatre.

Intervention: Designated single operating room
Comparator: No designated operating room
Summary
One study compared patients treated in a COVID-19-free pathway versus no defined pathway. Patients were classified
as being treated within a COVID-19–free pathway if there was a policy of complete segregation in the operating room,
critical care, and inpatient ward areas from patients with COVID-19 [107]. Patients were classified as being treated
within no defined pathway if any one of these areas was shared with patients with COVID-19. The rate of postoperative
SARS-CoV-2 infection was lower in a COVID-19–free surgical pathway compared to no defined pathway.
Comparator
Outcome Study results and Designated the Evidence
No designated Summary
Timeframe measurements single (Quality of
operating room
operating room evidence)
SARS-CoV-2 One observational study found a There were too few who
COVID-free pathway associated with Very low experienced SARS-
Infection CoV-2 infection to
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Comparator
Outcome Study results and Designated the Evidence
No designated Summary
Timeframe measurements single (Quality of
operating room
operating room evidence)
decreased risk of SARS-CoV-2

infection vs no COVID-free pathway determine whether a
(adjusted OR 0.53, 95% CI 0.36 to designated operating
0.76). The COVID-free pathway room for COVID-19
included elements other than a patients made a
COVID-free OR (COVID-free wards, difference
ICU).
Terminal cleaning of operating theatre after surgical intervention/procedures for patients with suspected or
confirmed COVID-19 should be performed according to national/subnational and local policies for transmission-
based precautions.
Practical info
COVID-19 specific considerations
• Regular cleaning and disinfection are essential to preventing the transmission of COVID-19.
• Operating theatres are to be cleaned and disinfected following established environmental cleaning processes [106].
• Clean and disinfect any surface that is visibly dirty, use detergents and hospital-grade disinfectant products in operating
theatres. Follow the instructions for dilution, contact times and safe use.
• Between patients, clean and disinfect frequently touched surfaces and shared equipment, including stethoscopes, blood
pressure cuffs, table and examination beds.
• Post-anesthetic recovery room and stretchers and areas are to be cleaned and disinfected after the patient is discharged/
transferred and before the next patient occupies the space.
• Sterile and clean supplies in patient care areas should be kept in closed cabinets or containers to minimize the risk of
contamination.
• All garbage, recyclables, used linen and contaminated instruments shall be removed at the end of each case and before
any cleaning commences. Waste containers located in semi-restricted and non-restricted areas should be emptied.
• Wear PPE as required to safely perform environmental cleaning for protection from microorganisms, from chemicals used
in cleaning and for prevention of transmission of microorganisms from one patient environment to another.
An operating theatre is cleaned at specific times [12]
• Before the first case of the day: Before surgical supplies are brought into the operating theatre for the first surgery of the
day, a few duties are recommended. Any overhead lights, the operating table, and any other flat surfaces, including
countertops, are to be damp-dusted. Surgical equipment trays for the first case should not be opened until after this
cleaning is completed.
• Between cases: After a surgical procedure, surgical equipment, the floor immediately surrounding the surgical bed, and
any furniture are considered contaminated. Clean and disinfect them along with any other objects identified by the facility.
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Remove soiled linen, trash and infectious waste.

• After the last case of the day: Perform a terminal cleaning of the operating theatre. This is a detailed process that follows
specific facility protocols. A terminal clean of an operating theatre includes removing infectious waste and soiled linen;
cleaning from top to bottom of all surfaces, including overhead lights; cleaning the operating table, including the mattress;
and mopping the floor.
Terminal cleaning of patient-care areas

Where applicable, follow health-care facility protocols for terminal or discharge cleaning specific to operating rooms and in
accordance with national/subnational and local policies for transmission-based precautions.
Justification
No studies compared the effects of terminal cleaning versus standard cleaning and the risk of SARS-CoV-2 infection.
Environmental cleaning practices, as part of standard precautions and transmission-based precautions, are integral to the
prevention and control of health-care-associated infections, including transmission of SARS-CoV-2. These standards are
subject to national, subnational, or local policy regulations for cleaning and disinfection requirements.

Intervention: Terminal Cleaning
Comparator: Standard cleaning
Summary
Certainty of
Standard Terminal Summary
cleaning Cleaning
evidence)
SARS-CoV-2
Infection No studies evaluated the
Very low impacts on the risk of
SARS-CoV-2 infection.
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3.5.3 Home-care settings

Background
Health and care workers providing direct care in home settings should assess infection risk and consider prevention strategies.
With a shift in the delivery of care from hospitals to other settings and reduced length of stay in health-care facilities, home care
may include a range of types and a broad scope of services, supporting patients with complex care needs and procedures. Health
and care workers providing care in the home should follow the same IPC measures in the home as they do in the health-care
facility.
In many contexts, health services are delivered at the community level and in the home by community health workers, social care
workers, traditional medicine practitioners, or a variety of formal and informal community-based providers, including caregivers.
The application of infection prevention and control practices in community settings presents different challenges for health and care
workers entering the home, as the environment and situations vary from one home to another [109]. This section is intended to
guide public health and infection prevention and control (IPC) professionals, health and care workers and other trained,
community-based providers when addressing issues related to home care for patients with suspected or confirmed COVID-19.
For more information on the care of persons with COVID-19 in the home by community workers and caregivers, see section 4.5.
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IPC measures during the provision of home care for patients with COVID-19. This additional information is based on IPC
principles and practices, expert opinion, and principles outlined in the core components for for IPC programmes [9][11][43][47]
Health and care workers must have appropriate training and guidance on how to care for patients as well as on how to
minimize the risk of infection in home-care settings. Caring for an infected person in the home increases the risk of transmitting
the virus to others.
• Standard precautions are designed to prevent infections in clinical settings;

• A risk assessment determines the need for additional measures, including PPE.
◦ See WHO recommendations for mask use in health-care and community settings.
◦ Before leaving the home, remove PPE and perform hand hygiene.
• One of the most important means to prevent infections is by practicing proper hand hygiene. This occurs after any type of
contact with the patient or the patient's immediate environment, following the WHO 5 moments.
◦ In home-care settings, ensure health and care workers have a supply of alcohol-based hand rub available for use [15].
◦ Household members and care providers are encouraged to clean hands regularly, after any type of contact with the
person or with the person's immediate environment, before and after preparing food, before eating, after using the
toilet, and whenever their hands look dirty.
▪ If hands are not visibly soiled, an alcohol-based hand rub can be used.
▪ For visibly soiled hands, always use soap and water.
▪ After washing hands with soap and water, use disposable paper towels to dry hands. If paper towels are not
available, use clean cloth towels and replace them frequently.
• Several factors must be considered in providing care for a COVID-19 patient (see factors to consider when assessing
households). They include strategies for isolation of patients with COVID-19 when they are sharing living spaces with
other household members.
◦ The decision to isolate considers a number of factors, such as the home setting, the patient's clinical condition (period
of infectivity) and the risk of viral transmission within the household.
◦ Isolation, when feasible, along with any other mitigation measures such as distancing and mask use, can help break
the chain of transmission of the SARS-CoV-2 virus in the home.
• When providing home care:
◦ Limit the patient’s movement around the house and, when necessary, provide the patient with a medical mask.
◦ Household members should avoid entering the room where the patient is located or, if that is not possible, maintain a
distance of at least 1 metre from the patient and wear a medical mask.
◦ Limit the number of caregivers and household members present during a visit. Wherever possible, only household
members who are essential for communication or to assist health and care workers should be in the same room as the
patient.
◦ Consider using natural ventilation by opening windows, if it is possible and safe to do so [7].
• Maintaining a clean environment in the home setting requires regular cleaning of the person's room and essential areas of
the home. This is achieved by:
◦ frequently cleaning and disinfecting high-touch surfaces and objects in the home;
◦ ensuring that only essential equipment and devices are taken into the home; disposing of waste generated from
providing care to the patient as infectious waste in strong bags or safety boxes, as appropriate, and ensuring that they
are closed completely and removed from the home;
◦ handling any linen and laundry as per routine processes and local guidance.
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• For more guidance on waste management, please refer to the section on Water, Sanitation, Hygiene and Waste
Management.
Info Box
Home-care Risk Assessment

A risk assessment is a standard part of IPC that informs infection prevention and control measures. Health and care workers
consider several factors when entering the home environment.
The following questions may be part of a risk assessment in the provision of care to a COVID-19 patient in the home.
• Is the person with COVID-19 living alone? If so, what support network do they have? If not, who is living in the household
with them?
• How are the person with COVID-19 and their family living? How feasible and practical would it be to implement
recommendations? What alternative options are available?
• What are the needs related to disability, caring responsibilities for adults, older adults or children? What are the needs of
other household members?
• How feasible would it be to identify one caregiver to support the person with COVID-19 at home?
• What do household members know about COVID-19 and preventing transmission in the home? What are their information
needs about COVID-19 and transmission prevention? Do the household members know where to seek additional support
or information related to care for the person with COVID-19, if needed?
• What do the person with COVID-19 and/or their household members think they need to be able to cope at home?
• Does the family members understand when to call for medical assistance? Do they have the means to call for medical
assistance?
• What are the psychosocial needs of the person with COVID-19 and household members?
• What is the economic impact on the household? Who is the primary provider financially? What would be the impact if that
person were to require isolation and/or need to carry additional household or care responsibilities?
• Which health facility and, if possible, which named professional is responsible for following up on the care of the person
with COVID-19? How will follow-up of this care be maintained?
3.5.4 Long-term care facilities

Background
Long-term care facilities (LTCFs) are high-risk settings for transmission of SARS-CoV-2 to and among residents and
staff [110][111].
People living and working in LTCFs, mostly older adults, were disproportionately affected by COVID-19 [112]. International
comparisons of deaths from COVID-19 among LTCF residents are challenging because of differences in testing capacity, policies
and approaches to recording deaths. Vaccination and immunity from infections did result in a decline in deaths; however, outbreaks
continued in these types of congregate-living settings with populations at risk of severe disease. COVID-19 was a leading cause of
hospital admission of older adults [112].
Residents of these facilities are at a higher risk of developing severe disease and dying because they tend to be older and have
underlying medical conditions and/or functional decline [110]. Early detection of COVID-19; adequate IPC training and education
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for all employees, residents and visitors; and consistent implementation of appropriate IPC policies and measures can significantly
reduce the risk of SARS-CoV-2 transmission among residents, staff and caregivers in LTCFs.
Types of LTCFs may vary by country or even at a subnational level. Nursing homes, skilled nursing facilities, assisted living
facilities, residential facilities and residential long-term care facilities – collectively known as LTCFs – provide a variety of services,
including medical and assistive care, to people who are unable to live independently in the community. Health and care workers
include personal care workers and social workers employed by the facility. IPC measures in LTCFs should aim to prevent the
introduction of SARS-CoV-2 into LTCFs and, if the virus is introduced, to take immediate and comprehensive measures to control
its spread.
IPC measures – in particular, the use of personal protective equipment (PPE) and restrictions on visitors and group activities – may
affect the mental and physical health and consequently the overall well-being of residents and staff. Public health and social
measures, although critical from a public health perspective, have the potential to further exacerbate health issues and social
connections among residents in long-term care homes. Those measures may include restrictions on movement, visits and the
imposition of quarantine measures and/or isolation to control the spread and impact of SARS-CoV-2.
To meet the complex care needs of residents in a congregate-living setting, the workforce must seek to maintain resident mobility
and strengthen social connections between residents and their families. Preventing the spread of COVID-19 in LTCFs is critical for
the health of residents, health and care workers, and other staff.
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IPC practices within the facility
IPC measures in long-term care facilities. This additional information is based on IPC principles and practices, expert opinion
and the minimum requirements for IPC programmes.
It is important that health and care workers have appropriate training and guidance on how to care for patients as well as on
how to minimize the risk of infection in long-term care settings. This includes training on how to put on and remove PPE, with
monitoring and feedback on compliance with IPC practices.
Standard precautions are designed to prevent infections in clinical settings, Health and care workers use a risk assessment to
determine the need for transmission-based precautions, including the selection and use of appropriate PPE when caring for
patients with suspect or confirmed COVID-19.
• Hand hygiene is a standard part of infection-control measures (according to the WHO five moments) [15].
◦ This occurs after any type of contact with the patient or his/her immediate environment.
▪ If hands are not visibly soiled, an alcohol-based hand rub can be used.
▪ For visibly soiled hands, always use soap and water.
▪ When washing hands with soap and water, use disposable paper towels to dry hands. If paper towels are not
available, use clean cloth towels and replace them frequently.
• A risk assessment determines the need for additional measures, including use of PPE.
◦ Refer to WHO recommendations and local policies for PPE, including mask use in health-care settings.
◦ Remove PPE and perform hand hygiene before leaving the home and discard disposable PPE.
• Beyond standard precautions, no additional measures are required for environmental cleaning for COVID-19. Follow
regular processes for environmental cleaning, handling of linen and laundry, and waste management, as per facility
requirements.
• Understanding and controlling building ventilation can improve the quality of the air we breathe and reduce the risk of
indoor health concerns, including by preventing the virus that causes COVID-19 from spreading indoors [7].
• Residents and staff should be vaccinated for influenza and COVID-19, and residents for Streptococcus pneumoniae,
according to local policies [113].
3.6 Prevention, identification and management of SARS-CoV-2 infections in health and

care workers
Background
The COVID-19 pandemic has placed a large burden on health systems worldwide and, in turn, affected hospital-acquired infections
and health and care workers [114]. Health and care workers are at higher risk than the general public of being infected with SARS-
CoV-2 [115].
Prevention of infections in the health-care setting requires a multi-pronged and multi-factorial approach that includes IPC and
occupational health and safety (OHS) measures as well as adherence to public health and social measures in the community by the
health workforce. In hospitals, this involves the hierarchy of controls (hazard elimination, engineering/environmental controls,
administrative controls and the optimal use of PPE) and, for IPC and OHS staff, the need to work collaboratively to implement these
protocols. See the section on Basic IPC Principles and the section on Introduction to public health and social measures for additional
information.
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This updated section of the WHO guidelines on infection prevention and control in the context of COVID-19 provides guidance to
health managers and OHS teams on the following topics:
• how COVID-19 infections in the health-care setting or during the provision of care can be prevented;
• how COVID-19 infections can be identified;
• once they occur, how COVID-19 infections can be managed safely to prevent onward transmission to other health and care
workers or to patients in the health-care setting.
The underpinning basis for all these statements is the notion that the early identification, and thus testing and quarantining of health
and care workers and/or other control measures, aim to decrease the risk of nosocomial infection [116].
This update supersedes the previous guidance on the prevention, identification and management of health and care worker infections
in the context of COVID-19, issued in October 2020.
Published 10 August 2023.
3.6.1 Identification of health and care workers infections in the health care setting
Countries should have national and subnational testing strategies for the detection of SARS-CoV-2 infections in
Practical info
When implementing a national testing strategy, the following contextual factors should be considered:
• Strategies outlined in the OHS and/or IPC national policies should include implementation plans that ensure health and
care worker testing is prioritized and made available in health-care facilities. This should include laboratory testing and
self-testing kits for SARS-CoV-2 infections [117].
• OHS and IPC programmes should include a committee of multidisciplinary experts to guide policies and protocols
implemented by employers/management teams and demonstrated through staff adherence.
• The local situation should be evaluated by considering dynamic indicators: SARS-CoV-2 epidemic trends, transmissibility,
the seriousness of COVID-19 and the impact on the health system.
Practical impacts and consequences of identifying COVID-19 cases in health and care workers (including potential absences
due to sick leave, or isolation, as well as the absence of the health workforce) and the ability to manage infections and a safe
return to work need to be considered. Furthermore, health-care facilities may consider providing self-testing kits to health and
care workers; testing free of charge on-site; testing health and care workers post-exposure; testing in settings with vulnerable
patients (e.g. ICUs and transplant units); and testing all health and care workers who have signs or symptoms suggestive of
COVID-19. These testing strategies for the health workforce should consider the availability of testing kits and the feasibility of
carrying out testing, as well as the impact on health systems and services of detecting active infections among workers and
having those workers stop working while they isolate (see section on duration of isolation).
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For guidance on testing strategies for SARS-CoV-2, refer to Use of SARS-CoV-2 antigen-detection rapid diagnostic tests for
COVID-19 self-testing [4].
Justification
GDG members noted the importance of having national and subnational testing strategies for SARS-CoV-2, including in the
health workforce. Having testing mechanisms in place allows for the quick identification, swift removal from the workplace and
isolation of health and care workers with SARS-CoV-2 infections, thus decreasing the risk of nosocomial transmission.
Passive screening of symptoms for SARS-CoV-2 and other respiratory infections should be performed based on
self-monitoring and reporting of symptoms by health and care workers.
Practical info
The GDG members recommended that passive screening for SARS-CoV-2 should be combined with screening for other
respiratory viruses (e.g. influenza). Early detection of COVID-19 infection among health and care workers can be achieved
through passive syndromic screening when combined with laboratory testing to confirm infection. Surveillance is generally seen
as a best practice in the field of IPC and as a key to preventing secondary transmission (otherwise referred to as nosocomial
transmission) to patients, between health and care workers and throughout health-care settings.
Syndromic screening can be conducted using passive or active methods. The selection of the appropriate method depends on
the health-care facility’s capacities and the levels of local circulation of the virus. In passive screening, health and care workers
self-screen for symptoms and are required to report any concerning symptoms. Active screening includes others screening the
health and care workers for symptoms; this process demands a heavy use of resources and often yields only a low number of
positive cases.
The key objectives of screening in the current context are:
• to identify possible cases and clusters of infections;

• to implement containment measures, such as quarantine or isolation and IPC measures, to prevent onward transmission;
• to identify the source of infection (whether hospital-acquired or community-acquired).
Definitions of syndromic screening, passive screening, and active screening can be found in the definitions section.
Health and care workers who report any of the symptoms associated with COVID-19 or other acute respiratory illnesses should
contact their local OHS service or IPC department for guidance on testing and quarantine/isolation processes. Health-care
facilities should ensure that employment policies, such as paid sick leave, having the ability to stay home, work from home or
rest, are in place. These policies should guarantee confidentiality and be non-punitive for health and care workers who become
infected with SARS-CoV-2 or for contacts of a case.
Justification
GDG members discussed that surveillance of health and care worker infections – even outside the context of SARS-CoV-2 – is
a best practice in any health-care setting. They noted the importance of having a system established and policies in place that
allow health and care workers to report any symptoms suggestive of respiratory infections, including SARS-CoV-2, and to be
referred for testing and abstain from physical presence in the workplace without penalty.
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There is evidence that symptoms of COVID-191 are the best indicators of active infection and indicate that the
symptomatic person is in the most infectious period of the course of the disease [118][119][120][121].
Thus, identifying these health and care workers early and testing them and/or preventing them from attending their shift can
break the transmission chain and limit the nosocomial transmission of SARS-CoV-2 [122][123][124].
The term passive screening was proposed by the GDG as a method for health workers to self-screen for symptoms and
potentially identify infections in the health setting. The GDG members agreed that screening refers to the identification of
unrecognized SARS-CoV-2 infections using tests, self-examinations or related procedures. Screening
of health and care workers should identify risk factors and prodromal symptoms for early evidence of infection [115]. GDG
members concurred that passive screening, versus active screening, was preferred. Their justification was the potential
cost savings and reduced burden on health administrators and health and care workers by allowing them to perform their own
syndromic surveillance and control their own health and well-being.
They noted the importance of establishing policies that would allow health and care workers to report any symptoms suggestive
of respiratory infections, including SARS-CoV-2, to be referred for testing and to abstain from physical presence in the
workplace.
Information on screening, triage and early recognition of patients with COVID-19 can be found in section 6 of the clinical
management of COVID-19: living guideline [52].
1
Refer to WHO COVID-19 Case Definition for the most up-to-date list of COVID-19 symptoms: fever, cough, general weakness/fatigue, headache, myalgia,
sore throat, coryza, dyspnoea, nausea, diarrhoea, anorexia. Symptoms may be non-specific to COVID-19 and may also indicate other influenza-like illnesses
for which health and care workers should be referred to their local guidance on those diseases [5].
Health and care workers should be prioritized for SARS-CoV-2 testing in the context of COVID-19 testing policies
for both the community and health-care facilities.
Reference can be made to WHO’s Recommendations for national SARS-CoV-2 testing strategies and diagnostic
capacities [125] and WHO’s Antigen-detection in the diagnosis of SARS-CoV-2 infection interim guidance [4].
Practical info
Health and care workers should be included in the health-care facility testing strategy. For example, testing could occur as a
follow-up to development of signs or symptoms of COVID-19 following a high-risk exposure to a patient or colleague positive
for SARS-CoV-2, or for routine testing. WHO’s guidance on testing for SARS-CoV-2 stresses that health and care workers who
work in COVID-19 services or facilities have the highest priority, followed by health and care workers prioritized by risk in other
clinical areas [127].
Testing for health and care workers can be done using PCR or antigen-based testing for SARS-CoV-2. Additional
implementation considerations can be found in WHO’s Antigen-detection in the diagnosis of SARS-CoV-2 infection
guidance [54].
Justification
Health and care workers are considered a priority group for testing, according to key WHO documents on testing strategies and
diagnosis of SARS-CoV-2 infection [54]. Based on these WHO guidance documents, the decision to formalize the above
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statement as a GPS was reached through discussions with the GDG and online voting. GDG members noted that health and
care workers should constitute a priority population since they are at high risk of SARS-CoV-2 acquisition due to the nature of
their work and their interaction with infected patients. Furthermore, if infected, they represent a risk for patients, especially
those at risk for COVID-19 complications. Prioritizing health and care workers for SARS-CoV-2 testing allows for their quick
identification and exclusion from in-person work; thus, preventing onward transmission to high-risk patients or other health and
care workers.
Health-care facilities should have protocols for reporting and managing health and care workers’ occupational and
non-occupational high-risk exposures to COVID-19.
Practical info
Health and care workers should be encouraged to report both occupational and non-occupational exposures to COVID-19 to
OHS or an equivalent department.
OHS teams, along with IPC focal points, should create comprehensive and clear protocols so that health and care workers are
able to quickly report high-risk exposures. These protocols should provide details on the essential information to include in the
report (such as situational events, symptoms, contacts and exposures) and the mechanism for submitting the report, including
next steps and follow-up actions.
The protocols should include instructions for health and care workers to wear a medical mask as soon as they recognize they
are symptomatic; to refrain from their work activities; and to report to their OHS/IPC focal point. The focal point should suggest
that the symptomatic health and care workers quarantine in a designated setting until testing is carried out; they know what their
status is; and can determine how to move forward.
The OHS team or the IPC focal point should:
• meet with the health worker to assess their symptoms and record exposure history (where resources permit);
• ask health and care workers to complete and submit the form for the WHO Risk assessment and management of exposure
of health care workers in the context of COVID-19
• identify a risk categorization based on the risk assessment tool for health and care workers who have had an exposure
without proper use of PPE and determine appropriate management, including deciding whether the health and care worker
should continue working or be excluded from in-person activities;
• arrange for testing following a high-risk exposure (see section 6.3).
Strategies to mitigate workforce shortages should be in place in the event that health and care workers are required to remain
off work due to quarantine or isolation.
Justification
GDG members discussed the importance of having protocols in place to facilitate the reporting of high-risk exposures to SARS-
CoV-2 and their rapid and appropriate management. Referral to OHS and/or IPC services after high-risk exposures to SARS-
CoV-2 is critical for early diagnosis of the infection in health and care workers and for minimizing the spread of infections to
other colleagues and patients in a health-care setting. The WHO COVID-19: Occupational health and safety for health and care
workers interim guidance [18] advises that workplace risk assessments be carried out by OHS and IPC to determine which roles
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are at high risk for exposure in health-care facilities, how well health and care workers are to return to work; and how health and
care workers can conduct their tasks safely upon their return. High-risk exposures are largely avoidable in health-care settings
where protocols and best practices are adhered to by all. If they do occur, they need to be followed up and learned from. High-
risk exposure definitions can be found in the definitions section of this guideline.
Preventing hospital-acquired infections requires a multi-pronged, comprehensive approach that involves a hierarchy of controls
(hazard elimination, engineering/environmental controls, administrative controls and optimal use of PPE) and for IPC and OHS
staff to work collaboratively to implement these protocols [18].
Any health and care worker who has signs or symptoms1 of SARS-CoV-2 infection2 should be excluded from
their activities at work that require providing in-person care to patients or other activities in the health-care
facility where they are in contact with other health and care personnel.
They should furthermore consult with their occupational health and safety department and plan for isolation in a designated
setting for the duration of the required period of isolation outlined by their local policy3.
1
Signs or symptoms of COVID-19 include: cough, general weakness/fatigue, headache, myalgia, sore throat, coryza,
dyspnoea, nausea, diarrhoea, anorexia [5].
2
For active infection definition, refer to Public Health Surveillance for COVID-19: Interim guidance [126].
3
WHO recommendations for the duration of isolation can be found here [52].
Practical info
Identifying health workers positive for SARS-CoV-2 infection can be achieved through nucleic acid amplification tests (NAATs),
such as real-time reverse-transcription polymerase chain reaction (rRT-PCR) tests, which are the most sensitive and specific
tests for diagnosing COVID-19. Otherwise, antigen-detection rapid diagnostic tests (Ag-RDTs) are recommended as a viable
alternative to confirm SARS-CoV-2 infection, especially in settings where NAATs are not available or results are not timely.
Facilities can follow the WHO guidance for testing or WHO policy brief: COVID-19 testing (14 September 2022) [128].
Health and care workers who are positive for SARS-CoV-2 infection should isolate themselves at home (if they are able to
safely isolate and their clinical condition allows them to do so) or in a designated setting such as a health-care facility or non-
traditional isolation facility, depending on the country’s approach. This decision of where to isolate should be made in
conjunction with local public health policies and with the individual's health-care practitioner.
Health and care workers are required to isolate for the duration of time outlined in their local public health policies or they can
follow WHO recommendations for the duration of isolation, which can be found under section 4 (COVID-19 care pathway) and
include options for using testing as a tool to enable an earlier return-to-work [52].
High-case load scenarios

Health-care facility administrators will need to balance the risk of excluding essential health and care workers, which may
contribute to facility-wide shortages, against the risks of possible onward transmission to patients and other health and care
workers according to the transmission scenarios in the facility and community. They may do this by choosing to assess infected
health and care workers on a case-by-case basis and assess their infectiousness based on symptoms and test results for
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earlier return-to-work options and select appropriate units in which these health and care workers may work. For example,
high-risk units such as ICUs, transplant units and oncology units may need to be excluded.
Health-care facility administrators should ensure adequate supplies of PPE are available for health and care workers and that
processes are in place for monitoring and evaluating IPC procedures, including fit testing, and correct procedures for putting
on, taking off and disposing of PPE.
OHS Follow up
Focal points for occupational health and safety should perform workplace risk assessments to determine if an infection was
acquired in the health-care facility. If the infection is related to an occupational exposure such as a breach in IPC practices,
appropriate corrective measures, such as refresher training on IPC measures, should be put in place to address the exposure.
Return to work
Upon return to work after an infection, health and care workers should continue to follow strict IPC measures; hand hygiene
practices; wearing a mask when indicated; wearing of PPE when indicated; and other practices outlined in this guideline. The
length of isolation should be determined by the health facility and local guidance for the period of infectiousness. Alternatively,
administrators can refer to the section on Duration of Isolation.
In this context, SARS-CoV-2 infection is defined in Public Health Surveillance for COVID-19: Interim guidance [126].
Justification
The decision to formalize the above statement as a good practice statement was reached through in-depth GDG discussions
and online voting. Many GDG members noted that health and care workers who have symptoms of SARS-CoV-2 infection pose
a high risk of being infectious and thus transmitting the virus to patient populations most at risk of developing complications
(those with co-morbidities, of older age or with compromised immune systems).
Testing after high-risk exposures and quarantine for health and care workers
Refer to the WHO Contact tracing and quarantine in the context of COVID-19: interim guidance for recommendations on
testing after a high-risk exposure and the length of quarantine for contacts of COVID-19 cases that may be applied to the
health and care worker population [127]. WHO advises that identification, contact, quarantine and follow-up of individuals at
high risk of acquiring SARS-CoV-2 infection who have been in contact with a confirmed or probable case of SARS-CoV-2
infection should be prioritized rather than targeting all contacts.
Health and care workers are a priority population. They should receive support regarding quarantine measures and access to
free or affordable and reliable testing (including self-tests).
Table 6 presents a summary of the quarantine scenarios for health and care workers according to vaccination status.
Extracted from the WHO Contact tracing and quarantine in the context of COVID-19: interim guidance for
recommendations on testing after a high-risk exposure and the length of quarantine for contacts of COVID-19 cases, which
may be applied to the health and care worker population [127].
Practical info
Quarantine arrangements can be implemented at home or in another designated setting where the contact can be regularly
monitored for signs and symptoms. During quarantine, adequate ventilation and IPC measures should be implemented and
maintained.
Quarantined individuals must be supported with adequate food, water, protection, hygiene and communication provisions,
including access to education, paid leave or remote work options. In addition, they need to regularly monitor their health status
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for symptoms and receive clear instructions on what to do in case they develop signs and symptoms of COVID-19. The
instructions need to include referrals to call centres, health care centres or medical staff in case of need as well as testing
facilities or self-testing options for the contacts.
All contacts in quarantine who develop signs and symptoms need to undergo testing. Staff supporting contacts in quarantine,
either through in-person visits or through call centres, need to be trained to assess and manage them or refer the contacts to
needed support.
If other people enter the room of a contact in quarantine, physical contact should be avoided, and face masks should be worn
by all parties, unless contraindicated (e.g. in infants). Quarantined individuals should avoid contact with people at high risk of
detrimental COVID-19 outcomes.
More implementation considerations can be found at the WHO Contact tracing and quarantine in the context of COVID-19:
interim guidance [127].
Table 8. Quarantine scenarios for health and care workers according to vaccination status
Status Quarantine Scenario

Vaccinated/infected No quarantine required.
within the last 90 days
If, in the last 90 days, a vulnerable contact or someone in a priority setting has been
vaccinated (i.e. has completed the primary series and/or received a booster dose) or
has experienced a confirmed SARS-CoV-2 infection, this contact is not considered
to be at high risk of infection or further transmission.
Vaccinated/infected Quarantine for 10 days

more than 90 days
Quarantine for 5 days plus negative test
High case load No quarantine required

scenarios
When the case load is high, and many health and care workers and essential
workers are off work due to exposure or infection, health systems may be
overstretched. In that context, vaccinated health and care workers and other
essential workers who are asymptomatic contacts may have a shortened quarantine
or continue to work without quarantine.
Daily Ag-RDT testing may be performed up to day 5 after exposure.
Extracted from the WHO Contact tracing and quarantine in the context of COVID-19: interim guidance for
recommendations on testing after a high-risk exposure and the length of quarantine for contacts of COVID-19 cases, which
may be applied to the health and care worker population [127].
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3.6.2 Duration of isolation for COVID-19 cases in health and care workers
We suggest 10 days of isolation for individuals who are symptomatic due to SARS-CoV-2 infection (very low
certainty of evidence).
We suggest 5 days of isolation for individuals who are asymptomatic with SARS-CoV-2 infection (very low
certainty of evidence).
We suggest the use of rapid antigen testing to reduce the period of isolation (very low certainty of evidence).
For the most up-to-date, evidence-based recommendations on the length of isolation for positive COVID-19 cases, see the
WHO Clinical Management of COVID-19: living guideline, which has been directly applied to the health and care worker
population; recommendations remain the same for anyone who becomes a COVID-19 case.
The current version was updated in January 2023: https://app.magicapp.org/#/guideline/6668/section/118562.
Practical info
Health facilities are advised to follow local protocols on the duration of isolation, testing options and return-to-work
management.
Upon termination of the isolation period, we recommend that health and care workers undergo a medical assessment in
conjunction with OHS and IPC services to determine whether the individuals are fit to return to work safely. These should
include factors such as (but not limited to):
• their work setting (dedicated to COVID-19 patients, ICU, or long-term care versus direct patient care or non-patient-facing
care);
• clinical conditions of the patients (e.g. immunocompromised) for whom the health and care worker may provide care;
• health facility IPC measures and use of universal masking as per WHO advice on the use of masks in the context of
COVID-19 guidance;
• the health and care worker’s general health and severity of previous illness with COVID-19.
Testing to reduce the length of isolation is dependent on local policies and could be used during an outbreak or high health
workforce absenteeism, based on availability, feasibility and economic abilities of the health-care facility to provide testing to
staff. In scenarios where health-care facilities choose to accept that health and care workers return to work before the
recommended timelines and the conclusion of the period of infectiousness, health and care workers should strictly adhere to
standard and transmission-based precautions and consider working on COVID-19 wards or non-high-risk wards to reduce any
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risk of onward transmission to patients and staff.
There should also be occupational health policies in place to ensure health and care workers who are off work for isolation
purposes have covered sick leave and are not penalized or otherwise negatively affected in the workplace by their infection.
This will help ensure that health and care workers report infections and do not attend work when sick. OHS and IPC staff will
need to balance the risk of shortages of essential health and care workers against the risks of exposure and implementation of
work restrictions according to the transmission scenarios in the facility and community.
Health and care workers should adhere to the following recommendations when returning to work after a COVID-19 infection:
• Attend refresher training on IPC practices such as hand and respiratory hygiene, fit test and fit check of respirators, PPE
use, masking policies and safe physical distancing.
• Continue to follow public health and social measures in their home and community settings [60].
• Continue to self-monitor for symptoms suggestive of COVID-19 and immediately stop working, report to their OHS
department and self-isolate if new or worsening symptoms develop/re-appear.
• Receive ongoing support and monitoring from OHS for longer-term health complications and potential psychological
implications.
Benefits and harms

See below for a copy of the evidence to decision table; for source and any other information, see Clinical Management of
COVID-19. The current version was published in January 2023: https://app.magicapp.org/#/guideline/6668/section/
118562
Isolation Period: The benefits outlined by the GDG relate to the impact on subsequent hospitalization and mortality across
contacts (very low certainty evidence) of a 10-day, compared with a 5-day, isolation period for symptomatic individuals.
Symptomatic individuals are much more likely to test positive than asymptomatic individuals and thus much more
likely to transmit SARS-CoV-2. This provides the rationale, despite the very low certainty of evidence on the impact of
isolation on subsequent transmission, hospitalization, and mortality, for the suggestion for 10 days in symptomatic and 5
days in asymptomatic cases. A shortened isolation period, where safe, was agreed upon as preferable as part of the
values and preferences, which further informed the recommendation for 5 days of isolation for asymptomatic individuals.
Given the uncertainty involved, the GDG did not incorporate into the evidence review the harms – on mental health,
finances or social interaction – related to varying periods of isolation.
Antigen testing: The possible benefit of using rapid tests to determine the period of isolation is, on average, a reduction of
3 days of the isolation period (very low certainty of evidence).
There are minimal harms of employing rapid tests to determine the period of isolation.
Isolation Period: The GDG deemed the evidence reviewed to inform this recommendation to be of very low certainty,
rated down due to the high degree of uncertainty in the parameters that inform the model and the indirectness of the data.
Specifically, there is a great deal of uncertainty across the following assumptions: i) the infectivity of individuals with
positive rapid antigen tests; ii) the effective reproduction number; iii) the assumed hospitalization rate of infected
individuals; and iv) the assumed case-fatality rate of infected individuals. Additional sources of uncertainty lie in
understanding the contributing role of different public health measures in place in different regions of the world, vaccination
status, history of prior infection and the infecting SARS-CoV-2 VoC(s) and resultant changes to infectivity and severity.
Evidence was reviewed regarding the duration of viral culture positivity and PCR positivity, which were in both cases
deemed to be of very low certainty.
A large source of uncertainty, as voiced by the GDG and not consistently defined in the available evidence, was the
definition of what constituted symptomatic infection. From clinical experience, noted by the GDG, classifying patients as
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either symptomatic or asymptomatic was not always straightforward.
Antigen testing: The evidence was of very low certainty, rated down for indirectness and uncertainty in the included model
parameters. Additional sources of uncertainty from the above recommendations that were not formally evaluated included
evaluations of the sensitivity and specificity of various types of rapid tests, the swab technique employed, vaccination
status, history of prior infection and the infecting variant(s) , leading to greater uncertainty as assessed by the GDG.
Values and preferences

Isolation Period:
• Given anticipated strong preferences in most individuals for shorter periods of isolation, and their positive social and
economic consequences, the Clinical Management GDG placed a high value on shorter periods of isolation.
• Despite the very low certainty of evidence, the Clinical Management GDG placed a high value on the possible
increase, in symptomatic patients, of transmission and resulting hospitalization in secondary infections resulting from
shorter periods of isolation.
• The GDG nevertheless acknowledged the substantial variability in these values and preferences that is likely to exist.
Antigen Testing: Given anticipated strong preferences in most individuals for shorter periods of isolation, and the positive
social and economic consequences of shorter periods of isolation, the Clinical Management GDG placed a high value on
shorter periods of isolation.
The Clinical Management GDG nevertheless acknowledges the substantial variability in these values and preferences that
is likely to exist.
Resources and other considerations

Isolation Period: The GDG emphasized that there are substantial resource considerations in asking individuals with mildly
symptomatic disease to isolate for 5 days. These resource considerations should be incorporated into policies to ensure
that the financial, social and mental health-specific impacts of periods of isolation on individuals are minimized.
Antigen Testing: The GDG acknowledged that the resource implications of prolonged periods of isolation may be
considerable and may reach beyond the individual, with varying social, economic and mental health impacts.
Implementation of the above recommendations should incorporate policies to ensure that those considerations are
addressed.
Justification
The clinical management team and respective GDG assessed the evidence and determined the updated recommendations for
the suggested duration of isolation timelines. They then were asked to present their findings and summary of evidence to the
IPC GDG, whose members agreed that, due to limited evidence on the risks of onward infection transmission among different
populations, such as health and care workers, there was no need to make different recommendations for health and care
workers.
The Clinical Management GDG reviewed the evidence for onward transmission that may lead to hospitalization or death
following contact with persons isolated for 5 days versus 10 for both symptomatic and asymptomatic cases and found there
were differences between symptomatic and asymptomatic individuals and therefore decided to make separate
recommendations for these two groups, although it may be initially difficult to classify cases into these categories. The Clinical
Management GDG discussed that hospitalization and mortality among contacts remain the crucial outcomes for consideration.
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Population: Asymptomatic COVID-19 patients
Intervention: Isolation for 5 days after positive test
Comparator: Isolation for 10 days after positive test
Certainty of
Isolation for 10 Isolation for 5 Summary
days days
evidence)
Onward
transmission
9 11 Whether isolation for 5
days would increase
per 1000 per 1000 Very low
leading to onward transmission
Due to certainty
hospitalization Difference: 2 more per 1000 of parameters in
leading to hospitalization
(28 days) 1 of secondary cases is
( CI 95% 2 more the model and
very uncertain compared
— 3 more ) indirectness. with isolation for 10
days.
Onward
transmission
2 3 Very low
Whether isolation for 5
days would increase
per 1000 per 1000
leading to death Due to certainty onward transmission
(90 days) 2 of parameters in leading to mortality of
Difference: 1 more per 1000 the model and secondary cases is very
( CI 95% 0 more uncertain compared with
indirectness.
— 1 more ) isolation for 10 days.

Population: Symptomatic COVID-19 patients
Intervention: Isolation for 5 days after symptom onset
Comparator: Isolation for 10 days after symptom onset plus 3 additional days without symptoms
Certainty of
days days
evidence)
Onward
transmission
9 28 Whether Isolation for 5
days would increase
per 1000 per 1000 Very low
leading to onward transmission
Due to certainty
hospitalization Difference: 19 more per of parameters in
leading to hospitalization
(28 days) 1 of secondary cases is
1000 the model and
very uncertain compared
( CI 95% 14 more indirectness. with isolation for 10
— 24 more ) days.
Onward
transmission
2 7 Very low
Due to certainty
Whether Isolation for 5
days would increase
per 1000 per 1000 onward transmission
leading to death of parameters in
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Certainty of
days days
evidence)
(90 days) 2 leading to death of

Difference: 5 more per 1000 the model and secondary cases is very
( CI 95% 4 more indirectness. uncertain compared with
— 6 more ) isolation for 10 days.

Population: Patients with COVID-19
Intervention: Remove isolation based on negative antigen test after Isolation 5 days
Comparator: Isolation for 10 days
Intervention
Certainty of
Comparator Remove
Isolation for 10 isolation based Summary
days on negative
evidence)
antigen test
Whether removing
Onward 9 9 isolation based on the
transmission per 1000 per 1000 negative antigen test
Very low
leading to would increase or
Due to
hospitalization parameters in the
decrease onward
(28 days) transmission leading to
model and
hospitalization of
indirectness. secondary cases is very
uncertain compared with
isolation for 10 days.
Whether removing
Onward
2 2 isolation based on the
per 1000 per 1000 negative antigen test
transmission Very low
would increase or
leading to death Due to
decrease onward
(90 days) parameters in the
transmission leading to
model and
mortality of secondary
indirectness. cases is very uncertain
compared with isolation
for 10 days.
Average
isolation period
10 7 Moderate
Removing isolation
based on the negative
Days (Mean) Days (Mean) Due to
(days) Lower better antigen test probably
parameters in the decreases average
CI 95% isolation compared with
model.
isolation for 10 days.
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3.6.3 Risk assessment and management of exposure
The guidance for Risk assessment and management of exposure of health care workers in the context of COVID-19: interim
guidance was published 19 March 2020.
3.7 IPC outbreak preparedness, readiness, response and recovery

The COVID-19 pandemic resulted in a high disease burden and impact across settings where health care was delivered, notably in
fragile health systems and among at-risk populations. It exposed challenges facing health-care systems and highlighted the need to
strengthen IPC programmes and infectious disease outbreak surge capacity and to institute overall reforms to improve care delivery.
Maintenance of the delivery of essential health services is critical to avoid increased morbidity and mortality in the population due to
COVID-19 and other infectious diseases and conditions [129][130]. Despite these efforts, the pandemic severely affected the health
systems, as was reported in several publications and WHO country situation reports [1][2].
Lessons learned from COVID-19 has been used to strengthen health systems for future pandemics through the global architecture for
health emergency prevention, preparedness, response, recovery and resilience and to address determinants of health that affect
populations and settings at risk [1][2][130].
IPC health emergency preparedness and operational readiness are critical for an effective response and prompt recovery.
• Preparedness includes strategies that are developed well in advance of a disease outbreak or imminent emergency threats is
detected; they include planning, organizing, training, equipping, practicing, evaluating and taking corrective actions. IPC aspects
of preparedness include establishing or strengthening the IPC core components or minimum requirements, stockpiling IPC
supplies, training staff and increasing compliance with recommended IPC practices.
• Operational Readiness responds to an emerging threat that is expected to affect a system within weeks to months. Building
surge capacity to be able to withstand threats that may externally overwhelm capacity and identifying internal gaps in current
practices that could allow a threat to amplify within the health facility must be addressed in this stage.
• Response to public health emergencies includes activities in reaction to a known or suspected event. This is when emergency
plans are operationalized. Depending upon the nature of the emergency, response activities may be restricted to the health-care
facility itself or may include local, community, regional and national actions and may continue for short, intermediate or long
periods.
• Once an emergency is declared “over,” the recovery efforts begin, including lessons learned to further increase the preparedness
level of a facility.
3.7.1 Key activities to strengthen IPC during heath emergencies

Key actions for strengthening IPC outbreak preparedness, readiness and response [129] include (though not necessarily in this
order)
• Assess IPC capacity

◦ Identify IPC areas needing strengthening at the national level.
• Develop or reinforce National emergency preparedness and response plans

◦ Develop or reinforce the IPC components of a national or subnational disease-specific outbreak preparedness and
response plan or multi-hazard plan.
• Evaluate national IPC guidelines for outbreak management.

◦ Develop and incorporate IPC outbreak management within national IPC guidelines.
• Develop and/or strengthen the outbreak component of the national IPC training program
◦ Develop or strengthen an outbreak training programme to be incorporated into the national or subnational IPC training
programme.
• Coordinate with national surveillance and reporting programme

◦ Coordinate with national and subnational surveillance networks that include syndromic and microbiologic surveillance for
diseases with outbreak potential. Surveillance and reporting of infections, especially health and care workers and
hospitalized patients should be considered an important to guide IPC activities.
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• Develop an IPC communication strategy

◦ Develop an outbreak communication strategy as it relates to IPC and integrate it with the broader outbreak communication
strategy. Work in collaboration with risk communication and community engagement (RCCE) partners.
• Develop surge capacity plans for IPC resources

◦ Develop management plans for surge capacity and ways to monitor IPC supplies in collaboration with operations and
logistics partners.
• Establish an IPC outbreak task force/working group

◦ The task force will serve as the coordinating mechanism for IPC in the context of health emergencies, and especially during
the response phase. It will develop, review, adopt and disseminate policies, guidelines, standard operating procedures
(SOPs), training material and other IPC outbreak-related activities.
• Develop and/or identify IPC partners

◦ Map and develop a network of partners for supporting and implementing IPC activities during an outbreak.
◦ Assess IPC outbreak preparedness, readiness and response
▪ Assess IPC outbreak preparedness and evaluate the status of outbreak readiness and areas to be adapted or modified
based on specific threats of concern through simulation exercises.
▪ In the case that an outbreak has occurred undertake an after-action review to identify areas for improvement.
These activities are designed to mitigate the impact of a specific outbreak on the health system and to reduce morbidity and
mortality as details on a communicable disease threat are emerging. By flattening the epidemic curve and avoiding a sharp peak of
cases, public health officials can better control the impact on the population and on health-care system capacity [129][130][131].
3.8 Lessons learned from COVID-19 and potential future strategies for overburdened
health systems
Lessons learned from the previous waves of COVID-19, paired with the unpredictability of SARS-CoV-2, highlight the need for health-
care facilities to be ready for future increase in cases. During the pandemic, there was a higher demand for patient hospitalization, bed
capacity and isolation rooms. This was often in response to a rapid surge of cases, coupled with demands on the health workforce and
increased incidence of COVID-19 among health and care workers [132].
During periods of the pandemic when COVID-19 was exerting a significant impact on health-care systems, strategies and novel
interventions were needed to address gaps. For example, when health-care facilities experienced a lack of or limited bed capacity, or
when they were called on to handle larger numbers of deaths, there were additional demands upon existing infrastructure and
resources (i.e. the number of hospital beds, intensive care unit (ICU) beds and equipment) and increased workforce requirements.
When isolation rooms or single-patient rooms were not available, strategies for patient placement included the establishment of
dedicated COVID-19 units and isolation units, increasing bed capacity through temporary measures, and cohorting of patients during
an outbreak situation for optimal bed utilization. Other examples included the creation of COVID-19 testing and assessment units for
screening; limiting points of entry; devising alternative methods of transportation and referral; imposing restrictions on patient transfer
and movement; and incorporating other operational considerations, including some related to facility design, patient placement and
workflow for implementation of IPC measures.
Agile health systems are required to ensure continuity of services during COVID-19 surges, with planning supported by estimation
tools1 to accurately predict needs for essential supplies, equipment and workforce personnel. A sustainable health workforce requires
human resource planning, recruitment, repurposing of responsibilities within the limits of training and skills, and redistributing of roles
among health and care workers. There were periods that involved training of staff and reassigning them to other patient-care areas in
the health-care facility, as well as considerations for changing working conditions and providing health and care workers with mental
health care and psychosocial support. Other strategies included screening and testing protocols for the early return to work of essential
staff who were asymptomatic or who had recovered from infections [127].
Access to testing for rapid identification of cases and active surveillance of health worker infections were critical during periods of
increased SARS-CoV-2 transmission. IPC managers should work with occupational health services to develop sustainable
occupational infection prevention measures, using COVID-19 as a model for outbreak management and timely implementation of
control measures.
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Beyond human resource needs, health facilities also experienced increased demands for personal protective equipment (PPE) and
supplies (including cleaning supplies and equipment, alcohol-based hand rubs [ABHRs], soaps, etc.), stockpiles and contingency plans
in the event of shortages. Where there were challenges with PPE availability, the use of PPE was optimized in health-care settings
where there were patients with COVID-19. For the protection of workers, the rational use of PPE included strategies for extended use,
re-use following reprocessing, and substitution with available equipment.
In addition to investing in the core components of IPC programmes, strengthening IPC health emergency capacity at the national and
health-care facility levels will mitigate healthcare-associated transmission risk and contribute to timely outbreak containment.
Issues that must be addressed include strengthening surge capacity to enable health-care facilities to withstand threats that may
overwhelm capacity and identifying gaps in current practices that could allow a threat to amplify within the health facility.
1 For additional information on essential resource planning for COVID-19 see, Coronavirus disease (COVID-19) technical guidance: Essential resource planning.
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4. Part 2: Mitigation measures in the community

The SARS-CoV-2 pandemic affected both health-care and community settings and led to the implementation of a number of public health
and social measures. The role of IPC in health-care settings is a specialized area of practice, a practical, evidence-informed approach to
preventing patients and health and care workers from being harmed by avoidable infections [42]. Application of IPC principles in the
context of community settings complements public health efforts, basic hygiene practices and mitigation measures to reduce infections,
morbidity and pressure on health systems.
Care for persons with COVID-19 was often provided at the community level, in the home, and by community health workers, social care
workers, traditional medicine practitioners, and a variety of formal and informal community-based providers, including caregivers.
This section describes mitigation measures for community settings, and the application of IPC principles, operational and implementation
considerations to reduce SARS-CoV-2 transmission and the impact of COVID-19 disease.
4.1 Introduction to public health and social measures

Mitigation measures have been implemented worldwide throughout the pandemic to suppress SARS-CoV-2 transmission and reduce
mortality and morbidity from COVID-19 [60]. Decisions to adjust (tighten, loosen or reintroduce) Public Health and Social Measures
(PHSMs) continue to be weighed against the positive and negative health, economic and social impacts these measures have on
societies and individuals.
Where there is widespread SARS-CoV-2 transmission, there remains a risk of additional variants, which have the potential to cause
more severe illness and possibly lead to the reintroduction of public health and social measures (PHSMs). This may include
heightened surveillance of SARS-CoV-2 in the community (see WHO policy brief: COVID-19 surveillance [133]) and monitoring of the
effectiveness of vaccination and non-pharmaceutical interventions (NPIs) on the burden of disease in all regions and their impact on
public health services and society [1].
What are PHSMs?
PHSMs are measures implemented in community settings (outside of health-care facility settings) that consist of the following:
personal protective measures (for example, physical distancing, avoiding crowded settings, practicing hand hygiene, respiratory
etiquette and mask-wearing); environmental measures (for example, cleaning, disinfection, ventilation); surveillance and response
measures (for example, testing, genetic sequencing, contact tracing, isolation and quarantine); physical distancing measures (for
example, regulating the number and flow of people attending gatherings; maintaining distance in public or workplaces; restricting
domestic movements); and the imposition of international travel-related measures. In this context, it does not include medical
countermeasures such as therapeutics or vaccination. Measures should be implemented by the lowest administrative level for which
situational assessment is possible and tailored to local settings and conditions. For more information, please refer to the
Considerations for implementing and adjusting public health and social measures in the context of COVID-19 [60].
Adjusting PHSMs
As the pandemic continues to evolve, PHSMs should be regularly reviewed and adjusted according to the local epidemiology and its
impact on the health system, including the community and the overall economy and society. This requires agile decision-making based
on ongoing situational assessments at the most local administrative level possible in a coherent and coordinated manner with
neighbouring areas at the subnational and national levels. Such assessments should be based on available data and a risk/benefit
approach considering the local epidemiology, the health system’s capacity to respond and other contextual considerations (such as
upcoming mass gathering events that may alter transmission or the health system's capacity). The choice of epidemiological indicators
and their thresholds will depend on a country’s data collection capacity, vaccination strategy and coverage, and the overall COVID-19
response strategy [60]. Important dynamic indicators to be considered to determine the local situation are SARS-CoV-2 transmissibility,
the seriousness of COVID-19, and the impact on the health system. Assessments based on these key indicators (transmissibility,
seriousness of disease and impact) need to be tailored to the local context. As a general principle, core PHSMs (for example, mask
use, physical distancing) should be maintained in priority groups, settings and situations, even during periods of low transmission. By
combining data regarding the above-mentioned three key indicators, the following situation levels can be identified to describe the local
situation:
Situational level 0: A situation with no known transmission of SARS-CoV-2 in the preceding 28 days. The health system and public
health authorities are ready to respond, but there are no restrictions needed on daily activities.
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Situational level 1: A situation with minimal transmission, morbidity and health system impact of SARS-CoV-2, with only basic
ongoing PHSM needed.
Situational level 2: A situation where there is a moderate impact of COVID-19, although there may be a higher impact in specific
subpopulations. Additional measures may be required to reduce transmission. However, disruptions to social and economic activities
can still be limited, particularly if PHSMs can be targeted strategically to more affected settings.
Situational level 3: A situation with a significant impact on the health system and a risk of health services becoming overwhelmed, or
unacceptably high morbidity and mortality, despite sufficient remaining health system capacity. A broader combination of PHSMs may
need to be put in place to limit transmission, manage morbidity and avoid overwhelming the health system.
Situational level 4: An uncontrolled epidemic with very high morbidity/mortality and limited or no additional health system response
capacity available, thus requiring extensive PHSMs to avoid overwhelming health services and to limit substantial excess morbidity
and mortality.
4.2 Mask use
4.2.1 Mask use in the community

Background
To assist national and global efforts to end the acute phase of the COVID-19 pandemic emergency worldwide, WHO published the
2022 COVID-19 Strategic preparedness, readiness and response plan outlining strategic interventions to support these efforts. The
first objective is to reduce and control the incidence of SARS-CoV-2 infections. This is essential to protect individuals from
exposure, especially vulnerable individuals at risk of severe disease or occupational exposure to the virus; reduce the probability
that new variants will arise; and reduce pressure on health systems. The second objective is to prevent, diagnose and treat
COVID-19 to reduce mortality, morbidity and long-term sequelae [134]. These actions may reduce pressure on the virus to evolve
and the potential that future variants will emerge while simultaneously reducing the burden on the health system [132].
Masks are one component of a comprehensive package of prevention and control measures to limit the spread of SARS-CoV-2.
When aiming to reduce community transmission and mitigate the impact of COVID-19 outbreaks on health and social services,
policies developed for mask use should be included as one element of a comprehensive package of preventive measures (physical
distancing, ventilation, mask use, hand hygiene, respiratory etiquette and vaccination) to reduce transmission.
Considering the current stage of the pandemic, the GDG considered all available evidence on the effectiveness of mask-
wearing [33], the epidemiology of variants of concern (VoCs), transmission (data or patterns where available), the severity of
disease and its impact on health systems, vaccine efficacy, access, uptake and potential immune evasion [135]. The
complementary strong and conditional recommendations on mask use in the community outline possible scenarios in which mask
use may be of benefit.
Published 13 January 2023
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Strong recommendation for
Strong recommendation for, low-to-moderate certainty of evidence
WHO recommends the use of a mask for the prevention of SARS-CoV-2 transmission in the community in the
following situations:
• when in crowded, enclosed or poorly ventilated spaces1 [7];

• following a recent exposure to COVID-19 (according to the WHO definition2) when sharing a space with others;
• when sharing a space with a person who displays signs or symptoms of COVID-193 or is COVID-19-positive;
• for individuals at high risk4 of severe complications from COVID-19.
1
For example, a setting in which it is not possible to physically distance at least 1 metre.
2
Exposure: contact with a probable or confirmed case or linked to a COVID-19 cluster [5][127].
3
dyspnoea, nausea/diarrhoea/anorexia [5]
4
High risk is defined as: people aged ≥60 years or those with underlying comorbidities, such as cardiovascular disease or
diabetes mellitus, chronic lung disease, cancer, cerebrovascular disease, immunosuppression, obesity or asthma [52].
Practical info
The implementation and adjustment of policies on mask use should be based on available scientific data and a risk/benefit
approach that considers the local epidemiology, the health system’s capacity to respond, and other contextual considerations
(events that may alter community transmission or the health system’s capacity to respond to a resurgence of cases). The
local situation can be determined based on the above-mentioned criteria related to the transmissibility of SARS-CoV-2, the
seriousness of the disease and the impact of the virus.
The evidence available on mask use in the community setting is based on the use of medical masks. Fabric (non-medical) masks
can be used when access to medical masks is limited. While filtering facepiece respirators have demonstrated a higher filtration
level, there is limited evidence to suggest that filtering facepiece respirators should be used in community settings.
The use of exhalation valves on respirators and non-medical masks is discouraged as they do not allow for adequate source
control from the wearer. Exhalation valves permit a bypass of the filtration layers when the wearer exhales, thus potentially
allowing infectious particles to pass through.
Face shields are considered to provide a level of eye protection only and should not be considered as an equivalent to masks
with respect to respiratory protection and/or source control. Current laboratory testing standards assess face shields only for
their ability to protect eyes from chemical splashes [136].
Additional details
For additional information on the environmental impact of mask use (and other PPE), please see the WHO's Global analysis of
health care waste in the context of COVID-19 [92].
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For information on assessing and improving indoor ventilation, please see WHO’s Roadmap to improve and ensure good indoor
ventilation in the context of COVID-19 [16].
For additional information on contact tracing and quarantine, please see Contact tracing and quarantine in the context of
COVID-19: interim guidance, 6 July 2022 [84].
For the essential parameters concerning fabric (non-medical) and medical masks, see the following implementation
consideration.
The utilization of masks in community settings is associated with a decreased risk of SARS-CoV-2 infections compared
with no mask-wearing. Despite the low-to-moderate certainty of the evidence, GDG members agreed that WHO should
issue recommendations, as the net benefits of mask use by the public outweigh the potential harms. The situations outlined
above have been identified by consensus as settings and conditions in which masks should always be utilized.
Available evidence includes two open-label RCTs and 10 observational studies. A large (n=342 183) cluster RCT found a
mask promotion intervention associated with decreased risk of symptomatic SARS-CoV-2 seroprevalence (adjusted
prevalence ratio 0.91, 95% CI 0.82 to 1.00) [137]. An individually randomized RCT (n=6024) found a recommendation to
use masks associated with decreased risk of SARS-CoV-2 infection, though the difference was not statistically significant
(odds ratio 0.82, 95% CI 0.54 to 1.23); this trial was not designed to evaluate effects of masks as source control [138]. The
RCTs had methodological limitations, including open-label design, attrition, incomplete outcome assessment, variable
adherence and differential recruitment. The RCTs were consistent and were not downgraded for imprecision (due to the
very large total sample size [greatly exceeding any optimum information size threshold] with a precise estimate from one of
the trials). Only one trial evaluated a mask recommendation directly [138]. The other evaluated a mask promotion
intervention and did not evaluate mask use or a mask recommendation directly [137]; this resulted in suboptimal uptake of
mask use and would underestimate the effects of mask use. Therefore, the RCTs were not downgraded for indirectness
(See Annex 2).
The observational studies were generally consistent with the RCTs, but had some imprecision, inconsistency and
methodological limitations [139][140][141][142][143][144][145][146][147][148]. Although the estimates of the 10 available
observational studies were imprecise and had a degree of variability, in addition to other biases intrinsic to observational
studies, overall, mask use was associated with a decreased risk of SARS-CoV-2 infection compared to no mask
use [139][140][141][142][143][144][145][146][147][148]. Ecological studies identified an association between a reduced
number of confirmed cases of COVID-19 and policies requiring the use of masks. No studies assessed the effectiveness of
mask use in specific settings (for example, indoor, outdoor, or ventilation status). Overall, the certainty of the evidence
(based primarily on the two RCTs, and supplemented by the 10 observational studies) is assessed as low-to-moderate.
Certainty of the Evidence

Available evidence includes two open-label RCTs and 10 observational studies. The cluster RCT explored the use of mask
promotion [137], while the other RCT presented an imprecise estimate and was not designed to assess the effectiveness of
source control [138]. The observational studies had some imprecision, inconsistency and methodological limitations.
Therefore, the certainty of the evidence is reported as low-to-moderate.
Discussions with GDG members indicated a general preference towards favouring mask use in community settings,
although the values and preferences of individuals may vary. Many members indicated that those at high risk of severe
disease may find more value in the use of masks compared to other individuals.
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GDG members indicated that the global supply chain for mask manufacturing has improved and would not pose a severe
obstacle to community masking. The cost of both medical masks and non-medical masks is relatively low and does not
pose a substantial barrier for low- and middle-income countries. However, medical masks should not be reused and should
be changed when wet or soiled, potentially requiring the use of multiple masks per day, leading to additional resource
implications, such as cost, availability and access. Additionally, there are environmental impacts associated with disposable
masks, such as additional waste and litter. Additional considerations are needed for proper disposal.
Gaps in knowledge and research needs

Investigations into the benefits and harms of masks and their utilization in the community setting are ongoing and published
work has identified this need for continued research. Well-conducted, observational studies and/or RCTs exploring the use
of masks versus no masks in various settings (for example, indoor, outdoor, ventilation status) would clarify outstanding
questions concerning mask use in community settings. In addition, research investigating the use of masks (including the
type of mask and transmission scenarios) in the context of the emerging variants of concern would provide powerful
evidence for future recommendations. However, GDG members discussed the challenges associated with obtaining
compelling evidence from an RCT on behavioural interventions. Furthermore, with the availability of SARS-CoV-2
immunization and increased natural immunity, further research will be needed on the impact of vaccination and,
consequently, the effect that immunization status will have on mask utilization in community settings. Additional research
and innovation is needed in the area of reusable and recyclable medical masks that comply with existing standards.
No issues were documented regarding inequities. Using masks as a preventive measure for SARS-CoV-2 infection may
reduce the burden of infection, especially for those at high risk of severe disease [105]. Studies did not examine equity
issues, such as providing information on race, gender or vulnerable populations. More studies addressing these aspects
should be carried out to inform the decision-making process.
Complex issues arise when examining the acceptability of mask use in communities. These include the type of mask
recommended, personal preference and ecological impact (environmental impact and waste
management) [74][149][150][151]. Members indicated that those individuals at high risk of severe sequelae might find more
benefit in mask-wearing compared to other individuals. Furthermore, it has been indicated that members of the general
public may not deem mask use as an acceptable public health intervention and, thus, may demonstrate resistance towards
masking policies. However, the evidence points to the benefits outweighing the harms. Variability exists in the published
studies examining mask compliance.
Given the current availability of masks, community masking is likely feasible, despite the acceptability issues mentioned
above.
Justification
In response to the shift in the epidemiology of COVID-19, GDG members reformulated the recommendations to no longer rely
on the local transmission scenario of SARS-CoV-2. Given the sustained SARS-CoV-2 transmission globally, a majority of GDG
members agreed that a situational approach to mask use is more appropriate than the previous, transmission-based
approach. GDG members indicated that the benefits of mask use outweigh the potential harms as masks are an effective
mitigation tool, especially in crowded, enclosed and poorly ventilated settings such as those that are common in public
transportation, busy stores, crowded workplaces and educational centres. The GDG decided for this strong recommendation in
conjunction with the conditional recommendation on a risk-based approach for mask use, to ensure coverage across all
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situations where masking may be beneficial.
Conditional recommendation for
Conditional recommendation for, low-to-moderate certainty of evidence
In situations not addressed by the strong recommendation, WHO suggests a risk-based approach to inform the
decision about whether to use a mask for the prevention of SARS-CoV-2 transmission in the community.
Factors that favour mask use:
• COVID-19 epidemiological trends at the community level indicating high or rising transmission or hospitalizations;
• low coverage of COVID-19 vaccination;
• low levels of population immunity to SARS-CoV-2;
• a greater degree of crowding1, poorer indoor ventilation and/or the presence of individual risk factors2.
1
The degree of crowding for the conditional recommendation refers to distances >1 metre, for which there is likely some
association between greater distancing and decreased risk.
2
For the conditional recommendation, in the absence of clear risk factors, one may consider whether one's overall status of
health may contribute to an increased risk of severe disease.
Published 13 January 2023.
Practical info
Practical considerations for policy-makers:
The potential advantages of mask use by healthy people in the general public include:
• reduced spread of potentially infectious aerosols or droplets from exhaled breath, including from infected people before
they develop symptoms [153];
• encouragement of concurrent transmission-prevention behaviours, such as washing hands and not touching the eyes,
nose and mouth [154][155][156]; and
• prevention of transmission of other respiratory illnesses, such as tuberculosis and influenza, and a reduction of the burden
of these diseases during the pandemic [157].
The potential disadvantages of mask use by healthy people in the general public include:
• headache and/or breathing difficulties, depending on the type of mask used [158][159]; potential physiological
changes [160]; development of facial skin lesions, irritant dermatitis or worsening acne when used frequently for long
periods of time [159][161][162][163][164];
• difficulty with communicating clearly, especially for persons who are deaf or have poor hearing or use lip
reading [165][166];
• poor compliance with mask-wearing, in particular by young children [161][167][168][169][170];
• waste management issues; improper mask disposal leading to increased litter in public places and environmental
hazards [171][74]; and
• further disadvantages for, or difficulty wearing masks by, certain members of the population, especially: children;
developmentally challenged people; those with mental illness or cognitive impairment; those with asthma, chronic
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respiratory or breathing problems; those who have had facial trauma or recent oral maxillofacial surgery; and those living
in hot and humid environments [158][161][168].
Additional details
For additional information on the environmental impact of the use of masks (and other PPE), please see the WHO's Global
analysis of health care waste in the context of COVID-19 [74].
For information on assessing and improving indoor ventilation, please see WHO’s Roadmap to improve and ensure good indoor
ventilation in the context of COVID-19 [7].
For additional information on contact tracing and quarantine, please see Contact tracing and quarantine in the context of
COVID-19: interim guidance, 6 July 2022 [127].
For the essential parameters concerning fabric (non-medical) and medical masks, see the following implementation
consideration.
The utilization of masks in community settings is associated with a decreased risk of SARS-CoV-2 infections compared with
no mask-wearing. Despite the low-to-moderate certainty of the evidence, GDG members agreed that WHO should issue
recommendations, as the net benefits of mask use by the public outweigh the potential harms. The situations outlined above
have been identified by consensus as settings and conditions in which masks should always be utilized.
Available evidence includes two open-label RCTs and 10 observational studies. A large (n=342 183) cluster RCT found a
mask promotion intervention associated with decreased risk of symptomatic SARS-CoV-2 seroprevalence (adjusted
prevalence ratio 0.91, 95% CI 0.82 to 1.00) [137]. An individually randomized RCT (n=6024) found a recommendation to
use masks associated with decreased risk of SARS-CoV-2 infection, though the difference was not statistically significant
(odds ratio 0.82, 95% CI 0.54 to 1.23); this trial was not designed to evaluate effects of masks as source control [138]. The
RCTs had methodological limitations, including open-label design, attrition, incomplete outcome assessment, variable
adherence and differential recruitment. The RCTs were consistent and were not downgraded for imprecision (due to the
very large total sample size [greatly exceeding any optimum information size threshold] with a precise estimate from one of
the trials). Only one trial evaluated a mask recommendation directly [138]. The other evaluated a mask promotion
intervention and did not evaluate mask use or a mask recommendation directly [137]; this resulted in suboptimal uptake of
mask use and would underestimate the effects of mask use. Therefore, the RCTs were not downgraded for indirectness
(See Annex 2).
The observational studies were generally consistent with the RCTs, but had some imprecision, inconsistency and
methodological limitations [139][140][141][142][143][144][145][146][147][148]. Although the estimates of the 10 available
observational studies were imprecise and had a degree of variability, in addition to other biases intrinsic to observational
studies, overall, mask use was associated with a decreased risk of SARS-CoV-2 infection compared to no mask
use [139][140][141][142][143][144][145][146][147][148]. Ecological studies identified an association between a reduced
number of confirmed cases of COVID-19 and policies requiring the use of masks. No studies assessed the effectiveness of
mask use in specific settings (for example, indoor, outdoor, or ventilation status). Overall, the certainty of the evidence
(based primarily on the two RCTs, and supplemented by the 10 observational studies) is assessed as low-to-moderate.
Certainty of the Evidence

Available evidence includes two open-label RCTs and 10 observational studies. The cluster RCT explored the use of mask
promotion [137], while the other RCT presented an imprecise estimate and was not designed to assess the effectiveness
of source control [138]. The observational studies had some imprecision, inconsistency and methodological limitations.
Therefore, the certainty of the evidence is reported as low-to-moderate.
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Discussions with GDG members indicated a general preference towards favouring mask use in community settings, although
the values and preferences of individuals may vary. Many members indicated that those at high risk of severe disease might
perceive the benefits of mask use to be greater compared to other individuals.
Many GDG members noted that the global supply chain for mask manufacturing has improved and would not pose a severe
obstacle to community masking. The cost of both medical and non-medical (fabric) masks is relatively low and does not
pose a substantial barrier for low- and middle-income countries. However, medical masks should not be reused and should
be changed when wet or soiled, potentially requiring the use of multiple masks per day, leading to additional resource
implications, such as cost, availability and access. Additionally, there are environmental impacts associated with disposable
masks, such as additional waste and litter. Additional considerations are needed for proper disposal.
Gaps in knowledge and research needs
Investigations into the utilization of masks in the community setting are ongoing, but published work has identified this as
an area that needs continued research. Observational studies and/or RCTs designed and conducted with rigorous scientific
methods exploring the use of masks versus no masks in various settings (for example, indoor, outdoor, ventilation status)
would clarify outstanding questions concerning mask use in community settings. In addition, research investigating the use
of masks (including the type of mask and transmission scenarios) in the context of VoCs would provide powerful evidence for
future recommendations. However, GDG members discussed the challenges associated with obtaining compelling evidence
from an RCT on behavioural interventions. Furthermore, with the availability of SARS-CoV-2 immunization and increases
in natural immunity, further research will be needed to reinforce the impact of vaccination and, consequently, the effect
immunization status will have on mask utilization in community settings. Additional research and innovation are needed in
the area of reusable and recyclable medical masks that comply with existing standards.
No important issues were documented regarding inequities, although this arena would benefit from further investigation.
Complex issues arise when examining the acceptability of mask use in communities. These include the type of mask
recommended, personal preference and ecological impact (environmental impact and waste
management) [74][149][150][151]. Members indicated that those individuals at high risk of severe sequelae might find more
benefit in mask-wearing compared to other individuals. Furthermore, it has been indicated that members of the general
public may not deem mask use as an acceptable public health intervention and, thus, may demonstrate resistance towards
masking policies. However, the evidence points to the benefits outweighing the harms. Variability exists in the published
studies examining mask compliance.
Given the availability of masks, community masking is likely feasible.
Justification
GDG members decided for this conditional recommendation in conjunction with the aforementioned strong recommendation. In
addition to situations where masks are strongly advised (when in crowded, enclosed or poorly ventilated spaces; following recent
exposure to COVID-19; when sharing a space with a person who displays symptoms of COVID-19 or is COVID-19-positive; and
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for individuals at high risk of severe complications from COVID-19), there are additional times when wearing a mask may be
beneficial. Although there are limited data on the effectiveness of a risk-based approach and implementation may be a challenge,
the benefits of mask wearing outweigh the risks.
Members indicated that masks should be considered when there are high-to-moderate levels of community transmission
(situational levels 2 to 4) and low-to-moderate vaccination coverage, while taking into consideration individual risk factors in
addition to personal values and preferences based on the perception of the risk and the potential harm and consequences of
being affected by COVID-19.
Mask management
For any type of mask, appropriate use, storage, cleaning and disposal are essential to ensure that they are as effective as
possible and to avoid any increased risk of transmission. Adherence to correct mask management practices varies, reinforcing
the need for appropriate messaging [152]. WHO provides the following guidance on the correct use of masks:
• Wash hands thoroughly before putting on the mask.

• Inspect the mask for tears or holes, and do not use a damaged mask.
• Place the mask carefully, ensuring it covers the mouth and nose; adjust to the nose bridge and tie it securely to minimize
any gaps between the face and the mask. If using ear loops, ensure these do not cross over as this widens the gap
between the face and the mask.
• Avoid touching the mask while wearing it. If the mask is accidently touched, wash hands thoroughly.
• Remove the mask using the appropriate technique. Do not touch the front of the mask; rather, untie it from behind.
• Replace the mask as soon as it becomes damp with a new, clean and dry mask.
• Either discard the mask or place it in a clean, plastic, resealable bag, leaving it there until it can be cleaned. Do not store
the mask around the arm or wrist or pull it down to rest around the chin or neck.
• Wash hands immediately after discarding a mask.
• Do not reuse single-use masks.
• Discard single-use masks after each use and properly dispose of them immediately upon removal.
• Do not remove the mask to speak.
• Do not share your mask with others.
• Wash fabric masks in soap or detergent and preferably hot water (at least 60° Centigrade/140° Fahrenheit) at least once a
day. If it is not possible to wash the fabric mask in hot water, then wash it in soap/detergent and room-temperature water,
followed by boiling the mask for 1 minute.
• A mask should be replaced by a clean mask at least once daily.
For more information on mask technical specifications, review the following technical document - “Technical specifications of
personal protective equipment for COVID-19”, published 13 November 2020.
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Individuals with any signs or symptoms1 suggestive of COVID-19 or who test positive for COVID-19 should
wear a medical mask when sharing a space with others until the signs or symptoms are resolved or the isolation
period is complete.
1
dyspnoea, nausea/diarrhoea/anorexia [5].
Practical info
• Individuals should self-isolate and seek medical advice as soon as they start to feel unwell with potential COVID-19
symptoms (even if symptoms are mild).
• Instructions on how to put on, take off and dispose of medical masks, and how to adequately perform hand
hygiene [172] should be followed.
• All additional measures should be followed, particularly respiratory hygiene, frequent hand hygiene, and maintaining a
physical distance of at least 1 metre from other persons [173].
• If a medical mask is not available for individuals with suspected or confirmed COVID-19, a fabric mask with fit, filtration
and breathability assessed to meet WHO’s essential parameters for non-medical masks should be worn by patients as a
source-control measure, pending access to a medical mask. The use of a non-medical mask can minimize the projection
of respiratory particles from the user [174][175].
• Persons with suspected COVID-19 or mild COVID-19 symptoms should wear a medical mask as much as possible,
especially when there is no alternative to being in the same room with other people.
• Caregivers or those sharing living space with anyone with suspected COVID-19 or mild COVID-19 symptoms should wear
a medical mask when in the same room as the affected person.
Justification
GDG members agreed that if an individual who has confirmed or suspected COVID-19 needs to interact with others in or outside
of their household, they should wear a medical mask. Members also noted that individuals who have confirmed or suspected
COVID-19 should self-isolate for the duration of their isolation period and/or until symptoms resolve. For additional information
on contract tracing and quarantine, please see Contact tracing and quarantine in the context of COVID-19: interim guidance, 6
July 2022 (who.int) [127].
Policies aimed at reducing the transmission of SARS-CoV-2 in the community should be revisited, strengthened and
updated according to the most recent scientific evidence.
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Practical info
Policies may include a package of interventions such as vaccination, ventilation, physical distancing, hand hygiene, respiratory
etiquette and mask adherence by the general public. Please refer to the document on IPC in the event of a surge or resurgence
in cases of COVID-19 [176].
Justification
GDG members agreed that national and subnational policy-makers should revisit, strengthen and update local policies according
to the most recent scientific evidence to mitigate SARS-CoV-2 transmission in community settings. These policies should be able
to be quickly scaled up should COVID-19 incidence increase in the community and if health-care systems are at risk of becoming
overwhelmed. Policies should be reviewed as necessary to account for any changes in the local context or new VoC(s).
4.2.1.1 Type of mask used by the general public

Implementation considerations for policy-makers when providing guidance or setting standards
for manufacturers on types of mask used by the general public
The following mask types are acceptable options for use by the general public:
• disposable medical masks, if the availability of medical masks meeting minimum performance criteria for health
workers has been assured1;
• non-medical masks that comply with standards for safety and efficacy2 and can be washed prior to reuse;
• if neither of the above options is available, other types of well-fitting, non-medical masks3 are acceptable options
(according to local policies).
1
Complying with medical mask standards (at minimum) EN 14683 type I, ASTM F2100 level 1, YY/T 0969, YY 0469 (or
equivalent). For requirements for health workers, please see PPE technical specifications.
2
Complying with the ASTM F3502-22a Standard Specification for Barrier Face Coverings, standard or a non-medical mask
meeting WHO essential parameters (see Practical information for more information).
3
Including homemade, multi-layered masks (see Practical information for more information).
Practical info
Table 9. Essential parameters (minimum and preferred thresholds) for manufactured non-medical mask
Essential
Minimum threshold Preferred threshold
Parameters
1. Filtration*
>50% at 0.3 µm, without

1.1 Filtration 70% at 3 µm
compromising breathability
efficiency
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Solid: sodium chloride (NaCl), talcum powder, holi

powder, dolomite, polystyrene latex spheres Solid: sodium chloride (NaCl),
1.2. Challenge
polystyrene latex spheres
particle
Liquid: DEHS Di-Ethyl-Hexyl-Sebacat, paraffin oil
Choose either size: 3 µm, 1 µm, or smaller 0.3 µm

1.3. Particle size
2. Breathability
Adult: ≤ 40 Pa/cm2
2.1. Breathing ≤70 Pa/cm2
resistance** Children: ≤ 20 Pa/cm2
2.2 Exhalation Not recommended N/A

valves
3. Fit
Full coverage of nose and mouth; consistent, snug

perimeter fit at the nose bridge, cheeks, chin and
lateral sides of the face; adequate surface area to Same as current requirements
3.1. Coverage
minimize breathing resistance and minimize side
leakage
Seal as good as FFR (respirator)
Fit factor of 100 for N95
Maximum total inward leakage of 25%

Not currently required
3.2 Face seal (FFP1 requirement)
OR
Leakage ratio of >5
Should cover from nose bridge to

below the chin and cheeks on either
side of the mouth
Adult and child
3.2. Sizing
Sizing for adults and children (6-9,
10-12, >12)
> 44.5 N
3.3 Strap strength
* Smaller particles may result in lower filtration.
** High resistance can cause bypass of the filtration layers of the mask. Unfiltered air will leak out the sides or around the nose on the path of least
resistance.
Table 10. Additional (optional) parameters for manufactured non-medical masks
Additional parameters Minimum thresholds
If reusable, the number of wash cycles 5 cycles
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If majority of mask is compostable, as per EN 13432, EN 14995, ASTM

Disposal
D5511 or other similar standards mimicking landfill or marine environments
ISO 18184 (virus)
ISO 20743 (bacteria)

Antimicrobial (bacteria, virus, fungus)
performance
ISO 13629 (fungus)
AATCC TM100 (bacteria)
Chemical safety Comply with REACH regulation, including inhalation safety
Standards organizations’ performance criteria
Manufacturers producing masks with consistent standardized performance can adhere to published, freely available
guidance from several organizations, including those from ASTM International, the French Standardization Association
(AFNOR Group), the European Committee for Standardization (CEN), the Swiss National COVID-19 Task Force, the South
Korean Ministry of Food and Drug Safety (MFDS), the Italian National Standards Body (UNI) and the Bangladesh
Directorate General of Drug Administration (DGDA).
Additional criteria:
• The non-medical mask, including all components and packaging, must be non-hazardous, non-toxic and child-friendly
(i.e. has no exposed sharp edges, protruding hardware or rough materials).
• Factory-made EN Type I, ASTM Level 1 medical masks or non-medical masks must be made using a process that is
certified to a quality management system (e.g. ISO 13485, ISO 9001).
• Social accountability standards (e.g. SAI SA8000) for multiple aspects of fair labour practices, health and safety of the
workforce and adherence to UNICEF’s Children’s Rights and Business Principles are strongly encouraged.
Figure 7. Illustration of the three essential parameters of filtration, breathability and fit.
Filtration and breathability
Filtration depends on the filtration efficiency (in %), the type of challenge particle (oils, solids, droplets containing bacteria)
and the particle size (see Table 2). Depending on the fabrics used, filtration and breathability can complement or work
against each other. Filtration is dependent on the tightness of the weave, fibre and thread diameter. Non-woven materials
used for disposable masks are manufactured using processes to create polymer fibres that are thinner than natural fibres
such as cotton, and that are held together by partial melting. Breathability is the difference in pressure across the mask and
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is typically reported in millibars (mbar) or Pascals (Pa) or normalized to the cm2 in mbar/cm2 or Pa/cm2. Non-medical fabric
masks consisting of two layers of polypropylene spunbond and two layers of cotton have been shown to meet the minimum
requirements for droplet filtration and breathability of the CEN/TS 17553:2022 guidance. It is preferable not to select elastic
material to make masks as the mask material may be stretched over the face, resulting in increased pore size and lower
filtration through reuse. Additionally, elastic fabrics are sensitive to washing at high temperatures and may therefore
degrade over time.
Coating the fabric with compounds such as wax may increase the barrier and render the mask fluid-resistant; however,
such coatings may inadvertently block the pores completely and make the mask difficult to breathe through. In addition to
decreasing the mask's breathability, the coating may cause unfiltered air to be more likely to escape from the sides of the
mask on exhalation. The coating is therefore not recommended.
Fit: shape and sizing
Fit is the third essential parameter, and takes into consideration coverage, seal, sizing and strap strength. Fit of masks is
currently not defined by any standard except for the anthropometric considerations of facial dimensions (ISO/TS 16976-2)
or simplified to mask height mask (South Korean standard for KF-AD). Ideally, the mask should not have contact with the
lips, unless hydrophobic fabrics are used in at least one layer of the mask [177]. Leaks where unfiltered air moves in and
out of the mask may be attributed to the size and shape of the mask [178].
Optional parameters for consideration
If reusable:
• biodegradability;
• antimicrobial performance (where applicable); and
• chemical safety (see Practical Info section).
Non-medical masks intended to be reusable should include instructions for washing and maintain initial performance after
each wash cycle. Advanced fabrics may be biodegradable or compostable at the end of service life, according to a
recognized standard process (e.g. UNI EN 13432, UNI EN 14995 and UNI/PdR 79).
Manufacturers sometimes claim their non-medical masks have antimicrobial performance. Antimicrobial performance may
be the result of coatings or additives to the fabric fibres. Treated fabrics must not come into direct contact with mucous
membranes; the innermost fabric should not be treated with antimicrobial additives, only the outermost layer. In addition,
antimicrobial fabric standards (e.g. ISO 18184, ISO 20743, AATCC TM100, AATCC 100) generally act slowly. The
inhibition on microbial growth may not take full effect until after a contact time of 2–24 hours, depending on the standard.
The standards have generally been used for athletic apparel and to substantiate claims of odour-control performance.
These standards are not appropriate for non-medical cloth masks and may provide a false sense of protection from
infectious agents. If claims are made, manufacturers should specify the standard that supports antimicrobial performance,
the challenge organism and the contact time.
The use of volatile additives is discouraged as these may pose a health risk when inhaled repeatedly during wear.
Certification according to organizations, including OEKO-TEX (Europe) or SEK (Japan), and additives complying with
REACH (Europe) or the United States Environmental Protection Agency (EPA), indicate that textile additives are added at
safe levels.
Justification
GDG members agreed with standardizing recommendations for the utilization and specifications of masks for the general
public. GDG members expressed concern about being overly prescriptive while the current state of evidence on the quality
and effectiveness of non-medical masks continues to evolve, as this may limit the social enterprise of homemade mask
production, a standard practice within many WHO Member States. However, GDG members agreed with laboratory
evidence confirming that non-medical masks without standardized quality-control processes can have large variabilities in
their key parameters (see practical information for information on essential parameters for non-medical masks). Members
also conveyed the importance of specifying the use of well-fitting masks, as the fit may be an essential parameter for
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effective source control and protection. In addition, GDG members discussed the potential harms associated with limited
resources and lack of personnel to test the essential parameters of masks in various low-income settings, together with
expressing concerns regarding waste disposal.
Adaptation
Homemade non-medical masks made from household fabrics (e.g. cotton, cotton blends and polyesters) should
ideally have a three-layer structure, with each layer serving a function (see Figure 1) [83].
1. an innermost layer (that will be in contact with the face) of a hydrophilic material (e.g. cotton or cotton blends of terry
cloth towel, quilting cotton and flannel) that is non-irritating against the skin and can contain droplets [177];
2. a middle, hydrophobic layer made of synthetic, breathable, non-woven material (spunbond polypropylene, polyester
and polyaramid), which may enhance filtration, prevent permeation of droplets or retain droplets [177][84]; and
3. an outermost layer made of hydrophobic material (e.g. spunbond polypropylene, polyester or their blends), which may
limit external contamination from penetrating through the layers to the wearer’s nose and mouth and maintains and
prevents water accumulation from blocking the pores of the fabric [177].
Figure 8. Non-medical mask three-layer layers
Non-medical mask construction using breathable fabrics such as cotton, cotton blends, polyesters, nylon and polypropylene
spunbond that are breathable may impart adequate filtration performance when layered. Single- or double-layer
combinations of advanced materials may be used if they meet performance requirements.
Figure 9. How to make a fabric mask
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Although at least three layers are recommended for non-medical masks for the most common fabric used, single, double or
other layered combinations of advanced materials may be used if they meet performance requirements.
Assumptions regarding homemade masks are that individual makers have access only to common household fabrics and
do not have access to test equipment to confirm target performance (filtration and breathability). Figure 1 illustrates a multi-
layer mask construction with examples of fabric options. Very porous materials, such as gauze, even with multiple layers,
may provide very low filtration efficiency [152]. Fabrics with higher thread counts offer improved filtration performance [153].
Coffee filters, vacuum bags and materials not meant for clothing should be avoided, as they may contain injurious material
when breathed in. Microporous films such as Gore-Tex are not recommended [154].
When wearing a mask in community settings, individuals should use a well-fitting mask with full coverage of
the nose and mouth.
• Ensure a snug fit at the nose bridge, cheeks, chin and lateral sides of the face.
• The “knot-and-tuck” and “linking-ear-loops-behind-the-head” techniques improve medical mask fit by reducing gaps on
the sides of medical masks with ear loops.
Practical info
Medical masks
Improving the fit of medical masks may not always be possible in low-resource settings, given the resource requirements.
However, techniques such as the “tie-and-tuck” method may benefit low- and middle-income countries since the techniques
do not require additional materials. The “knot-and-tuck” and “linking-ear-loops-behind-the-head” techniques improve
medical mask fit by reducing gaps on the sides of medical masks with ear loops. Such gaps allow leakage of air (potentially
containing infectious particles) to bypass the filtration layers of the medical mask when the wearer inhales or exhales.
Considerations on the use of linking-ear-loops-behind-the-head techniques to improve medical mask fit
• Always use a clean, unused, rectangular, pleated medical mask meeting the minimum performance standards (or
equivalent) [14].
• Always clean hands thoroughly (per WHO guidance) prior to putting on, taking off and/or manipulating a mask.
• Where connectors are used to link ear loops behind the head, ensure that these connectors are clean for use upon
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putting on (either new, cleaned and disinfected or laundered, depending on the connector and local implementation
strategy). When connectors are removed, they should be treated as potentially contaminated. A local strategy should
be in place to manage used connectors through cleaning and disinfection processes, laundering or discarding used
connectors through standard waste management.
Justification
GDG members unanimously agreed that mask fit was among the most important considerations for choosing a mask. If a
medical mask does not snugly fit an individual's face, the individual can use techniques (i.e. “knot-and-tuck” and “linking-
ear-loops-behind-the-head”) to improve its fit.

Population: Community
Intervention: Methods to improve mask fitting
Comparator: An ill-fitting mask (does not fit snugly, gaps)
Summary
The research of the included studies had been conducted over a large range of countries, with the most frequent
research coming from the USA
Studies aimed to evaluate:
• modifications to improve fit to reduce the number of expelled particles.
• amount of leakage associated with double masking.
• fitted filtration efficiency of consumer grade masks.
• aerosol particle leaking/leakage and standard surgical mask fitting with 3 elastomeric harness designs
Studies found that crossing ear loops or using mask brackets made no significant improvement . However,
modifications such as knot-and-tuck methods and double masking did improve the fit, blocking of particles from the
wearer and reducing exposure Furthermore, increasing the tension through a brace, connector, ‘ear-guards’, etc.
did improve fit and protection. Lastly, an elastomeric harness may improve the fit and protection of a standard
surgical mask.
Comparator
An ill-fitting
Outcome Study results and Methods to the Evidence
mask (does Summary
Timeframe measurements improve mask (Quality of
not fit snuggly,
fitting evidence)
gaps)
Evidence was There were too few who

SARS-CoV-2 experienced SARS-
not GRADE’ d as
Infection all studies were CoV-2 infection, to
performed in the determine whether
laboratory setting methods to improve
mask fitting made a
difference.
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4.2.1.2 Mask use during physical activity
Conditional recommendation against , Low certainty evidence
WHO suggests that people do not wear masks during vigorous-intensity physical activity
1
Vigorous-intensity physical activity (VPA) refers to physical activity that is performed at 6.0 or more Metabolic equivalent
of task (METs) (on an absolute scale). On a scale relative to an individual’s personal capacity, VPA is usually a 7 or 8 on a
rating scale of perceived exertion scale of 0–10 [179].
Practical info
• People may choose to wear a mask during light to moderate physical activity, especially indoors where a physical
distance cannot be maintained.
• Facilities should ensure proper ventilation.
Evidence suggests that there may be potential discomforts when wearing masks during vigorous-intensity physical
activity.
The certainty of the evidence has been assessed as low.
Values and preferences We expect few to want the intervention
Given the discomforts, people would likely prefer not wearing masks during vigorous-intensity physical activity.
This intervention is unlikely to have resource implications.
This intervention likely does not have an impact on equity.
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Acceptability Intervention is likely poorly accepted
Given the effects on perceived exertion and performance, masks during vigorous-intensity physical activity may not be
deemed acceptable.
This intervention is likely feasible.
Justification
The GDG determined that benefits of wearing a mask during vigorous-intensity physical activity did not outweigh any
potential harms and discomforts. This was based on the low certainty of evidence and likely lack of acceptability. The GDG
also considered the lack of feasibility and impacts on equity and agreed that a recommendation was not appropriate. While
this recommendation does not favour the use of a mask during intense, vigorous activity, masks are recommended in other
settings as outlined in the WHO recommendations on mask use in the community.

Population: All people
Intervention: Wearing of facemask during physical activity
Comparator: Not using face mask during physical activity
Certainty of
Not using face Wearing of
mask during facemask Summary
physical during physical
evidence)
activity activity
SARS-CoV-2
Infection No studies were found
CoV-2 infection.
4 RCT (Surgical Mask)

Tolerability
Outcomes: (i) MD 0.22 lower
(0.47 lower to 0.03 higher) Wearing a mask during
Exercise
intense physical activity
performance 1 RCT (Respirator)
Low may worsen exercise
performance.
MD 14 lower
(49.09 lower to 21.09 higher)

(ii) Rate of MD 0.48 higher
perceived (0.01 higher to 0.94 higher) Wearing a mask during
exertion intense physical activity
3 RCT (respirators)
Low may increase the rate of
perceived exertion.
MD 1.88 higher
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Certainty of
Not using face Wearing of
mask during facemask Summary
physical during physical
evidence)
activity activity
(iii) oxygen MD 0.50 lower

saturation intense physical activity
2 RCT (respirators)
Low may worsen oxygen
saturation.
MD 0.91 lower
(iv) oxygen MD 5.49 lower

uptake intense physical activity
2 RCT (respirators)
Low may worsen oxygen
uptake.
MD 8.08 lower
(13.96 lower to 2.21 lower)
4.2.2 Mask use by children

Guiding Principles
Given the limited evidence on the use of masks by children in the context of COVID-19, including limited evidence on transmission
of SARS-CoV-2 in children at specific ages, policy formulation by national authorities should be guided by the following overarching
principles:
• Do no harm: the best interest, health and well-being of the child should be prioritized.
• The application of these guidelines should not affect development or learning outcomes, including access to education.
• The guidelines should consider the feasibility of implementing recommendations in different social, cultural and geographic
contexts, including limited-resource and humanitarian settings, and among children with disabilities or specific health
conditions.
• Any recommendation for mask use for children should encompass needed flexibility to enable children to maintain their rights
to play and to education and their ability to engage in everyday activities [3].
• National policies on the use of masks by children should be adapted based on social, cultural and environmental
considerations, including in settings with limited resources and humanitarian settings.
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4.2.2.1 Introduction
Introduction
WHO guidance on the use of masks by children in the community was first published in August 2020 as an annex to the
document Mask use in the context of COVID-19 [181][180]. In December 2021, it was incorporated into the online version
1.0 of the WHO IPC COVID-19 living guideline published using the MAGICapp platform [182]. This updated version
includes new recommendations for mask use by children of different ages, accommodations for children living with
disabilities and updated implementation considerations, including for school settings.
WHO and UNICEF jointly developed this guideline. A guideline development group, the WHO-UNICEF GDG for the use of
masks by children in the context of COVID-19, was established. Details on the composition of the GDG and the retrieval,
synthesis and assessment of evidence can be found in the methods and acknowledgements sections of the document.
When aiming to reduce community transmission and mitigate the impact of COVID-19 outbreaks on health and social
services, health officials should ensure that policies developed for mask use are included as one element of a
comprehensive package of preventive measures to reduce transmission (ventilation, physical distance, hand hygiene and
respiratory etiquette). In any decision being made related to the use of masks by children, the guiding principles for the
best interests of children and a “do-no-harm” approach should prevail.
Each country is facing a different situation in the pandemic depending on a number of factors, including the intensity of
SARS-CoV-2 circulation, amount of population-level immunity, capacities to respond and agility to adjust measures. As the
pandemic continues and the virus evolves, changes in transmission intensity, the circulating variants of concern, and the
capacities for health systems to respond based on the situation will result in a need for policy adjustments related to IPC
and PHSM. National policies should be evidence-based, agile and adjusted as needed, taking into consideration these and
other factors. Countries should conduct an assessment of the transmission scenario and the health system response
capacity – and assign a situational level to a geographic area. The assessment should examine quantitative and
qualitative information from available sources, and can refer to the situational and community transmission (CT) Levels
CT1-CT4 as described in Considerations for implementing and adjusting public health and social measures in the context
of COVID-19 [60]. Additional factors, including population-level immunity, will need to be taken into account when setting
national and subnational policies, as outlined above.
This section of the guideline focuses on the use of masks by children in the context of COVID-19 in community settings,
such as schools and recreational areas. Children typically spend a considerable portion of their time in schools, which may
have indoor and outdoor areas, and there are existing specific guidance documents available that address school-related
public health measures.
Recommendations on types of masks can be found in the mask use in community settings section of the document.
There are five statements for the use of masks by children, including three recommendations by age group (≤ 5, 6-11, 12
and over), and two good practice statements.
Published 7 March 2022
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SARS-CoV-2 transmission in children

Disease severity and mortality due to COVID-19, including infections with VoCs, increase with age, and children tend to
present with milder courses of illness than do older population groups [183][135][184]. The transmission characteristics
among children need to be interpreted in light of new VoCs, in particular, Omicron; vaccination strategies and age-specific
vaccination coverage and changes in mixing patterns as a result of the implementation of PHSM. Evidence early in the
pandemic from household, serological and infection prevalence studies suggested that young children may be at lower risk
of infection than adolescents and adults and potentially transmit SARS-CoV-2 less
frequently [183][184][186][187][188][189][190][191][192][193][194][195][196]. However, more recent epidemiological trends
seem to indicate that children contribute to transmission similarly to adults, due to their social mixing patterns in some
settings and in light of emerging VoCs such as Omicron [197][198][199][200][201][202]. This has been well documented in
settings where extensive community testing has been undertaken (e.g. the REACT study in the United Kingdom) [203].
Researchers at the European Centre for Disease Prevention and Control (ECDC) reported the age distribution of
COVID-19 among children, as of July 2021, in the European Union (EU), European Economic Area (EEA) and the United
Kingdom. They found that children made up an increasing proportion of weekly case numbers, with the most noticeable
increase among those aged 5-11 years. These findings should be interpreted in light of the proportion of vaccinated
adolescents, social mixing patterns by age and adults in those countries at the time [184][198].
Also, studies from high-income countries have shown that, in some settings, children tend to have more extensive social
mixing patterns than adults do and, consequently, more contacts than adults [200]. Thus, even though the propensity to
transmit may be lower for children, in some settings, they may be contributors to transmission as a consequence of their
social mixing patterns, especially if PHSMs have been relaxed [197][188][189][196][204][205][206].
The Omicron variant has resulted in very high levels of incidence in most countries, across all age groups, with higher
incidence levels than observed earlier in the pandemic [197]. There is currently limited evidence to suggest a difference in
transmission risk of Omicron according to age group, other than that modulated by vaccination, but more data are required
to know for sure. In the context of the Delta and Omicron VoCs, increased transmission and growth rates have been
documented [197].
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Figure 8. When should children wear masks?
Published
25 April
2022
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4.2.2.2 Age-specific recommendations

Recommendation for children 5 years of age and under
Masks are not required for children 5 years of age and under
Practical info
As mask use is not recommended in this age group, IPC and public health and social measures should be prioritized to
minimize the risk of SARS-CoV-2 transmission.
• Adults and staff working with children should follow national guidelines for vaccination against COVID-19.
• Adequate ventilation* should be in place and maintained in settings where children are congregating or cared for.
• Adults and staff working with children should wear masks (see WHO recommendations for mask use in adults).
• Adequate sanitation and hygiene requirements and a regimen for environmental cleaning and disinfection should be in
place in settings where children congregate or are cared for.
• Children should be taught to perform frequent hand hygiene and respect respiratory etiquette using an age-appropriate
approach and materials.
In the event that policy-makers decide to adjust the age range for mask recommendations (i.e. children under the age of 5
years would utilize a mask), relevant settings should have adequate human resources to ensure safe mask use. Adoption
of the mask recommendation should include appropriate and consistent supervision by an adult and the ability to ensure
mask compliance and adherence, especially if mask-wearing is expected for an extended period. The guiding principles of
the best interests of children and a “do-no-harm” approach should prevail.
*For adequate ventilation refer to regional or national institutions or heating, refrigerating and air-conditioning societies
implementing ventilation requirements. If recommendations are not in place, a recommended ventilation rate of 10l/s/
person should be met (except in health-care facilities that have specific requirements). For more information, consult
Roadmap to improve and ensure good indoor ventilation in the context of COVID-19 [7].
Benefits and harms
Uncertain benefits and harms

The wearing of a well-fitting mask is associated with a decrease in SARS-CoV-2 transmission in the community and
provides protective benefits to the individual [38][32]. A systematic review of the clinical effectiveness of masks that
included two RCTs and three observational studies in adult populations provided some evidence that mask-wearing in
the community is associated with decreased risk of COVID-19 infection [32][?][140][147][148][137][138]. The
systematic review found inconsistent effects of masks on reducing the risk of influenza-like illness (ILI) in community
settings, although a cluster RCT found that hand hygiene and face masks may prevent household transmission of
influenza if applied early after symptom onset in an index case [167]. A systematic review evaluating 21 ecological
studies in adults reports that mask use is associated with reduced mortality, reduced incidence of disease, and reduced
hospitalization in the community in the context of COVID-19 [38]. Studies from the United States, Spain, Germany and
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the United Kingdom looked at the effectiveness of mask use in ages 4-18; and 11 studies reported an association
between mask use and decreased COVID-19 incidence in
children [207][208][209][210][211][212][213][214][215][216][217]. These studies were generally observational and
ecological, with important shortcomings, including limited reporting of other infection-control measures and exposures.
The systematic review did not find evidence of serious harms with masks in adults in community settings, although
bothersome harms were common. Evidence of potential harms, specifically in children aged 5 years or younger, is
limited. Parents who completed an online survey conducted in France reported behavioural and mood changes (e.g.
anxiety, sadness, anguish), headaches, speaking difficulties and breathing discomfort attributed to mask-wearing [218].
There is currently no evidence on the long-term impact of mask use on the physical and mental health, development
and well-being of children.
Given the lack of direct evidence in this age group, evidence was extrapolated from adults. The GDG found that
evidence from adults is less applicable (more indirect) to children 5 and under compared to older children due to lower
COVID-19 incidence and severity. Even if masks are associated with the same relative reduction in COVID-19
incidence in children 5 and under as in adults, the absolute benefits would be smaller due to lower incidence and
severity. Furthermore, benefits in children 5 and under are likely further reduced due to suboptimal adherence.
Additionally, despite the limited/lack of evidence of harms in this age group, there were concerns regarding potential
greater harms with regard to childhood development. The GDG, therefore, determined that, given the above
information, the benefits of mask-wearing in children aged 5 and under are trivial to none and do not outweigh potential
harms.
The evidence certainty is very low due to the limited evidence in this age group and lower applicability of evidence in
adults to this age group compared to older children.
The GDG determined that, given the close balance of benefits and harms, different preferences (e.g. focusing on
potential benefits in terms of reducing infection risk versus focusing on potential developmental harms) could change
the decision. Therefore, variability in preferences/values could affect judgements about mask use in this population.
Given that masks are not recommended for this age group, minimal resource implications are anticipated.
Equity
Effect on equity variable

Risk factors that increase the likelihood of contracting COVID-19 include race, ethnicity and community-level
socioeconomic status [219][220].
The GDG assessed effects on equity as uncertain or variable.Because masks are not required in this age group, their
effects on equity would depend upon how mask use is implemented. If masks are widely available, using masks could
improve equity by reducing the risk of transmission overall, including among socioeconomically disadvantaged groups
more affected by COVID-19. However, there is a need to ensure that lack of access to masks does not have a negative
impact on children (which would decrease equity), and that certain populations (such as disabled individuals) are not
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adversely affected.
Acceptability
There is a significant lack of evidence as to the acceptability of mask use for children in this age group across different
contexts [221][207]. Additionally, despite limited evidence on harms in this age group, there are concerns regarding
potential greater harms with regard to childhood development.
The GDG felt that the acceptability of mask use in children under 5 years of age is variable.
Feasibility
The GDG judged that use of masks is less feasible in this age group since it requires more supervision and children
may have more difficulty wearing masks for prolonged periods and during certain activities.
Justification
The GDG determined that benefits of masks in children <5 years of age did not outweigh harms. This was based on the low
certainty of the evidence and the lower incidence (and severity) of SARS-CoV-2 transmission in this age group relative to
older children and adults. The GDG also considered the low acceptability and preference for mask use and agreed that a
recommendation for the use of masks for this age group was not appropriate.
Decisions for children under the age of 5 years to wear masks may be informed by factors such as contact with high-risk
individuals; local incidence of COVID-19; ability to adhere to and tolerate mask-wearing; local vaccination rates; and
parental preferences. There was agreement among the GDG members that, in settings where children of this age group
are congregating – for example, childcare settings – it is important to adhere to PHSM and IPC measures, including
adequate ventilation, hand hygiene and environmental hygiene measures, regardless of whether masks are used.
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Recommendation for children 6 - 11 years of age
Conditional recommendation for , Low certainty evidence
In areas where there is known or suspected community transmission1 of SARS-

CoV- 2, masks are recommended for use in children ages 6-11 years in the following settings:
• in indoor settings where ventilation is known to be poor or cannot be assessed, or

the ventilation system is not properly maintained2, regardless of whether physical distancing of at least 1 metre can b
e maintained3;
• in indoor settings that have adequate ventilation** if physical distancing of at least 1 metre cannot be maintained.
1
Details on the levels of community transmission (CT1-CT4) can be found in Considerations for implementing and
adjusting public health and social measures in the context of COVID-19 [60]. Countries should regularly assess the
intensity of spread and health systems' capacities at the most localized levels possible.
2
For adequate ventilation, refer to regional or national institutions or heating, refrigerating and air-conditioning societies
implementing ventilation requirements. If regulations are not in place, a recommended ventilation rate of 10l/s/person
should be met (except in health-care facilities that have specific requirements). For more information, consult Roadmap to
improve and ensure good indoor ventilation in the context of COVID-19 [7].
3
Physical distance should be increased beyond 1 metre whenever feasible.
Practical info
Countries should regularly assess the intensity of spread and health systems' capacities at the most localized levels
possible. The assessment should examine the quantitative and qualitative information from available sources and can refer
to the situational level (S0-S4) and community transmission (CT) Levels CT1-CT4 as described in Considerations for
implementing and adjusting public health and social measures in the context of COVID-19 [60] Additional factors, including
population-level immunity, will need to be taken into account when setting national and sub-national policies.
Policy-makers and decision-makers are encouraged to ensure the following considerations are addressed when
implementing the use of masks in this age group:
• Factors that can influence the decision on implementing the use of masks include the age range in this group, the
impact on education and development, the impact on routine activities, equity and the general health and well-being of
the children.
• Masks should be made accessible (free of charge) to children in schools, health-care settings and any other setting
where they congregate (e.g. recreational areas), to ensure all children – including those living in households or
geographic areas with social vulnerabilities and limited resources – have equitable access. No child should be denied
access to these activities for not wearing a mask.
• Efforts should be made to accommodate children who do not have access to masks or are unable to tolerate a mask
so they can participate in activities involving face-to-face gatherings. No child should be denied access to these
activities for not wearing a mask.
• In cases where children are expected to wear masks for a longer duration, routine mask breaks should be
implemented.
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• The child’s capacity to adhere to correct mask use and availability of appropriate supervision should be addressed,
especially in younger children within this age group.
• Age-appropriate communication should aim to help the child understand the purpose and proper use of mask-wearing.
• The design of masks for children should take into consideration the safety and overall quality of the material(s) and
ensure a proper fit without compromising breathability, comfort and child-friendliness (appropriate size, colours,
patterns).
• Key stakeholders should develop and implement strategies for ensuring that each reusable mask is worn by no more
than one child and stored safely; for disposing of soiled masks (e.g. in dedicated bags or containers); and for
addressing the need for masks to be changed when they become soiled or wet.
• The use of masks is part of a comprehensive package of preventive measures to reduce transmission that includes
ventilation, physical distance, hand hygiene and respiratory etiquette.
The wearing of a well-fitting mask is associated with a decrease in SARS-CoV-2 transmission in the community and the
provision of protective benefits to the individual [38][32]. A systematic review of the clinical effectiveness of masks
included two RCTs and three observational studies in adult populations that provided some evidence that mask-
wearing in the community is associated with decreased risk of COVID-19 infection [32]. The systematic review found
inconsistent effects of masks on reducing the risk of ILI in community settings, though a cluster RCT found that hand
hygiene and face masks may prevent household transmission of influenza if applied early after symptom onset in an
index case [167]. A systematic review evaluating 21 ecological studies in adults found that mask use is associated with
reduced mortality, reduced incidence of disease, and reduced hospitalization in the community [38]. Studies from the
United States, Spain, Germany and the United Kingdom looked at the effectiveness of mask use in children ages 4-18.
Ten studies reported an association between mask use and decreased COVID-19 incidence in children. However,
these studies were generally observational and ecological with several limitations, including limited reporting of other
control measures [208][209][210][211][212][213][214][215][216][217]. Furthermore, two studies of influenza (one RCT
and one observational study) found a reduced incidence of COVID-19 with mask-wearing in households and school
settings [167][170].
bothersome harms were common. Evidence of potential harms, specifically in children aged 6-11, is limited. Parents
who completed an online survey conducted in France -- among whom only 9% had children over the age of 11 --
reported behavioural and mood changes (e.g. anxiety, sadness, anguish), headaches, speaking difficulties and
breathing discomfort that they attributed to mask-wearing [218]. There is currently no evidence on the long-term impact
of mask use on the physical and mental health, development and well-being of children.
The GDG previously determined that, in adults, mask use in community settings is likely associated with a decreased
risk of SARS-CoV-2 infections compared with no mask-wearing. The evidence is indirect since it is from adults.
Emerging variants such as SARS-CoV-2 B.1.617.2 (Delta) and SARS-CoV-2 B.1.1.529 (Omicron) have been reported
to have increased transmissibility [32]. The GDG judged that the benefits in this group are smaller than in adolescents
12 years of age and older, given lower incidence/severity and reduced adherence (at least in the younger children in
this age range).
Evidence on the harms in this age group is also limited. An online survey conducted in France among parents of
children in a wide age range (>6 years to >11 years) found that parents attributed behavioural changes and mood
changes (e.g. anxiety, sadness, anguish), headaches, speaking difficulties and breathing discomfort to mask-
wearing [218]. However, a study in the United States of America found no apparent adverse biological effects
(e.g. impacts on memory, heart rate, oxygen saturation, and emotional state) after mask wearing for at least 30 minutes
in elementary school children [222]. There is currently no evidence on the long-term impact of mask use on the physical
and mental health, development and well-being of children.
The evidence is indirect since it is from adults; the GDG judged that the benefits in this age group are smaller than in
adolescents aged 10-12, given lower incidence/severity and reduced adherence (at least in younger children in this age
range). Therefore, the GDG judged that the benefits of mask-wearing slightly outweigh the harms. Benefits are likely to
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be larger in situations in which the risks of infection are higher, e.g. areas with poor ventilation and/or where people are
unable to physically distance from one another.
There is limited evidence on the benefits and harms of mask-wearing in this age group. Although ecological studies that
include children aged 4-18 years have reported an association between mask mandates and a reduced incidence of
infection, these studies were judged to be of low quality, with few studies available from low- and middle-income
countries [208][209][210][211][212][213][215][216][217][225][226]. Even though this evidence is largely indirect, it was
judged by the GDG to have applicability, especially to older children in this group.
Substantial variability in preferences, ideas and values is expected regarding the potential outcomes of mask use
(prevention of SARS-CoV-2 infection, side effects). Such differences could have an impact on the decision about
whether to use masks in this age group.
The GDG determined that, given the close balance of benefits and harms, different preferences (e.g. focusing on
potential benefits in terms of reducing infection risk versus focusing on potential harms) could change the decision.
Consequently, variability in preferences/values could affect judgements about mask use in this population.
There are no formal data available on costs. Given the widespread availability and relatively low costs of non-medical
and medical masks, the GDG judged costs and resources / availability of masks to be low.
Equity
Effect on equity variable

Risk factors that increase the likelihood of contracting COVID-19 include race, ethnicity and community-level
The GDG assessed effects on equity as uncertain or variable as they would depend on how mask use is
implemented. If masks are widely available, their use could reduce the overall risk of transmission and thereby improve
equity, including among socioeconomically disadvantaged groups, which are typically more affected by COVID-19.
However, there is a need to ensure that a lack of access to masks does not negatively affect children (which would
decrease equity) and that certain populations (disabled individuals) are not adversely affected.
Acceptability
The limited evidence available indicates variability in the acceptance of masks in children aged 6 to 11. One online
study found that parents were generally opposed to children between the ages of 6-10 wearing masks, especially in
school settings. Other studies reported that children in this age group demonstrated good adherence to mask-wearing,
in particular in school settings [207][215][223].
The GDG decided to make a conditional recommendation despite the low certainty of the evidence because the
benefits of mask-wearing – reduction of SARS-CoV-2 transmission – outweigh potential harms, and preferences,
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values and acceptability generally all favour mask-wearing.
Feasibility
Adherence is generally feasible in this age group, though there may be some issues in younger children within this
range [207][224].
Justification
Although there may be a net benefit in mask wearing, this was judged to be small. After reviewing the limited evidence
available on the effectiveness of mask use in this age group, a survey was completed by GDG members, 80% of whom
voted in favour of a conditional recommendation for mask use. Other factors informing the conditional recommendation
were low certainty of evidence, variability in preferences and values that could affect decisions and variability in
acceptability and feasibility.
Settings in which the recommendation applies were also discussed, and members voted 70% in favour of applying the
recommendation to indoor settings where ventilation is known to be poor or cannot be assessed or the ventilation system is
not adequate and where a distance of at least 1 metre cannot be maintained. The GDG acknowledged the importance of
the guiding principles noted earlier, including the right to play and the importance of children continuing to attend school in
the context of the COVID-19 pandemic.
Recommendation for adolescents 12 years of age or older
Strong recommendation for , Low certainty evidence
Adolescents 12 years or older should follow the same WHO recommendations for mask use as adults.
Practical info
Policy-makers and decision-makers are encouraged to ensure the following considerations are addressed when
implementing the use of masks in this age group, irrespective of vaccination status:
• Even where national guidelines apply, additional considerations and adaptations will need to be specified for special
settings, such as schools, during sports or for children with disabilities or underlying medical conditions.
• Masks should be made accessible free of charge to children in schools, health-care settings and any other settings
where they congregate (such as recreational areas) to ensure that all children – including those living in households or
geographic areas with social vulnerabilities and limited resources – have equitable access. No child should be denied
access to these activities for not wearing a mask.
• Efforts should be made to accommodate children who do not have access to masks or are unable to tolerate a mask
so they can participate in activities involving face-to-face gatherings. No child should be denied access to these
activities for not wearing a mask.
• Routine mask breaks should be implemented when children are expected to wear masks for a longer duration.
• Age-appropriate communication should aim to help the child understand the purpose and proper use of mask-
wearing.
• Key stakeholders should develop and implement strategies for ensuring each reusable mask is worn by no more than
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one child and stored safely; for disposing of soiled masks (e.g. in dedicated bags or containers); and for addressing
the need for masks to be changed when they become soiled or wet.
• The use of masks is part of a comprehensive package of preventive measures to reduce transmission that includes ,
ventilation, physical distance, hand hygiene and respiratory etiquette.
The wearing of a well-fitting mask is associated with a decrease in SARS-CoV-2 transmission in the community and
provides protective benefits to the individual [38][32]. A systematic review of the clinical effectiveness of masks
included two RCTs and three observational studies in adult populations that provided some evidence that mask-
wearing in the community is associated with decreased risk of COVID-19 infection [32]. The systematic review found
inconsistent effects of masks on reducing the risk of ILI in community settings, though a cluster RCT found that hand
hygiene and face masks may prevent household transmission of influenza if applied early after symptom onset in an
index case [167].
A systematic review evaluating 21 ecological studies reports that mask use is associated with reduced mortality and
reduced incidence of disease and hospitalization in the community [38]. Studies from the United States, Spain,
Germany and the United Kingdom looked at the effectiveness of mask use in people ages 4-18; 12 studies reported an
association between mask use and decreased COVID-19
incidence [208][209][210][211][212][213][214][215][216][217][225][226]. However, these studies were generally
observational and ecological with important shortcomings, including limited reporting of other infection-control
measures and exposures.
bothersome harms were common. Evidence of potential harms specifically in adolescents 12-18 years of age is limited.
In France, an online survey of parents – only 9% of whom had children over the age of 11 – reported that their children
experienced behavioural and mood changes (e.g. anxiety, sadness, anguish), headaches, speaking difficulties and
breathing discomfort attributed to mask-wearing [218].
The GDG previously determined that in adults, mask-wearing in community settings is likely associated with a
decreased risk of SARS-CoV-2 infections compared with no mask-wearing. The GDG found that evidence on the use of
masks in community settings in adults is likely applicable to adolescents 12 years of age and older due to the similarity
in the incidence of SARS-CoV-2 infection (compared with young adults) and ability to adhere to mask-wearing
recommendations. Emerging variants such as SARS-CoV-2 B.1.617.2 (Delta) and SARS-CoV-2 B.1.1.529 (Omicron)
have been reported to have increased transmissibility [32].
The GDG judged the benefits, such as reduced transmission and facilitating increased access to schools/in-person
learning, in adolescents to be small but agreed that, in the context of the Delta and Omicron variants, the benefits of
mask-wearing in the community setting outweigh potential harms.
There is limited evidence on the benefits and harms of mask-wearing in this age group. Although ecological studies that
include children aged 4-18 years have reported an association between mask mandates and a reduced incidence of
infection, these studies were judged to be of low quality, with few studies available from low- and middle-income
countries [208][209][210][211][212][213][214][215][216][217][225][226]. Evidence on the effectiveness of masks in
adolescents can also be extrapolated from adults. Even though this evidence is indirect, it was judged by the GDG to
be more applicable to this age group due to the similarity in incidence and severity of SARS-CoV-2 infection in young
adults and adolescents.
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There is limited data available on adolescents' perception of the value and benefits or harms of wearing masks. Some
studies conducted in European settings looking at parental perceptions, showing mixed results but generally favouring
mask use in children over the age of 12 [223][227][228]. Given the potential benefits of masks for preventing infections
and considering the presence of bothersome but non-serious harms, the GDG determined that differences in values/
preference regarding outcomes would not impact the decision to wear masks. This supports a strong recommendation,
despite the low certainty of evidence.
There are no formal data available on costs. Given the widespread availability and relatively low costs of non-medical
and medical masks, the GDG judged the impact of costs and resource availability to be low.
Risk factors that increase the likelihood of contracting COVID-19 include race, ethnicity and community-level low
The GDG assessed the effects of mask use on equity as uncertain or variable as it depends on how mask use is
implemented. If masks are widely available, their use could improve equity by reducing the risk of transmission overall,
including among socioeconomically disadvantaged groups, who tend to be more affected by COVID-19. However, there
is a need to ensure that lack of access to masks does not negatively affect children (which would decrease equity) and
that certain populations (such as disabled individuals) are not adversely affected.
This recommendation was assessed by the GDG as likely acceptable in this age group. Studies on the perception of
the effectiveness of mask use are limited and generally focused on European countries for children over the age of 10.
The GDG considered the limited evidence and discussed knowledge of practice in their respective countries, including
the evolution of acceptance of mask use as the pandemic has continued and the emergence of VoCs. The GDG
agreed that, for children over the age of 10, mask-wearing was generally regarded as useful [223][227][228].
GDG members noted that masks are widely recommended and used in many contexts throughout the world in this age
group. The feasibility of implementing this recommendation was judged to be acceptable given low concerns about
tolerance and likely higher adherence to mask-wearing in older age groups [207].
Justification
The GDG considered the low certainty of evidence and, although the majority of the evidence was in the adult population,
felt it was reasonable to extrapolate from what had been observed in (young) adults. The GDG noted that the benefits of
mask use, such as a potential reduction in transmission and a greater ability to keep schools functioning, outweighed any
potential bothersome harms and considered other factors (not preference-sensitive, low costs, acceptability, feasibility) and
concluded that a strong recommendation was justified.
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4.2.2.3 Special populations
Children with cognitive or respiratory impairments, developmental disorders, disabilities1 or other specific
health conditions who experience difficulties wearing a mask or have health conditions that interfere with
mask-wearing should not be required to wear a mask.
1
According to the Convention on the Rights of persons with disabilities, children with disabilities “include those who have
long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their
full and effective participation in society on an equal basis” [229].
Practical info
• The individual decision for a child to wear a mask should be discussed in consultation with the child's medical provider
when possible.
• A safe environment should be created for children who are not able to tolerate a mask, including requirements for
caregivers, teachers or other adults to wear a mask when interacting with the child and to be vaccinated against
COVID-19 according to national vaccination policies.
• The use of masks with a transparent component may be considered, where available, for children with hearing
impairment and people who interact with them. These masks should meet approved regulatory standards, if available.
Justification
The GDG acknowledged that children with several health conditions may experience difficulties or harm while wearing a
mask. Despite little direct evidence but considering equity and ethical issues, the GDG determined that a good practice
statement was justified.
The use of a medical mask is recommended for children with a higher risk1 of severe complication from
COVID-19 but should be assessed in consultation with the child’s medical provider.
1
This includes paediatric patients with underlying non-communicable diseases (for example, diabetes, cardiac disease,
chronic lung disease, chronic kidney disease, immunosuppression, obesity, mental disorders and cancer) and those living
with HIV [52].
Justification
The GDG noted that, in some low-resource settings, there may be challenges for families to access medical masks
or health-care providers. It was proposed that it may be more appropriate in some circumstances for caregivers to
wear
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mask when interacting with the child. In conclusion, the GDG agreed that, while there is no direct evidence, a good practice
statement was justified due to this population's higher risk of COVID-19 complications.
4.2.2.4 Implementation considerations for use of masks in schools
Policy-makers and decision-makers are encouraged to consider the following when
implementing mask-wearing by children in school settings:
• Policies should be evidence-based, agile and adjusted as needed, taking into consideration factors such as changes
in transmission intensity, the circulating variant(s) of concern and the capacities for health systems to respond based
on the situation.
• No child should be denied access to education because of mask-wearing or the lack of a mask due to low resources
or unavailability.
• The views of teachers and other educators on risks and time burden required to ensure mask adherence by children
should be considered.
• Situations where wearing a mask can significantly interfere with the learning process or have a negative impact on
critical school activities such as physical education or sports and recreation (during which the mask may reduce the
child's ability to breathe comfortably) and meal programmes require special consideration.
• Specific instructions and supplies should be provided for the availability, safe handling and storage of masks.
• A sufficient supply of appropriate masks should be ensured.
• Masks should not increase social inequalities in access to schools, especially for marginalized communities. No child
should be denied access to these activities for not wearing a mask.
• Basic water, sanitation, hygiene, ventilation and space requirements should be met in the school building so that IPC
and PHSMs can be implemented.
• If disposable masks are used, a system for waste management of used masks needs to be established to reduce the
risk of contaminated masks being disposed of in the classroom and recreational or sports settings.
The recommendations for wearing masks in the different age groups of children in this document supersede those existing
in other WHO documents published prior to this update. The following guidance documents can be used to inform policy
-making and programming for a comprehensive school safety strategy when re-opening or during normal operations in the
context of COVID-19:
• WHO considerations for school-related public health measures in the context of COVID-19
• WB/WFP/UNESCO/UNICEF framework for school reopening
• WHO/UNICEF/IFRC Interim Guidance for COVID-19 Prevention and Control in Schools
Justification
GDG members agreed that the recommendations on mask-wearing in this document should be implemented in the context
of school settings. They also noted the importance of applying existing public health and social measures and infection
prevention and control measures in schools, in addition to mask-wearing.
4.3 Glove use

Background
In the health-care facility, medical gloves are recommended to be worn for two main reasons:
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1) To reduce the risk of contamination of health and care workers' hands with blood and other body fluids [102].
2) To reduce the risk of germ dissemination to the environment and of transmission from the health-care worker to the patient and vice
versa, as well as from one patient to another [102].
Wearing gloves as a form of PPE in the community setting became popularized in the early days of the COVID-19 pandemic. However,
the use of gloves when not indicated represents a waste of resources; does not contribute to a reduction of cross-transmission in the
community; and has a negative impact on the environment due to increased waste [74][102]. Wearing gloves may result in missed
opportunities for hand hygiene as gloves do not provide complete protection against hand contamination [102]. If worn for extended
periods, after contact with contaminated surfaces, and when not removed properly, gloves may may contribute to cross-contamination.
Gloves are not a substitute for hand hygiene. In situations where glove use is indicated, gloves should be changed when damaged
or soiled.
WHO suggests that the general public not wear gloves for routine activities in community settings in the context of
COVID-19.
Remarks: Hand hygiene should be performed frequently.
Practical info
• Gloves may be indicated in the community when a community member comes in contact with blood or another body fluid,
including contact with non-intact skin and mucous membranes.
• Gloves may also be indicated for preparation or application of disinfectant products to avoid contact with chemicals or
ingredients that can be irritating when in direct contact with hands (skin).
• As medical gloves are single-use items, glove decontamination and reprocessing are not recommended and should be
avoided.
• Because intact skin is the first line of defence against microorganisms, it is important to maintain good skin care.
Clean hands regularly

• after any type of contact with a person with COVID-19, or the immediate environment;
• before and after preparing food, before eating, after using the toilet, and whenever hands look dirty;
• before and after the use of PPE (masks or gloves), follow recommended steps on how to clean hands (hand washing or using
hand rubs);
• If hands are not visibly soiled, an alcohol-based hand rub can be used;
• for visibly soiled hands, always use soap and water.
Handwashing with soap

• Remove any hand or arm jewelry and wet your hands with warm (not hot) running water.
• Add soap, and then rub your hands together, making a soapy lather. Do this for at least 15 seconds, being careful not to wash
away the lather. Wash the front and back of your hands, as well as between your fingers and under your nails.
• Rinse your hands well under warm, running water, using a rubbing motion.
• Wipe and dry hands gently with a paper towel. Rubbing vigorously with paper towels can damage the skin.
• Turn off tap using a paper towel so that you do not re-contaminate your hands.
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Alcohol-based hand rubs (ABHRs)

• ABHRs are widely used in health-care settings and in situations where running water is not available.
• Alcohol-based hand rubs should be used only if no visible dirt is present on the hands.
• Remove any hand or arm jewelry.
• Apply to your hand enough alcohol-based hand rub (1-2 pumps) to have enough so that, when you rub your hands together,
you cover all areas of your hands, including under your nails.
• Use a rubbing motion to evenly distribute the alcohol-based hand rub over all surfaces of the hands, particularly between
fingers, fingertips, back of hands and base of thumbs.
• Rub your hands until they feel dry (15-30 seconds).
For further information on hand hygiene, see:
• WHO IPC - Hand Hygiene [230]

• Hygiene for all (UNICEF) [231]
No studies investigated glove use in the community, although it is well known that inappropriate glove use in the health-care
setting can lead to potential harms [102].
The quality of the evidence is indirect and very low.
It was not possible to assess the values and preferences as there is a lack of evidence on the effects of glove use in the
community and on the impact it may have on SARS-CoV-2 infection.
Resources Important negative issues
Research evidence
The use of gloves is likely to have a negative impact on resources and an increase in waste [74].
Summary
The use of gloves is likely to have a negative impact on resources and to result in an increase in waste [74].
This intervention likely does not have an impact on equity.
This intervention is likely acceptable.
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This intervention is likely feasible.
Justification
No studies compared glove use to no glove use and risk of SARS-CoV-2 infection in the community; however, inappropriate glove
use in the health-care setting has been linked to potential harms such as missed opportunities for hand hygiene and excess
waste [102]. Furthermore, the use of gloves at the improper moment with the wrong technique of putting on and taking off gloves
may result in unintentional cross-contamination and pathogen transmission. Therefore, the GDG elected a conditional
recommendation against glove use in the community as a preventive measure for SARS-CoV-2 transmission.
Hand hygiene (hand washing or use of hand rub) is the preferred practice [15], unless there are additional considerations based on
a risk assessment, where glove use protects workers from potential hazards (chemicals) or contact with spills or body fluids.

Population: Community/households
Intervention: Glove use
Comparator: No glove use
Summary
No studies compared glove use to no glove use and the risk of SARS-CoV-2 infection.
Certainty of
Outcome Study results and Comparator Intervention the Evidence
Summary
Timeframe measurements No glove use Glove use (Quality of
evidence)
SARS-CoV-2
Infection There were no studies
Very low looking at impact on
SARS-CoV-2 infection.
4.4 Caring for persons with COVID-19 in the home

Background
In many contexts, health services are delivered at the community level and in the home by community health workers, traditional
medicine practitioners, social care workers, or a variety of formal and informal community-based providers, including caregivers. A
caregiver refers to anyone – parents, spouses, other family members or friends – who provides informal care as opposed to the care
provided by formal health-care providers [10]. This section outlines practices that caregivers should take to reduce the risk of
spreading COVID-19 in a household.
Caregivers should try to minimize the risk of infection and be attentive to signs that the COVID-19 patient’s condition is worsening and
when to send that patient to a health facility. Household members and individuals who are caring for a person with probable or
confirmed COVID-19 are to follow instructions from local public health officials.
General public health practices and IPC principles apply to situations involving care for persons with COVID-19 in home and
community settings.
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It is important that community-based providers and caregivers have instruction on important hygiene measures to care for persons
with COVID-19, including hand hygiene and the use of personal protective equipment (PPE) for the tasks that they are expected to
perform.
• The risk of getting COVID-19 is higher in crowded and inadequately ventilated spaces where infected people spend periods of
time near uninfected people. Understanding and controlling building ventilation can improve the quality of the air we breathe
and reduce the risk of indoor health concerns, including preventing the virus that causes COVID-19 from spreading
indoors [7].
◦ It is therefore important to keep the space well-ventilated; to maintain a distance of at least 1 metre when possible; and to
limit in-person interactions and time spent in shared spaces.
◦ Isolation of persons with COVID-19 can help break the chain of transmission of the virus.
◦ Household members should avoid entering the room where the patient is located or, if that is not possible, wear a mask
and keep a distance of at least 1 metre from the patient.
• See WHO recommendations for mask use in the community and home .
◦ When providing care within 1 metre of a person infected with SARS-CoV-2, ask that that person wear a well-fitted medical
mask.
▪ Individuals who cannot tolerate a medical mask should practice respiratory hygiene by coughing or sneezing into a bent
elbow or tissue and then disposing of the tissue, followed by hand hygiene.
• One of the most effective means of preventing infections from spreading to others is by practicing proper hand hygiene.
◦ Clean hands regularly: after any type of contact with the person or the person's immediate environment; before and after
preparing food; before eating; after using the toilet; and whenever hands look dirty.
◦ if hands are not visibly soiled, an alcohol-based hand rub can be used.
◦ For visibly soiled hands, always use soap and water.
◦ When washing hands with soap and water, use disposable paper towels to dry hands. If paper towels are not available, use
clean cloth towels and replace them frequently.
• Maintaining a clean environment in the home setting requires regular cleaning of the person's room and other essential areas
of the home that are shared living spaces.
◦ This requires frequent cleaning and disinfecting of high-touch surfaces and objects in the home.
◦ For proper handling of linens, laundry and waste, follow routine processes according to local guidance.
4.5 Water, sanitation, hygiene, and waste management

Background
The provision of safe water, sanitation and waste management and hygienic conditions is essential for protecting human health during
all infectious disease outbreaks, including COVID-19. Ensuring evidenced-based and consistently applied WASH and waste
management practices in communities, homes, schools, marketplaces and health-care facilities will help prevent human-to-human
transmission of pathogens, including SARS-CoV-2, the virus that causes COVID-19.
The most important information concerning WASH and SARS-CoV-2 is summarized as follows:
• Frequent and correct hand hygiene is one of the most important measures to prevent infection with SARS-CoV-2.
• Existing WHO guidance on the safe management of drinking water and sanitation services also applies to the COVID-19
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pandemic.
• Many other infectious diseases can be prevented by safely managing water and sanitation services and by applying good hygiene
practices and waste management.
4.5.1 Environmental Cleaning

Background
For suspect or confirmed COVID-19 cases in community and home settings, maintaining a clean environment includes regular
cleaning, changing of linens and clothing when they become soiled and routine laundering. Existing WHO guidance on the WASH
also applies to COVID-19.
Cleaning and disinfection practices are important to reduce the potential for COVID-19 virus contamination in non-health-care
settings, such as in the home, office, schools, gyms, publicly accessible buildings, faith-based community centres, markets,
transportation and business settings or restaurants. High-touch surfaces -- such as door and window handles, kitchen and food-
preparation areas, countertops, bathroom surfaces, toilets and taps, touch-screen personal devices, personal computer keyboards,
and work surfaces -- in these non-health-care settings should be identified for priority disinfection [232].
In the context of COVID-19, households and community settings should follow routine environmental cleaning
and disinfection practices.
Practical info
No additional measures are required for SARS-CoV-2; households should follow routine cleaning and disinfection practices.
• Cleaning should occur before disinfection; this will allow the disinfectant to work more effectively as dirt and grime may
make it harder for the chemicals to kill the germs.
• Clean surfaces with soap and water or a regular household detergent to remove many germs, dirt, and other substances.
• Ensure that surfaces are frequently cleaned and disinfected.
• Pay special attention to high- touch surfaces, especially if anyone in your household is sick.
◦ High touch surfaces include: door and window handles, kitchen and food preparation areas, counter tops, bathroom
surfaces, toilets and taps, touchscreen personal devices, personal computer keyboards, and work surfaces.
• Follow product instructions on preparation, use, disposal and storage.

• Pay particular attention to how long the product should remain on the surface, and ensure the surfaces stays wet during
the duration of the required contact time.
• Perform hand hygiene often, and after contact with contaminated surfaces or items, handling soiled linen or waste [15].
Justification
Rapid reviews of cleaning and disinfection methods found no evidence that any one cleaning modality was better than another
in terms of its impact on SARS-CoV-2 infection. Therefore, the GDG determined that there was insufficient evidence to suggest
added precautions are needed for environmental cleaning in the context of COVID-19.
While there was no evidence to support spraying versus wiping when cleaning, GDG members noted that, for safety, products
need to be applied according to manufacturer's instructions for dilution, application and contact time. Harms may be associated
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with application of higher-than-recommended concentrations and the use of spraying as a method of application, or that differ
from those recommended by the manufacturer. Wiping is the preferred method for application. GDG members noted that it is
not appropriate to spray disinfectant on individuals nor is it appropriate to spray large areas (i.e. sidewalks), as doing so would
be unlikely to prevent the spread of SARS-CoV-2.

Population: Community/households
Intervention: Soap and water (cleaning alone)
Comparator: Bleach-based cleaner (disinfectants)
Summary
No studies compared cleaning practices to cleaning and disinfection and the risk of SARS-CoV-2 infection.
Comparator Intervention Certainty of

Outcome Study results and Bleach-based Soap and water the Evidence
Summary
Timeframe measurements cleaner (cleaning (Quality of
(disinfectants) alone) evidence)
SARS-CoV-2 There were no studies

looking at the impact on
infection SARS-CoV-2 infection,
Very low evidence was insufficient
to determine impacts on
the risk of infection

Population: Communities
Intervention: Spraying
Comparator: Mechanical cleaning (wiping, brushing, scrubbing)
Summary
No studies evaluated the effects of SARS-CoV-2 infection. Three studies were found and included in the narrative
syntheses that compared spraying versus wiping. The evidence was inconclusive as surface contamination varied
greatly by the health-care facility, the disinfectant used and the cleaning regime. A qualitative synthesis was also
performed on this topic ( for full details see Annex 3).
Comparator
Summary
brushing, evidence)
scrubbing)
SARS-CoV-2 Few studies looked at

Very low the outcome of SARS-
infection
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Comparator
Summary
brushing, evidence)
scrubbing)
CoV-2 infection.
Evidence was
inconclusive.
4.5.2 Waste Management

Background
In the context of COVID-19, there is no need to take special WASH precautions; however, it is imperative that communities
strengthen, monitor and assess their existing WASH programmes. Existing WHO guidance on the safe management of water and
sanitation services also applies to the COVID-19 pandemic [232].
The COVID-19 pandemic had numerous environmental consequences, including impacts on municipal waste management
systems, changes in consumption and waste disposal patterns [233].
Proper waste management protects community members, sanitation workers and the environment. It is imperative to follow
national/subnational and local regulations for the disposal of household waste. Where feasible, minimizing garbage is a good waste
management practice.
Waste generated in the community from persons with suspected or confirmed COVID-19 should be handled
and disposed of according to national/subnational/local regulations for waste management.
Practical info
If someone in a household has tested positive for COVID-19, carefully handle and dispose of waste, and follow national/
subnational and local regulations for waste management.
• Place all materials into garbage bags and tie them securely closed before putting them in waste receptacles;
• put all cleaning wipes and disposable paper towels with cleaning products in the garbage;
• if there is a household member with COVID-19, dispose of any tissues (respiratory hygiene) and empty waste frequently;
• frequently clean hands;
• separate items and materials that are considered hazardous waste; ensure that sharps and other hazardous materials are
properly disposed of as per local processes, to not risk harm to sanitation workers;
• minimize waste (i.e. avoid unnecessary packaging, recycle, consider reusable items).
Justification
A systematic review found no study comparing the handling of COVID-19-related waste as infectious versus non-infectious and
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the GDG found no evidence to support handling COVID-19-related waste differently from other waste. Upon review of the
evidence, the GDG determined that waste produced from SARS-CoV-2 was not infectious and did not require special handling
beyond what was currently the standard advised through national, subnational or local policies for waste.

Population: Personnel handling waste
Intervention: Infectious waste
Comparator: Noninfectious waste
Summary
Certainty of
Noninfectious Infectious Summary
waste waste
evidence)
SARS-CoV-2
CoV-2 infection.
4.5.3 Handling of linens and laundry

Background
Maintaining a clean environment includes changing of linens and clothing when they become soiled and routine laundering. In
health-care settings, no added measures beyond following standard precautions are required for handling of linens and laundry.
These same IPC principles apply to persons with COVID-19 in home and community settings.
Regular household processes should be used for laundering1 items for persons with suspected or confirmed
COVID-19.
1
Laundering includes the handling, sorting and washing/drying
Practical info
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• Bed linen and clothing should be changed regularly and when soiled.
• Soiled linen and waste should be handled carefully (with minimal manipulation or agitation) to prevent personal
contamination. It can be rolled or folded to contain the heaviest soil in the centre of the bundle.
• Contaminated and soiled laundry can be washed with other laundry, with soap or laundry detergent in warm water,
preferably at a temperature of 60-90 C.
• If a washing machine is not available, wash by hand with soap and water.
• Perform hand hygiene often, and after handling soiled linen [15].
Justification
The GDG found insufficient evidence to support added measures and precautions in the context of COVID-19 regarding
handling, transporting, sorting and laundering of linens. The evidence on the effects of SARS-CoV-2 infection was limited to
one observational study [97].

Population: Personnel handling linens
Intervention: Above standard
Comparator: Standard precautions for routine handling of linens and laundry
Summary
One study addressed the PICO question, reporting that SARS-CoV-2 RNA was not detected in rinse water after
washing with tap water, disinfecting with sodium hypochlorite, or disinfecting with 80 °C water. However, SARS-CoV-2
was detected in one of five samples after washing with laundry detergent and in one of six samples after washing with
fabric softener.
Comparator
Standard
Certainty of
precautions for
Outcome Study results and Intervention the Evidence
routine Summary
Timeframe measurements Above standard (Quality of
handling of
evidence)
linens and
laundry

SARS-CoV-2 experienced the SARS-
Transmission CoV-2 infection to
Very low determine a difference
between standard
versus above-standard
cleaning.
4.6 Safe dead body management

Background
Deaths from COVID-19 may occur in health-care facilities, at home or in other locations. The safe management of dead bodies
protects those who have died of COVID-19, their families, health and care and funeral home workers. For safe handling of bodies in
the community, practices would follow the same measures for death due to other respiratory illnesses (e.g. influenza). The dignity of
the dead, their cultural and religious traditions and their families should be respected and protected throughout, balancing the rights of
the family, the need to investigate the cause of death, and the risks of exposure to infection.
Measures for managing the bodies of deceased persons infected with SARS-CoV-2 should be consistent with those applied to persons
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who have died of an infectious disease and following national, subnational and local public health guidance.
Burial by family members for deaths at home

No added precautions are needed for SARS-CoV-2, besides those already routine for those who die of a respiratory illness,
following local, national and public health guidance and regulations.
In contexts where mortuary services are not standard or not available, or where traditional funeral rituals are required, families and
traditional burial attendants can be instructed in the preparation of bodies for burial or cremation.
For handling bodies at the community level, handling practices would follow those followed after death due to other respiratory
illnesses (e.g. influenza). Cover the body with a sheet before handling, turning, or rolling it, if culturally appropriate; plastic or cloth
sheeting can be used. Alternatively, a body bag can be used, if culturally appropriate and available. The dignity of the dead, their
cultural and religious traditions, and their families should be respected and protected throughout.
As a general practice, before attending to a dead body, people should ensure that necessary hand hygiene supplies and facilities,
PPE, and cleaning and disinfection supplies are readily available. Any person (e.g. family member, religious leader) preparing the
deceased (e.g. washing, cleaning or dressing body, tidying/shaving hair or trimming nails) in a community setting should wear
gloves during any physical contact with the body. For any activity that may involve the splashing of body fluids, eye and mouth
protection, i.e. face shield/goggles and medical mask, are recommended.
Apply principles of cultural sensitivity and ensure that family members reduce their exposure as much as possible. Family
members, traditional and religious leaders and others may typically be involved in burials at the community level.
• Those preparing the body should instruct family and friends not to kiss or touch the deceased. Anyone who assists in
preparing the body should wash their hands thoroughly with soap and water when finished (6,7).
◦ Identify local alternatives to kissing and touching the dead body in settings where such contact is traditionally part of funeral
procedures.
• Family and friends may view the body after it has been prepared for burial, per customs, where possible.
◦ If family members wish to view the body, allow them to do so, but instruct them not to touch or kiss the body; to maintain at
least a 1-metre distance from one another and any staff during the viewing; and to perform hand hygiene after the viewing.
• The belongings of the deceased person do not need to be burned or otherwise disposed of.
• All those involved in such burials should follow WHO guidelines for mask use in the community.
• People who have died from COVID-19 can be buried or cremated according to local standards and family preferences.
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5. Acknowledgements
WHO would like to thank the following groups and individuals for their support and contribution to this guideline. This includes Part 1:
Health-care and Part 2: Mitigation measures in the community.
5.1 Part 1: Health care setting authorship, acknowledgements and contributions

Authorship, contributions, and acknowledgements
WHO would like to thank the collaborative efforts of all those involved to make this process rapid, efficient, trustworthy and transparent.
WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Secretariat (alphabetically)
Benedetta Allegranzi (WHO/HQ), April Baller (WHO/HQ), Kathy Dunn (WHO/HQ), Hannah Hamilton (WHO/HQ), João Paulo
Toledo (WHO/HQ).
WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Steering Group (alphabetically)
Lisa Askie (WHO/HQ), Anshu Banerjee (WHO/HQ), Adriana Velazquez Berumen (WHO/HQ), Astrid Lydia Chojnacki (WPRO), Landry
Kabego Cihambanya (AFRO), Jennifer Collins (EURO), Giorgio Cometto (WHO/HQ), Janet Victoria Diaz (WHO/HQ), Sergey Eremin
(WHO/HQ), Dennis Falzon (WHO/HQ), Luca Fontana (WHO/HQ), Melinda Frost (WHO/HQ), Bruce Allan Gordon (WHO/HQ), Iman
Heweidy (EMRO), Maha Talaat Ismail (EMRO), Ivan Dimov Ivanov (WHO/HQ), Kathryn Johnston (PAHO), Ying Ling Lin (WHO/HQ),
Tendai Makamure (AFRO), Madison Moon (WHO/HQ), Leandro Pecchia (WHO/HQ), Mark Perkins (WHO/HQ), Ana Paula Coutinho
Rehse (EURO), Nahoko Shindo (WHO/HQ), Alice Simniceanu (WHO/HQ), Aparna Singh Shah (SEARO), Valeska Stempliuk (PAHO),
Maria Van Kerkhove (WHO/HQ), Victoria Willet (WHO/HQ).
UNICEF Steering Committee Members Observers

Nagwa Hasanin (UNICEF), Raoul Kamadjeu (UNICEF), Pierre-Yves Oger (UNICEF).
WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Guideline Development Group
(alphabetically)
Yewande Alimi (Africa Centres for Disease Control and Prevention, Ethiopia), Jameela Al-Salman (Ministry of Health of Bahrain,
Bahrain), Baba Aye (Public Services International, France – Civil Society Representative), Hanene Tiouiri Benaissa (Ministry of Health
of Tunisia, Tunisia), May C. Chu (Colorado School of Public Health, Center for Global Health, United States of America), John
Conly (Cumming School of Medicine, University of Calgary, Canada), Barry David Cookson (Division of lnfection and lmmunity,
University College London, United Kingdom of Great Britain and Northern Ireland), Nizam Damani (Sindh Institute of Urology and
Transplant Centre, Karachi, Pakistan (Dow University of Health Sciences, Pakistan), United Kingdom), Dale Fisher (Infectious Disease
Division, Department of Medicine, National University Health System, Singapore), Fernanda C. Lessa (US Centers for Disease Control
and Prevention, United States of America), Kushlani Jayatilleke (Sri Jayewardenepura General Hospital, Nugegoda, Sri Lanka, Sri
Lanka), Souha Kanj (American University of Beirut Medical Center, Lebanon), Daniele Lantagne (Tufts University, United States of
America), Anna Levin (University of São Paulo, Hospital das Clinicas, FM-USP, Brazil), Yuguo Li (Department of Mechanical
Engineering, The University of Hong Kong, Hong Kong Special Administrative Region (Hong Kong SAR)), Moi Lin Ling (Singapore
General Hospital, SingHealth, Singapore), Caline Mattar (Division of Infectious Diseases, Washington University in St Louis (WUSTL),
United States of America), Mary-Louise McLaws (Honorary clinical Epidemiology – University of New South Wales, Australia), Geeta
Mehta (Journal of Patient Safety and Infection Control, India), Shaheen Mehtar (Infection Control Africa Network, South Africa), Ziad
Memish (Ministry of Health of Saudi Arabia, Kingdom of Saudi Arabia), Tochi Okwor (Nigeria Centre for Disease Control,
Nigeria), Mauro Orsini (Ministry of Health of Chile, Chile), Diamantis Plachouras (European Centre for Disease Prevention and Control,
Sweden), Mathias W Pletz (Institute for Infectious Diseases and Infection Control of the University Hospital of the Friedrich Schiller
University, Germany), Marina Salvadori (Public Health Agency of Canada, Canada ), Ingrid Schoeman (TB Proof, South Africa – Civil
Society Representative), Mitchell Schwaber (Ministry of Health of Israel, Israel), Mark Sobsey (University of North Carolina and
Aquagenx, LLC, United States of America), Paul Ananth Tambyah (National University of Singapore, Singapore), Walter Zingg (Clinic
for Infectious Diseases and Hospital Epidemiology, Zurich University Hospital, Zurich, Switzerland).
Declaration of conflicts of interest

Researchers may be eligible to sit on GDGs. However, the participation of researchers who have been involved in any “major
academic programme of work that concerns the intervention, approach, or exposure under consideration in the guideline, including
conducting trials or systematic reviews and publishing conclusions or opinion on the benefits and/or harms” should be carefully
considered and managed by the Responsible Technical Officer and director of the relevant technical unit. In most cases, such
involvement would constitute a conflict of interest, and should be appropriately managed by limiting their participation in the process
147 of 209
(i.e. provide specific information but be excluded from the formulation of recommendations and/or discussion), or if significant interests
are identified, full recusal. As an observer, a member can follow the discussions and may be permitted by the Chair to speak and/or to
respond to technical questions the other GDG members may have.
Disclosures of interests and any required actions were reviewed by the WHO Secretariat in consultation with the WHO Ethics Office,
prior to deliberations. The following conflicts of interest were reviewed and managed accordingly:
Dr J. Conly is an author of a randomized controlled trial used as one piece of evidence to determine the type of mask to use while
caring for a suspected or confirmed COVID-19 patient. Given his role as a researcher, he has recused himself from discussions and
development of the recommendation for health and care workers on masks and respirator use.
Dr Y. Li is an author involved in various research studies and in particular opinion papers concerning the use of N95 and medical
masks. His participation was restricted to observing the GDG meeting on this topic without being involved in the discussion and/or
formulation of recommendations.
Dr T. Okwor partook as a member of the rapid review team for the reviews on cleaning and disinfection in the community. Dr. Okwor
recused themselves from the decision-making process.
Methodologist
Roger Chou (Methodologist, Department of Medicine and Department of Medical Informatics and Clinical Epidemiology, Oregon Health
& Science University, United States of America).

Dr R. Chou is an author on some of the evidence used to inform some recommendations. However, as a methodologist, he provided
guidance to the GDG on methodologic issues and is not a voting member of the GDG. In some meetings, he presented evidence and
provided clarification on methods to guide discussions regarding the EtD tables; however, all decisions were made by voting members
of the GDG.
External reviewers (alphabetically)

Anita Desai (Department of Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India), Kalisavar
Marimuthu, (National Centre for Infectious Diseases, Singapore Yong Loo Lin School of Medicine, National University of Singapore,
Singapore), Rima Moghnieh (Lebanese American University, Lebanon), Folasade Ogunsola (University of Lagos, Nigeria), Nalini Singh
(Department of Global Health, The Milken Institute School of Public Health, George Washington University).
Declarations of interest of external reviewers were collected and assessed, and no conflict of interest was identified for these thematic
areas.
Editor
Many thanks to Tom Watkins for editing this document.
5.2 Part 2: Mitigation measures in the community authorship, acknowledgements and

contributions
5.2.1 Mitigation measures in the community authorship, acknowledgements and

contributors
Authorship, contributions and acknowledgements
WHO would like to thank the collaborative efforts of all those involved to make this process rapid, efficient, trustworthy and
transparent.
WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Secretariat (alphabetically)
Benedetta Allegranzi (WHO/HQ), April Baller (WHO/HQ), Kathy Dunn (WHO/HQ), Nathan Ford (WHO/HQ), Hannah Hamilton
(WHO/HQ), João Paulo Toledo (WHO/HQ).
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WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Steering Group (alphabetically)
Lisa Askie (WHO/HQ), Anshu Banerjee (WHO/HQ), Adriana Velazquez Berumen (WHO/HQ), Astrid Lydia Chojnacki (WPRO),
Landry Kabego Cihambanya (AFRO), Jennifer Collins (EURO), Giorgio Cometto (WHO/HQ), Janet Victoria Diaz (WHO/HQ),
Sergey Eremin (WHO/HQ), Dennis Falzon (WHO/HQ), Luca Fontana (WHO/HQ), Melinda Frost (WHO/HQ), Bruce Allan Gordon
(WHO/HQ), Iman Heweidy (EMRO), Maha Talaat Ismail (EMRO), Ivan Dimov Ivanov (WHO/HQ), Kathryn Johnston (PAHO), Ying
Ling Lin (WHO/HQ), Tendai Makamure (AFRO), Madison Moon (WHO/HQ), Leandro Pecchia (WHO/HQ), Mark Perkins (WHO/
HQ), Ana Paula Coutinho Rehse (EURO), Nahoko Shindo (WHO/HQ), Alice Simniceanu (WHO/HQ), Aparna Singh Shah
(SEARO), Valeska Stempliuk (PAHO), Maria Van Kerkhove (WHO/HQ) Victoria Willet (WHO/HQ),
UNICEF Observers
Nagwa Hasanin (UNICEF), Raoul Kamadjeu (UNICEF), Pierre-Yves Oger (UNICEF).
WHO Health Emergencies Programme COVID-19 Infection Prevention and Control Guideline Development Group
(alphabetically)
Yewande Alimi (Africa Centres for Disease Control and Prevention, Ethiopia), Jameela Al-Salman (Ministry of Health of Bahrain,
Bahrain), Baba Aye (Public Services International, France – Civil Society Representative), Hanene Tiouiri Benaissa (Ministry of
Health of Tunisia, Tunisia), May C. Chu (Colorado School of Public Health, Center for Global Health, United States of America),
John Conly (Cumming School of Medicine, University of Calgary, Canada), Barry David Cookson (Division of lnfection and
lmmunity, University College London, United Kingdom of Great Britain and Northern Ireland), Nizam Damani (Sindh Institute of
Urology and Transplant Centre, Karachi, Pakistan (Dow University of Health Sciences, Pakistan), United Kingdom), Dale Fisher
(Infectious Disease Division, Department of Medicine, National University Health System, Singapore), Fernanda C. Lessa (US
Centers for Disease Control and Prevention, United States of America), Mohammad Mushtuq Husain (Institute of Epidemiology
Disease Control and Research (IEDCR), Bangladesh), Kushlani Jayatilleke (Sri Jayewardenepura General Hospital, Nugegoda, Sri
Lanka, Sri Lanka), Souha Kanj (American University of Beirut Medical Center, Lebanon), Daniele Lantagne (Tufts University,
United States of America), Anna Levin (University of São Paulo, Hospital das Clinicas, FM-USP, Brazil), Yuguo Li (Department of
Mechanical Engineering, The University of Hong Kong, Hong Kong Special Administrative Region (Hong Kong SAR)), Moi Lin Ling
(Singapore General Hospital, SingHealth, Singapore), Caline Mattar (Division of Infectious Diseases, Washington University in St
Louis (WUSTL), United States of America), Mary-Louise McLaws (Honorary clinical Epidemiology – University of New South
Wales, Australia), Geeta Mehta (Journal of Patient Safety and Infection Control, India), Shaheen Mehtar (Infection Control Africa
Network, South Africa), Ziad Memish (Ministry of Health of Saudi Arabia, Kingdom of Saudi Arabia), Tochi Okwor (Nigeria Centre
for Disease Control, Nigeria), Diamantis Plachouras (European Centre for Disease Prevention and Control (ECDC), Sweden),
Mathias W Pletz (Institute for Infectious Diseases and Infection Control of the University Hospital of the Friedrich Schiller University,
Germany), Marina Salvadori (Public Health Agency of Canada, Canada), Ingrid Schoeman (TB Proof, South Africa – Civil Society
Representative), Mitchell Schwaber (Ministry of Health of Israel, Israel), Mark Sobsey (University of North Carolina and Aquagenx,
LLC, United States of America), Paul Ananth Tambyah (National University of Singapore, Singapore), Walter Zingg (Clinic for
Infectious Diseases and Hospital Epidemiology, Zurich University Hospital, Zurich, Switzerland).
Methodologist
Roger Chou (Methodologist, Department of Medicine and Department of Medical Informatics and Clinical Epidemiology, Oregon
Health & Science University, United States of America)

Dr R. Chou is an author on some of the evidence used to inform some recommendations. However, as a methodologist, he
provided guidance to the GDG on methodologic issues and is not a voting member of the GDG. In some meetings, he presented
evidence and provided clarification on methods to guide discussions regarding the EtD tables; however, all decisions were made
by voting members of the GDG.
External reviewers (alphabetically)

Paul Hunter (University of East Anglia, United Kingdom), Mark Loeb (McMaster University, Canada), Nalini Singh (Department of
Global Health, The Milken Institute School of Public Health, George Washington University)
Declarations of interest of external reviewers were collected and assessed, and no conflict of interest was identified.
Editor
Many thanks to Tom Watkins for editing this document.
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5.2.2 Mask use by children authorship, acknowledgements and contributors

The WHO Health Emergencies Programme and UNICEF Joint Steering group for Masks for Children in the context of
COVID-19 (for the update on masks for children, in alphabetical order)
Benedetta Allegranzi (WHO/HQ), April Baller (WHO/HQ), Valentine Baltag (WHO/HQ), Anshu Banerjee (WHO/HQ), Anne Detjen
(UNICEF), Marjam Esmail (UNICEF), Nathan Ford (WHO/HQ), Hannah Hamilton (WHO/HQ), Nagwa Hasanin (UNICEF), Raoul
Kamadjeu (UNICEF), Sarah Karmin (UNICEF), Jerome Pfaffmann (UNICEF), Emma Sacks (UNICEF), Wilson Were (WHO/HQ),
Victoria Willet (WHO/HQ).
The joint WHO-UNICEF Guideline Development Group for Masks for children in the context of COVID-19 (in alphabetical
order)
Yewande Alimi (Africa CDC, Ethiopia), Jameela Alsalman (Ministry of Health, Bahrain), Shelina Bhamani (Aga Khan University,
Pakistan), Katherine Holland (Perkins International, United States of America– Civil Society Representative), Kushlani Jayatilleke
(Sri Jayewardenapura General Hospital, Sri Lanka), Roberta Petrucci (Médecins Sans Frontières (MSF), Geneva, Switzerland),
Mathias Pletz (Jena University Hospital/Friedrich-Schiller-University, The Netherlands), Fiona Russell (Department of Paediatrics,
The University of Melbourne, Australia), Marina Salvadori (Public Health Agency of Canada, Canada), Paul Anath Tambyah
(National University Hospital, Singapore), Russell M. Viner (Faculty of Population Health Sciences, University College London and
Royal College of Pediatrics and Child Health, United Kingdom), Heather Zar (School of Child and Adolescent Health at the
University of Cape Town (UCT), South Africa).
Methodologist
Roger Chou (Methodologist, Department of Medicine and Department of Medical Informatics and Clinical Epidemiology, Oregon
Health & Science University, United States of America)

R. Chou is an author on some of the evidence used to inform some recommendations. However, as a methodologist, he provided
guidance to the GDG on methodologic issues and is not a voting member of the GDG. In some meetings, he presented evidence
and provided clarification on methods to guide discussions regarding the EtD tables; however, all decisions were made by voting
members of the GDG.
Temporary Advisor
Dr Fernanda C. Lessa (US Centers for Disease Control and Prevention, United States of America).

Dr F. Lessa reported she is an employee of the United States CDC who provided funding towards the development of this
guideline. After consulting with the WHO Ethics Committee, it was determined Dr Lessa could contribute to discussions as she
brings significant technical and field expertise to the discussions but would be recused from voting on recommendations.
External reviewers (for the update on mask use by children, in alphabetical order)
Zulfiqar A. Bhutta, Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada and Center of Excellence In
Women and Child Health, The Aga Khan University Karachi, Pakistan, Jon Klein, University of Illinois, United States of America,
Shamez Ladhani, St. George’s University of London, United Kingdom, Erin Maughan, College of Health and Human Services,
George Mason University, United States of America, Nina Schwalbe, Columbia University, United States of America
Declarations of conflicts of interest

• J. Klein reported receipt of a grant from the International Pediatric Association and UNICEF for contribution of child health and
COVID-19 information to pediatric societies. No actions were required.
• E. Maughan reported she is also a member of the WHO Technical Advisory Group of Experts on Educational Institutions and
COVID-19. No actions were required.
• Professor F. Russell declared receipt of funds for research to study school outbreak data and develop mitigation strategies for
return to school from the Department of Health, Victoria. No actions were required.
WHO and UNICEF reviewers (for the update on mask use by children, in alphabetical order)
Ida Marie Ameda (UNICEF), Astrid Chojnacki (WHO-WPR), Landry Cihambanya (WHO-AFR), Delphine Sauvageot (UNICEF),
Aparna Singh Shah (WHO-SEAR), Howard Sobel (WHO-WPR), Valeska Stempliuk (WHO-AMR), Maha Talaat (WHO-EMR),
Bassim Zayed, (WHO-EMR).
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5.3 Systematic review teams

Cochrane Nigeria
Wunmi Adaramoye, David Akeju, Ememobong Aquaisua, Ingrid Arevalo-Rodriguez, Dachi Arikpo, Iwara Arikpo, Obasesam Arikpo Ikpi,
Marcel Ashima Otonkue, Osamagbe Asemota, Glory Bassey, Segun Bello, Moses Bernard, Grahan Chan, Moriam Chibuzor,
Nkwachukwu Chukwu, Elise Cogo, Chukwuemelie Ebere Chisom, Josephine Egbung, Abiodun Egwuenu, John Ehiri, Emmanuel Effa,
Olughu Ella Ezinne, Grace Esebanmen, Ekpereonne Esu, Atana Ewa, Chisom Ezema, Nicholas Henschke, Ehimario Igumbor,
Freedman Ita-Lincoln, Francis Iwomi, Ugo James Agbor, Aruk Johnson Eteng, Ekinya I. Mboto, Anne Meremikwu, Chiamaka
Meremikwu, Chibuike Meremikwu, Chibu Meremikwu, Joshua Meremikwu, Kelechi Meremikwu, Martin Meremikwu, Chioma
Moses, Veronica Moses Barde, Joshua Mwankon, Gadaya Muzzammil, Deborah Ndukwu, Anthony Nlemadim, Okoh Nneoma Petra-
Favour, Nuria Nwachuku, Ogonna Nwankwo, Eleanor Ochodo, Chinwe Ochu, Friday Odey, Olabisi Oduwole, Edward Ogar Odey,
Cornelius Ohonsi, Eghosa Ohenhen, Hope Okebalama, Ezinne Okebe, Joseph Okebe, Enembe Okokon, Ita Okokon, Uduak
Okomo, Anthony Okoro, Tochi Okwor, Affiong Oku, David Olatunji, Patience Omang Idiege, Temitope Omotosho, Augustina Onyema,
Peter Onyenemerem, Sidney Opara, Chukwudi Oringanje, Mavis Otonkue, Babasola Okusanya, Faithman Ovat, Angela Oyo-Ita,
Funmi Siyanbade, Samuel Shoyinka, Helen Smith, Ekong Udoh, Ubong Udoh, Alice Uzuta Abuh, Gemma Villanueva.
Rapid Research Evaluation and Appraisal Lab (RREAL) at University College London
Megan Bowers, Sigrun Clark, Ailey McLeod, Lucy Mitchinson, Sophie Moniz, Thomas Moniz, Norha Vera San Juan, Gianna Cadorna,
Monica Gonzalez, Amelia Karia, Federico Redin, Roberto Wright, Matthew Bain, Cecilia Vindrola-Padros.
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6. Annexes
6.1 Annex 1: Research Gaps

The recommendations in this guideline are based on the scientific evidence available at the time of publication; however, limitations in
the quality of studies and persistent research gaps were recognized by the GDG when formulating the recommendations. These
limitations included the cost and resource implications of interventions to reduce transmission of SARS-CoV-2, and the social and
cultural factors that influence compliance with the application of interventions.
The GDG noted that a number of research gaps for COVID-19 are ongoing and relevant to IPC practices in general. For example, the
lack of high-quality research on several facets of the transmission of acute respiratory infections (ARIs) and the effectiveness of
interventions to reduce transmission were described in the 2014 WHO guideline Infection prevention and control of epidemic-and
pandemic prone acute respiratory infections in health care [8].
Specific research gaps identified in 2014 include:
• Transmission in health-care and community settings, and effectiveness of interventions to reduce transmission
• Aerosol-generating procedures (AGPs) and transmission from patients to health-care workers during procedures
• Epidemiology of transmission of specific ARIs from patients to health-care workers, and to other patients, during care delivery in
health-care settings
• The use of specific precautions, triage and early identification, spatial separation with the use of other selected precautions
• The duration of additional IPC precautions for patients with ARIs in health-care settings to reduce the risk of transmission to other
patients and to health-care workers, including use of laboratory tests as a guide
• Placement of patients, cohorting and other measures to separate potentially infectious patients, for the reduction of transmission
of ARI pathogens
• Cost and resource implications in different settings around the world
• Other interventions, innovative technologies and cost-effective measures
• Need for high-quality studies
While COVID-19 will remain a critical area for future research, the need for high-quality studies and broadening recommendations to
other respiratory pathogens was discussed. Furthermore, GDG members noted that many of the gaps highlighted in the 2014 guideline
still persist. Research is needed to further investigate IPC interventions in the context of public health emergencies, readiness,
outbreak management and pandemic response. There is a need for high-quality studies utilizing various methodologies (e.g. modeling
or laboratory-based) and study types (e.g. RCTs). IPC practices are often implemented as a bundled approach and, therefore, it is
difficult to separate and define the impact of individual measures.
The following themes were identified as areas for future study by the COVID-19 GDG:
• Management of health and care workers in the context of COVID-19 and other respiratory infections (i.e. period of isolation,
impact of syndromic surveillance and testing protocols for detection and management of occupational infections);
• PPE innovation, interventions to improve fit and effectiveness;
• Ventilation standards in health-care settings to effectively reduce the risk of SARS-CoV-2 transmission; effectiveness of air
cleaning and purifier technologies;
• Aerosol-generating procedures (AGPs);
• Environmental cleaning and disinfection practices, products and technologies that require further study (i.e. UVGI, environmental
sampling, application of products, effectiveness, adverse effects, harms and benefits);
• Use of physical barriers in health-care and community settings (i.e. Impact, design, ventilation, potential harms);
• Physical distancing and other interventions to reduce and mitigate transmission;
• Implementation science, behavioural factors and social science (e.g. human) factors to improve understanding of factors that
influence application of IPC practices;
• Context of IPC practices in low-resource settings, and considerations across all settings where health care is delivered.
The COVID-19 pandemic has been at the centre of WHO’s research endeavours. The Global Research and Innovation Forum
(GRIF) - COVID-19 and beyond builds on lessons learned from COVID-19 to identify and support research priorities [234]. The
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COVID-19 pandemic saw an augmented and integrated research response, which helped accelerate the testing of vaccines,
treatments and diagnostics, but also underpinned public policy, regulatory and communications initiatives to tackle the spread of
disease and reduce its health and social harms.
For IPC, research areas identified include:
• Understanding risk factors in exposures to SARS-CoV-2 and other pathogens in the health-care work environment;
• Rethinking existing IPC medical devices and equipment based on key enabling technologies;
• Defining pragmatic protocols for guiding local implementers in executing safe and effective IPC practices;
• Working with laboratory experts to bridge knowledge gaps on how to deactivate novel pathogens;
• Establishing research and innovation (RI) priorities that should be brought to the attention of the international community.
The COVID-19 pandemic highlighted the critical role of IPC for protection and control in the context of public health emergencies due
to novel high-threat pathogens of epidemiologic concern. The identification of research gaps is useful in planning and conducting future
studies in areas relevant to COVID-19 and other ARIs; in the evaluation of IPC interventions and outcomes to reduce the transmission
of infections in health-care settings; and in the implementation of mitigation measures in the community.
6.2 Annex 2. Evidence tables for mask use in the community

This section contains a table highlighting the application of GRADE to the available literature reviewed for mask use in community
settings.
Table 2.1 GRADE table for assessment of mask use versus no mask use in the community setting
Outcome SARS-CoV-2 infection
Number and type of 2 RCTs [137][138]and 10 observational studies [139][140][141][142][143][144][145][146][147][148].

studies
Study limitations Serious
Consistency No serious inconsistency
Precision No serious imprecisions*
Directness Direct
Strength of evidence Low-to-moderate
Main findings 2 RCTs: adjusted prevalence ratio 0.90 (95% CI 0.82 to 0.995) for symptomatic SARS-CoV-2
seroprevalence and OR 0.82 (95% CI 0.52 to 1.23) for SARS-CoV-2 infection;
10 observational studies: OR/HR/RR estimates ranged from 0.04 to 0.86 in 8

studies [139][140][141][142][143][144][145][146][147][148];
One additional study of health workers reported an imprecise estimate for mask use outside work (yes vs
no; OR 2.35; 95% CI 0.67 to 8.25) [147] and one study found mask use in a household with an index case of
SARS-CoV-2 infection associated with a decreased risk of secondary infection of family members (all family
members using masks all the time vs no family members [OR 0.20; 95% CI 0.07 to 0.60])[148].
RCT, randomized controlled trial; OR, odds ratio; HR, hazard ratio; RR, relative risk; CI, confidence interval.
*The RCTs had methodological limitations, including open-label design, attrition, incomplete outcome assessment, variable adherence
and differential recruitment. The RCTs were consistent and were not downgraded for imprecision (due to the very large total sample
size [greatly exceeding any optimum information size threshold] with a precise estimate from one of the trials). One trial evaluated a
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mask recommendation directly; although the other evaluated a mask promotion intervention and did not evaluate mask use or a mask
recommendation directly, this resulted in suboptimal uptake of mask use and would underestimate the effects of mask use. Therefore,
the RCTs were not downgraded for indirectness.
6.3 Annex 3. Evidence tables for mask use by children

This section contains two tables highlighting the application of GRADE to available literature reviewed for mask use by children.
Table 3.1. GRADE table for assessment of masks versus no mask use in community settings
Outcome SARS-CoV-2 infection
Number and type of studies 2 RCT and 3 observational studies [140][147][148][137][138]
Consistently Moderate
Precision Some imprecision*
Directness Some indirectness*
Strength of evidence Low-to-moderate
RCT1 (cluster): Mask promotion intervention associated with increased mask use and
decreased risk of symptomatic SARS-CoV-2 seroprevalence; adjusted prevalence ratio of
0.91, 95% CI 0.82 to 1.00 [137].
RCT 2: OR 0.82, 95% CI 0.52 to 1.23 [138]

Main findings
Two observational studies reported inconsistent and imprecise estimates for mask use vs no
mask use in community settings outside the home [147][148]. One observational study found
mask use by all members of a household or prior to index case illness onset associated with
decreased risk of secondary infection vs no mask use [140].
Note: All studies were conducted in settings without widespread Delta variant. Also, ecological studies were not included in this table
but they consistently found that policies requiring masks were associated with decreased risk of SARS-CoV-2 infection.
*Of two RCTs, one reported an imprecise estimate while the other evaluated an indirect intervention (mask promotion).
Table 3.2 GRADE assessment of observational and ecological studies on mask effectiveness
Influenza
Adult Studies Ecological Studies
Studies
SARS-CoV-2
Outcome SAR-CoV-2 infection SARS-CoV-2 infection
infection
1
RCT [167]and
Number of 2 RCTs and 3 observational
13 [208][209][210][211][212][213][214][215][216][217][223][225][226]. 1
studies studies [140][147][148][137][138]
observational
study [170].
Risk of bias Moderate High 2 Moderate
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Consistency Consistent Consistent Consistent
Some
Precision Some imprecision Some imprecision
imprecision 4
Serious
Directness Serious indirectness 1 Serious indirectness 3
indirectness 5
Strength of
Low Very low Very Low
evidence
1 Different population, adult evidence strength rated as moderate. Rated down 1 for children.
2 Studies did not control for the effect of concurrent interventions.
3 Different interventions. Studies did not assess actual mask-wearing or adherence to the intervention.
4 RCT outcomes had wide confidence intervals (0.31 - 0.087).
5 Different outcomes were measured. Different population. RCT was a cluster household trial including adults and children. Differences in the intervention: RCT
randomized households to face masks plus “enhanced hand hygiene” (educational materials provided).
6.4 Annex 4. Systematic review for prevention, identification, management of COVID-19

in health and care workers
PICO Questions
The PICO questions included in this systematic review were:
1. Should health and care workers be tested following a high-risk exposure to SARS-CoV-2?
2. Should routine testing of asymptomatic health and care workers for COVID-19 surveillance be conducted?
3. Should health and care workers who have had a positive test or have indication of active SARS-CoV-2 infection be
excluded from work (isolate in designated setting) versus continue to work?
4. What should be the duration of exclusion from work/isolation for health and care workers (infectious period)?
Q1. Should health workers be tested following a high-risk exposure to SARS-CoV-2?

Setting Health-care facilities
Defining high-risk exposures (breaches in PPE, inappropriate PPE)
Background
interventions Review evidence to determine if testing is still needed
Population Health workers

Intervention Continue with normal duties (no testing) or proceed to quarantine
Not being tested and continuing to provide care
• NB To compare groups, there would need to be some metric reported of positive

Comparator(s)
testing, either detected by the testing intervention protocol, or health workers
calling in sick, or reporting a positive home test.
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Infection with SARS-CoV-2 following an exposure
• Suggest reporting findings in the manner of Blazeby et al.

Outcome 2021 https://www.comet-initiative.org/Studies/Details/1594) and possibly also
including (if available) severity of disease, missed days from work/ loss of
income/ staffing shortages).
Potential effect
As above
modifiers
Q2. Should routine testing of asymptomatic health workers for COVID-19 surveillance be conducted?
Background
Standard of care
interventions
Periodic testing of health workers (at what intervals, and in what type of
Intervention
transmission scenario (community, or sporadic, low case risk)?)
Testing according to need when a known exposure occurs, or when
Comparator(s)
symptomatic
Percentage of study population testing positive by PCR compared to the
Outcome
percentage with self-reported infection
Potential effect
As above
modifiers
Q3. Should health workers who have had a positive test or have indication of SARS-CoV-2 infection be
excluded from work (isolate in designated setting) versus continue to work?
Sub-question: what should be the duration of exclusion from work/isolation for health workers
(infectious period)?

Background
Current standard of care
interventions
Intervention Excused from work (for X days)
Comparator(s) Continue with normal duties (no work exclusion)
Reduction in secondary transmission from infected health workers in specific
Outcome
facilities
Potential effect
As above
modifiers
Q4. What should be the duration of exclusion from work/isolation for health workers (infectious
period)?
Sub question: symptomatic versus asymptomatic (different types of symptoms reporting and testing
to be considered)?
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Sub question: test versus no test?

Background
Standards of care
interventions
Intervention Returning to work after SARS-CoV-2 infection recovery
Comparator(s) 10+3 days is current guidance
Infectious period of SARS-CoV-2 (we can draw from literature, which was
Outcome
included in the evidence for the contact-tracing guidance update)
Potential effect
As above
modifiers
Search terms
"health personnel"~3 OR "healthcare personnel"~3 OR "health provider"~3 OR "health providers"~3 OR "healthcare provider"~3 OR
"healthcare providers"~3 OR "health worker"~3 OR "health workers"~3 OR "healthcare worker"~3 OR "healthcare workers"~3 OR
"health proffessional"~3 OR "health proffesionals"~3 OR "healthcare professional"~3 OR "healthcare professionals"~3 OR "healthcare
staff" OR "health care staff" OR "healthcare staffs" OR "health care staffs" OR "health workforce"~3 OR "healthcare assistant" OR
"healthcare assistants" OR "health assistant"~3 OR "health assistants"~3 OR "Community Health Aides" OR "Community Health Aide"
OR "Family Planning Personnel" OR "Village Health Workers" OR "Village Health Worker" OR "Barefoot Doctors" OR "Barefoot
Doctor" OR "Family Planning Personnel" OR "Dental Auxiliary" OR "Dental Receptionist" OR "Dental Receptionists" OR "Dental
hygienist" OR "Dental hygienists" OR "Emergency Medicine Technicians" OR "Emergency Medicine Technician" OR Paramedic* OR
"Emergency Medical Technician" OR "Emergency Medical Technicians" OR "Home Health Aide" OR "Home Health Aides" OR "Home
Care Aides" OR "Home Care Aide" OR "care home staff"~3 OR nurse* OR "advanced practice provider" OR "advanced practice
providers" OR "Nursing Assistant" OR "Nurses' Aides" OR "Nurse's Aides" OR "Nurses Aides" OR "Nurses' Aide" OR "Nursing
Auxiliaries" OR "Nursing Auxiliary" OR "Nurse Aide" OR "Nurse Aides" OR "Operating Room Technician" OR "Operating Room
Technicians" OR "surgical technician" OR "Surgical technicians" OR "Scrub technicians" OR "Scrub Technician" OR "Surgical staff" OR
"Surgical staffs" OR "Pharmacy Technician" OR "Pharmacists' Aides" OR "Pharmacist Aides" OR "Pharmacist's Aides" OR
"Pharmacists Aides" OR "Pharmacists' Aide" OR "Physical Therapist Assistant" OR "Physical Therapy Assistants" OR "Physical
Therapy Assistant" OR "Doctor's Assistant" OR "Doctor Assistant" OR "Doctors Assistant" OR "Physicians' Extender" OR "Physician
Extender" OR "Physician's Extender" OR "Physicians Extender" OR "Physicians' Extenders" OR "Physician Extenders" OR
"Physician's Extenders" OR "Doctor's Assistants" OR "Doctor Assistants" OR "Physicians' Assistants" OR "Physician's Assistants" OR
"Physicians Assistants" OR "Physicians' Assistant" OR "Physician Assistant" OR Feldsher* OR Anesthesiologist* OR anesthetist* OR
"Anaesthesiology assistant" OR perfusionist* OR Caregiver* OR Carer* OR "Care Givers" OR "Care Giver" OR "Case Manager" OR
"Case Managers" OR "Care Manager" OR "Care Managers" OR Coroner* OR "Medical Examiner" OR "Medical Examiners" OR
"mortuary staff" OR mortition* OR "autopsy technician" OR "autopsy technicians" OR "Dental Staff" OR "Dental staffs" OR "dental
practitioner" OR "dental practitioners" OR Dentist* OR *dontist* OR "Dentofacial Orthopedists" OR "Dentofacial Orthopedist" OR
Doula* OR "Labor Coaches" OR "Labor Coach" OR "Labour Coach" OR "Labour Coaches" OR Midwife OR Midwives OR "Maternity
staff" OR "Maternity Staffs" OR "Emergency Medical Dispatchers" OR "911 Dispatcher" OR "911 Dispatchers" OR "9-1-1 Dispatcher"
OR "9 1 1 Dispatcher" OR "9-1-1 Dispatchers" OR "Emergency dispatcher" OR "Emergency dispatchers" OR Epidemiologist* OR
"Dental Faculty" OR "Dental Faculties" OR "Medical Faculties" OR "Medical Faculty" OR "Nursing Faculties" OR "Nursing Faculty" OR
"Health Educator" OR "Health Educators" OR "Health Facility Administrator" OR "Health Facility Administrators" OR "Hospital
Administrator" OR "Hospital Administrators" OR "Infection Control Practitioner"~3 OR "Infection Control Practitioners"~3 OR "infection
prevention staff"~3 OR "infection prevention staffs"~3 OR "Laboratory Personnels" OR "Laboratory Personnel" OR "Laboratory
Scientists" OR "Laboratory Scientist" OR "Medical Technologists" OR "Medical Technologist" OR "Laboratory Technicians" OR
"Laboratory Technician" OR "Laboratory Assistants" OR "Laboratory Assistant" OR microbiologist* OR "Medical Staff" OR "Medical
Staffs" OR "medical personnel" OR "medical practitioner" OR "Medical practitioners" OR Physician* OR "Hospital Registrar" OR
"Hospital Registrars" OR "hospital staff" OR "hospital staffs" OR "hospital Personnel" OR nurse* OR "nursing personnel" OR "Patient
tehnician"~3 OR "Emergency room Technician" OR "Emergency department technician" OR "Health Visitors" OR "Health Visitor" OR
"nursing staff" OR "nursing staffs" OR "Occupational Therapist" OR "Occupational Therapists" OR Pathologist* OR Optometrist* OR
"Hospital Administrator" OR "Hospital Administrators" OR "Hospital Volunteer" OR "Hospital Volunteers" OR pharmacist* OR "Physical
Therapist" OR "Physical Therapists" OR Physiotherapist* OR physician* OR doctor* OR Allergist* OR immunologist* OR
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Anesthesiologist* OR Cardiologist* OR Dermatologist* OR Endocrinologist* OR "Medical Graduate" OR "Medical Graduates" OR

"Medical resident" OR "Medical residents" "Medical students" OR "medical student" OR "Gastroenterologist" OR "Hepatologists" OR
"Hepatologist" OR "General Practitioner" OR "General Practitioners" OR "Medical Practioner"~2 OR "Medical Practioners"~2 OR
"Geriatrician" OR "Gerontologists" OR "Gerontologist" OR *Gynecologist* OR Obstetrician* OR *Gynaecologist* OR Hospitalist* OR
internisit OR internist OR internists OR Intensivist* OR Nephrologist* OR Neurologist* OR Haematologist* OR hematologist* OR
Oncologist* OR Opthalmologist* OR Optometrist* OR Osteopath* OR Otolaryngologist* OR Otologist* Or rhinologist* "ENT specialist"
OR Pathologist* OR "Pathology assistant" OR "Pathology Assistant" OR Pediatrician* OR Neonatologist* OR Physiatrist* OR
Podiatrist* OR Toxicologist* OR Pulmonologist* OR Radiologist* OR Rheumatologist* OR *Surgeon* OR Orthopedist* OR exodontist*
OR Urologist* OR Psychotherapist* OR psychologist* OR *Therapist* OR "Social workers" OR "Social Workers" OR healer* OR
"practitioners medicine"~3 OR "Respiratory technician" OR Radiographer* OR "radiology technician" OR "MRI technician" OR
sonographer*
Search output using health worker terms

Results
# Search (review MESH results(all)
filter)
"health personnel"~3 OR
"healthcare personnel"~3 OR
"health provider"~3 OR "health
providers"~3 OR "healthcare
provider"~3 OR "healthcare
providers"~3 OR "health worker"~3
OR "health workers"~3 OR
"healthcare worker"~3 OR
1 2107 Health Personnel 30 865
"healthcare workers"~3 OR "health
proffessional"~3 OR "health
proffesionals"~3 OR "healthcare
professional"~3 OR "healthcare
professionals"~3 OR "healthcare
staff" OR "health care staff" OR
"healthcare staffs" OR "health care
staffs" OR "health workforce"~3
"healthcare assistant" OR
"healthcare assistants" OR "health
2 55 Allied health professional 1751
assistant"~3 OR "health
assistants"~3 OR paramedic*
"Community Health Aides" OR
"Community Health Aide" OR
"Family Planning Personnel" OR
"Village Health Workers" OR
4 7 Community Health Workers
"Village Health Worker" OR
"Barefoot Doctors" OR "Barefoot
Doctor" OR "Family Planning
Personnel"
"Dental Auxiliary" OR "Dental
Receptionist" OR "Dental
5 0 Dental Auxiliaries 11
Receptionists" OR "Dental
hygienist" OR "Dental hygienists"
158 of 209
"Emergency Medicine Technicians"

OR "Emergency Medicine
Technician" OR Paramedic* OR
6 1 Emergency Medical Technicians 29
"Emergency Medical Technician"
OR "Emergency Medical
Technicians"
"Home Health Aide" OR "Home
Health Aides" OR "Home Care
7 0 Home Health Aides 25
Aides" OR "Home Care Aide" OR
"care home staff"~3
nurse* OR "advanced practice
8 provider" OR "advanced practice 513 Licensed Practical Nurses 11 176
providers"
"Nursing Assistant" OR "Nurses'
Aides" OR "Nurse's Aides" OR
"Nurses Aides" OR "Nurses' Aide"
9 2 Nursing Assistants
OR "Nursing Auxiliaries" OR
"Nursing Auxiliary" OR "Nurse Aide"
OR "Nurse Aides"
"Operating Room Technician" OR
"Operating Room Technicians" OR
"surgical technician" OR "Surgical
10 0 Operating Room Technicians
technicians" OR "Scrub technicians"
OR "Scrub Technician" OR "Surgical
staff" OR "Surgical staffs"
"Pharmacy Technician" OR
"Pharmacists' Aides" OR
"Pharmacist Aides" OR
11 1 Pharmacy Technicians
"Pharmacist's Aides" OR
"Pharmacists Aides" OR
"Pharmacists' Aide"
"Physical Therapist Assistant" OR
12 "Physical Therapy Assistants" OR 0 Physical Therapist Assistants
"Physical Therapy Assistant"
"Doctor's Assistant" OR "Doctor
Assistant" OR "Doctors Assistant"
OR "Physicians' Extender" OR
"Physician Extender" OR
"Physician's Extender" OR
"Physicians Extender" OR
"Physicians' Extenders" OR
"Physician Extenders" OR
13 3 Physician Assistants
"Physician's Extenders" OR
"Doctor's Assistants" OR "Doctor
Assistants" OR "Physicians'
Assistants" OR "Physician's
Assistants" OR "Physicians
Assistants" OR "Physicians'
Assistant" OR "Physician Assistant"
OR Feldsher*
Anesthesiologist* OR anesthetist*
14 OR "Anaesthesiology assistant" OR 41 Anaesthetists
perfusionist*
159 of 209
Caregiver* OR Carer* OR "Care

17 306 Caregivers 5204
Givers" OR "Care Giver"
"Case Manager" OR "Case
18 Managers" OR "Care Manager" OR 1 Case Managers
"Care Managers"
Coroner* OR "Medical Examiner"
OR "Medical Examiners" OR
19 "mortuary staff" OR mortition* OR 0 Coroners and Medical Examiners
"autopsy technician" OR "autopsy
technicians"
"Dental Staff" OR "Dental staffs" OR
20 "dental practitioner" OR "dental 16 Dental Staff
practitioners"
21 Dentist* OR *dontist* 225 Dentists
"Dentofacial Orthopedists" OR
23 1 Orthodontists
"Dentofacial Orthopedist"
Doula* OR "Labor Coaches" OR
"Labor Coach" OR "Labour Coach"
24 OR "Labour Coaches" OR Midwife 0 Doulas
OR Midwives OR "Maternity staff"
OR "Maternity Staffs"
"Emergency Medical Dispatchers"
OR "911 Dispatcher" OR "911
Dispatchers" OR "9-1-1 Dispatcher"
25 OR "9 1 1 Dispatcher" OR "9-1-1 0 Emergency Medical Dispatcher
Dispatchers" OR "Emergency
dispatcher" OR "Emergency
dispatchers"
26 Epidemiologist* 31 Epidemiologists
"Dental Faculty" OR "Dental
27 0 Faculty, Dental
Faculties"
"Medical Faculties" OR "Medical
28 5 Faculty, Medical
Faculty"
"Nursing Faculties" OR "Nursing
29 Faculty, Nursing
Faculty"
"Health Educator" OR "Health
30 Health Educators
Educators"
"Health Facility Administrator" OR
31 1 Health Facility Administrators
"Health Facility Administrators"
"Hospital Administrator" OR
32 2 Hospital Administrators +
"Hospital Administrators"
"Infection Control Practitioner"~3
OR "Infection Control
33 Practitioners"~3 OR "infection 3 Infection Control Practitioners 45
prevention staff"~3 OR "infection
prevention staffs"~3
"Laboratory Personnels" OR
"Laboratory Personnel" OR
"Laboratory Scientists" OR
35 "Laboratory Scientist" OR "Medical Medical Laboratory Personnel
Technologists" OR "Medical
Technologist" OR "Laboratory
Technicians" OR "Laboratory
160 of 209
Technician" OR "Laboratory
Assistants" OR "Laboratory
Assistant" OR microbiologist*
"Medical Staff" OR "Medical Staffs"
OR "medical personnel" OR
36 210 Medical Staff 3828
"medical practitioner" OR "Medical
practitioners"
Physician* OR "Hospital Registrar"
OR "Hospital Registrars" OR Medical Staff, Hospital +; Personnel,
37 691 14 555
"hospital staff" OR "hospital staffs" Hospital
OR "hospital Personnel"
nurse* OR "nursing personnel" OR
"Patient tehnician"~3 OR
38 "Emergency room Technician" OR 486 Nurses
"Emergency department
technician"
42 "Health Visitors" OR "Health Visitor" 0 Nurses, Community Health
46 "nursing staff" OR "nursing staffs" 43 Nursing Staff
"Occupational Therapist" OR
49 "Occupational Therapists" OR 7 Occupational Therapists
Pathologist*
50 Optometrist* 0 Optometrists
"Hospital Administrator" OR
53 2 Hospital Administrators +
"Hospital Administrators"
"Hospital Volunteer" OR "Hospital
54 0 Hospital Volunteers
Volunteers"
56 pharmacist* 73 Nursing Staff, Hospital
"Physical Therapist" OR "Physical
58 34 Physical Therapists
Therapists" OR Physiotherapist*
60 physician* OR doctor* 903 Physicians 20 354
61 Allergist* OR immunologist* 11 Allergists
62 Anesthesiologist* 33 Anesthesiologists
63 Cardiologist* 12 Cardiologists
64 Dermatologist* 35 Dermatologists
65 Endocrinologist* 4 Endocrinologists
"Medical Graduate" OR "Medical
66 Graduates" OR "Medical students" 9 Foreign Medical Graduates
OR "medical student"
"Gastroenterologist" OR
67 3 Gastroenterologists
"Hepatologists" OR "Hepatologist"
"General Practitioner" OR "General
Practitioners" OR "Medical
68 46 General Practitioners 1132
Practioner"~2 OR "Medical
Practioners"~2
"Geriatrician" OR "Gerontologists"
69 3 Geriatricians
OR "Gerontologist"
*Gynecologist* OR Obstetrician* OR
*Gynaecologist*
Hospitalist* OR internisit OR
70 internist OR internists OR 4 Hospitalists
Intensivist*
161 of 209
71 Nephrologist* 13 Nephrologists
72 Neurologist* 32 Neurologists
Haematologist* OR hematologist*
74 Oncologist* 33 Oncologists +
75 Opthalmologist* OR Optometrist* 42 Ophthalmologists
76 Osteopath* 5 Osteopathic Physicians
Otolaryngologist* OR Otologist* Or
77 40 Otolaryngologists
rhinologist* "ENT specialist"
Pathologist* OR "Pathology
78 22 Pathologists
assistant" OR "Pathology Assistant"
79 Pediatrician* OR Neonatologist* 31 Pediatricians +
80 Physiatrist* OR Podiatrist* 1 Physiatrists
toxicologist*
84 Pulmonologist* 9 Pulmonologists
85 Radiologist* 40 Radiologists +
86 Rheumatologist* 27 Rheumatologists
*Surgeon* OR Orthopedist* OR
87 205 Surgeons +
exodontist*
88 Urologist* 34 Urologists
Psychotherapist* OR psychologist*
89 OR *Therapist* OR "Social workers" 5 Psychotherapists
OR "Social Workers"
healer* OR "practitioners
90 Practitioners of Traditional Medicine
medicine"~3
91 "Respiratory technician"
Radiographer* OR "radiology
92 technician" OR "MRI technician" OR Imaging
sonographer*
Stratification issues relevant to synthesizing and reporting the literature for

each question
Element Stratification issues
Setting Definition/description of health-care facilities (e.g. acute care hospitals – various units such as
ER, ICU, community care, primary care).
Risk stratification of infection potential in settings.
Population Health workers - suggest reporting findings in a manner similar to Nguyen et al (34).
Include all health workers in an overview, and then report by sub-groups to account for risks
within the facility.
Health worker demographics (age, gender, health status, etc.).
Stratification of health worker risk of infection by role, tasks and settings.
Potential effect Vaccination status, health worker’s health status, health worker settings and duties, health
modifiers worker knowledge about risk minimization, contact “dose” (amount of time spent in close
contact with potential source), dose-response risk of infection, circulation of variants of concern,
availability of PPE, correct use of PPE.
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Implementation • COVID-19 infection risk stratification according to settings.

considerations • COVID-19 infection risk stratification according to health worker roles/responsibilities.
• vaccination status of health workers and risk of reinfection in those who have been
vaccinated versus those who have not (35).
• type of testing (PCR, rapid antigen, self-testing), sensitivity/specificity, how it is
administered (by professional or self-collected), costs.
• behaviours, perspectives, availability and use of PPE.
• PPE cost, acceptability, waste disposal.
163 of 209
PRISMA Flowchart for included studies
164 of 209
Studies characteristics
Table 1. Author, year, preliminary critical appraisal score, study aim
Author Year Aim

Abbas 2021 explore current literature in hospital-onset COVID-19 infections surveillance
Bobrovitz 2021 synthesize seroprevalence data to better estimate the level and distribution of SARS-
CoV-2 infection among health workers? identify high-risk groups, and inform public
health decision making
Caló 2020 critically analyse the evidence on surveillance and risk to support public health
strategies that protect health workers in hospital settings
Carrara 2022 test asymptomatic individuals, including health and care workers? OR test
asymptomatic health and care workers?
Chen 2022 describe COVID-19 reinfection in health and care workers?
Chou 2020 examine the burden of SARS-CoV-2 on health and care workers and risk factors for
infection
D'Ettore 2022 evaluate the literature and discover what are the latest developments about the
management of the occupational health surveillance of health and care workers
during COVID-19 pandemic.
Egunsola PP identify comparative observational studies and randomized controlled trials (RCTs)
2021 evaluating the efficacy and effectiveness of COVID-19 vaccination in reducing forward
transmission from vaccinated people (health and care workers and the general
population), and studies examining the biological plausibility of vaccination-induced
transmission reduction.
Elmore 2020 generate a rapid evidence map of risk and protective factors to comprehensively
inform areas that affect COVID-19 outcomes for different sub-populations to better
protect the public.
Fakhruddin 2021 is SARS-CoV-2 detectable in the saliva of asymptomatic individuals?
Flumignan 2020 identify and summarize the evidence from Cochrane systematic reviews regarding
measures for controlling the dissemination of COVID-19 infection.
Gadenstaedter 2021 provide an overview of nasal specimen collection methods for SARS-CoV-2 detection
in various populational groups, including health workers.
Galanis 2021 determine the seroprevalence of SARS-CoV-2 antibodies among health workers and
identify the factors associated with this seroprevalence.
Gross 2021 examine health risks at workplaces regarding COVID-19, and effectiveness of
preventative recommendations.
Helfand 2022 synthesize evidence on protection against reinfection after SARS-CoV-2 infection in
various population groups, including health workers.
Hossain 2021 determine seroprevalence of SARS-CoV-2 IgG antibodies over geographic regions
among health workers.
Jafari 2021 identify evidence on IPC practices/measures adopted by hospitals.
Jang 2021 review whether national and international guidelines provide recommendations for
infection prevention and control to prevent the spread of COVID-19 in hospitals.
Kayi 2021 investigate the seroprevalence of SARS-CoV-2 among health and care workers and
related risk factors by including studies published in 2020, which were conducted
before the unpredictable effects of highly spreading new variants appeared and
vaccination programmes put in place in 2021.
Kim 2022 evaluate the diagnostic utility of self-collected saliva in coronavirus desease-19
(COVID-19) screening procedures
Mackey 2021 synthesize evidence on the prevalence, levels, and durability of the antibody response
to SARS-CoV-2 infection among adults and how antibodies correlate with protective
immunity.
165 of 209
Mei 2022 identify optimal health and care workers' monitoring mechanisms and provide
practical recommendations for administrators, leaders, policy- makers.
Mhango 2020 identify risk factors for COVID-19 in health and care workers.
Muller 2022 review and appraise the evidence of SARS-CoV-2 seroprevalence and its risk factors
in health and care workers in Africa to inform response and preparedness strategies
during the SARS-CoV-2 pandemic.
O'Murchu 2021 evaluate the risk and relative risk of SARS‐CoV‐2 reinfection over time, comparing
previously infected individuals to those without evidence of prior infection.
Rahmani 2022 synthesize the available evidence for the duration of SARS-CoV-2 infectivity of
working-age populations
Ravindra 2022 investigate the role of asymptomatic infection and transmission reported in family
clusters, adults, children and health and care workers.
Tian 2021 investigate risk factors for health and care worker infection in viral respiratory
pandemics.
Vegas 2021 analyse evidence concerning the risks of occupational illnesses to which health and
care workers providing care to patients infected with COVID-19 are exposed.
Viswanathan 2020 assess (1) the effectiveness of universal screening for SARS-CoV-2 infection
compared with no screening and (2) the accuracy of universal screening in people
who have not presented to clinical care for symptoms of COVID-19.
Zhou 2021 compares the incidence of nosocomial infections during the COVID-19, SARS and
MERS epidemics and analyses the characteristics of the nosocomial infections.
Table 2. Description of included reviews
Author Year Type of paper Category Setting

Chen 2022 SR & MA Antibody protection against any health-care setting
reinfection
Chou 2020 Living Rapid Review Burden of disease any health-care setting
Budiyatno 2022 SR Comparative testing any health-care setting
procedures
Gadenstaetter 2021 SR Comparative testing hospital
procedures
Kim 2022 SR & MA Comparative testing any health-care setting
procedures
Flumignan 2020 Narrative review Controlling disease hospital
transmission (including
quarantine, PPE)
Jafari 2021 SR Infection control procedures any health-care setting
Jang 2021 SR & analysis of Infection control procedures any health-care setting
guidelines
Zhou 2020 Rapid review & MA Nosocomial infection hospital
Elmore 2020 Rapid Evidence Map Risk factors for disease any health-care setting
Calisti 2020 SR Risk factors for infection hospital
Gross 2020 Rapid SR Risk factors for infection any health-care setting
Mhango 2020 rapid review Risk factors for infection any health-care setting
Tian 2021 SR & MA Risk factors for infection hospital
Vega 2021 integrative review Risk factors for infection any COVID-19 care
setting
Helfand 2022 Living Rapid Review Risk of reinfection any health-care setting
O'Murchu 2021 SR Risk of reinfection hospitals and LTCF
166 of 209
Fakhruddin 2022 SR & MA Saliva as SARS-CoV-2 source dentists

Bobrovitz 2021 SR & MA Seroprevalence / sero- any health-care setting
surveillance
Galanis 2021 SR & MA Seroprevalence / sero- hospital, primary health-
surveillance care facilities
Kayi 2021 SR & MA Seroprevalence / sero- any health-care setting
surveillance
Mackey 2021 Rapid Living Review Seroprevalence / sero- any health-care setting
surveillance
Muller 2022 Scoping review, Seroprevalence / sero- any health-care setting
appraisal of existing surveillance (African countries)
evidence
Hossain 2021 SR & MA Seroprevalence prior to any health-care setting
vaccination
Abbas 2021 SR Surveillance hospital
Calo 2020 scoping review Surveillance hospital
D’Ettore 2022 Narrative review Surveillance any health-care setting
Mei 2022 SR & MA Surveillance hospital
Viswanathan 2020 Rapid review Surveillance ED
Ravindra 2022 SR & MA Surveillance of asymptomatic any health-care setting
Transmission in clusters
Carrara 2022 guidelines Testing asymptomatic any health-care setting
individuals
Egunsola 2021 Rapid Literature Review Vaccination in reducing risk hospital
PP update #1
Rahmani 2022 SR & MA Viral shedding and infectivity in any health-care setting
workers
Published 10 August 2023
6.5 Annex 5: Results of rapid qualitative evidence synthesis

Summary of qualitative evidence synthesis (QES) findings - PPE/Masks (Health and care workers)
Analytical themes Descriptive themes (review findings)

Health and care workers valued the use of masks and PPE gave peace of mind
PPE in patient care Masks create a safety climate to deliver optimal care
Masks and PPE cause physical discomfort to health Health and care workers experience physical discomfort wearing masks
and care workers and PPE
Masks and PPE compromise communication with colleagues
Masks and PPE challenge effective communication Masks and PPE affect communication and relationship with patients
Learning to communicate effectively with patients while wearing a mask
Familiarity with masks and PPE helped health and Already familiar with PPE pre-pandemic (varies)
care workers adapt for COVID-19 Progressive adaptation over time occurs with masks (varies)
Health and care workers in care homes experienced
Inequality in access to PPE
unequal access to PPE
Putting on PPE takes time and affects ability to carry out clinical
Individual health and care worker factors affecting PPE
procedures
use
PPE design and fit influence risk of contamination
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Questions about the effectiveness of PPE

Availability and supply of PPE (varies)
Health-system factors that prevented PPE use
Gap between guidelines and protocols and implementation of PPE
Institutional support and role modelling helped PPE use (varies)
Facility-level factors that affected PPE use
Layout of health facility affected PPE use
Health and care workers were anxious about being put Anxiety and insecurity about the level of protection
at risk Perception of susceptibility and risk
Health and care workers responded creatively to the Re-using, rationing, and improvising with PPE/masks
lack of masks/PPE Procurement and quality control of masks
Summary of QES findings – Cleaning and Disinfection

Cleaning is a cornerstone of patient care Importance of cleaning recognized
Organizational culture affects cleaning practices Cleaning practices are undervalued (by management)
Individual judgement influences uptake Differential disinfection practices in risk areas of facility
Historic standards, norms and practices influence COVID exposed/ poor cleaning practices and standards
uptake
Pivoting practice quickly as guidance changed Lack of clear guidance/changing guidance
Resource considerations for cleaning uptake Resources required for disinfecting and cleaning
No studies reported on equity and cleaning/disinfecting
Summary of QES findings – Physical distance (Health and care workers)

Beliefs and cultural norms compete with the logic of Changing perception of susceptibility and risk
physical distancing Community distrust of health professionals and disbelief in COVID-19
People value cultural norms and beliefs that preclude physical distancing
Security is a greater priority than physical distancing
Solidarity in not physically distancing Peer and social pressure to comply (or not) with physical distancing
(varies)
Difficulty complying with physical distancing among friends and family
Physical distancing is a barrier to relational patient Physical distancing affects relationships with patients
care
Difficult to challenge those higher up in the hierarchy Workplace hierarchy influences social distancing
Physical infrastructure prevents physical distancing Health-facility infrastructure prevents physical distancing
Infrastructure in IDP camps/informal settlements influences physical

distancing
Service delivery presents barriers to distancing Clinical workflows require health and care workers to gather in proximity
Social and political factors and physical distancing Social space supports or discourages physical distancing
Confusing and contradictory messaging from government/regulatory
agencies
No studies reported on costs or resource requirements for physical distancing
168 of 209
6.6 Annex 6: Search Strategies
6.6.1 Airborne Precautions

Outcome terms
Exp Virus Diseases/ Exp Respiratory Tract Infections/ “respiratory infection*”.ti,ab. “respiratory virus*”.ti,ab. “respiratory tract
infections”.ti,ab. Exp Pneumonia/ Exp COVID-19/ Exp SARS-CoV-2/ Exp Cornavirus/ Coronavirus*.ti,ab. “Coronavirus
infection*”.ti,ab. 2019-nCoV.ti,ab. 2019 ncov.ti,ab. nCov.ti,ab. Covid19.ti,ab. SARSCoV-2.ti,ab. “novel coronavirus”.ti,ab. “novel
corona virus”.ti,ab. covid*.ti,ab. “severe acute respiratory syndrome”.ti,ab. “coronavirus 2”.ti,ab. “coronavirus disease”.ti,ab. “corona
virus disease”.ti,ab. “new coronavirus”.ti,ab. “new corona virus”.ti,ab. “new coronaviruses”.ti,ab. “novel coronaviruses”.ti,ab.
Sars.ti,ab. “sars corona virus”.ti,ab. “respiratory infectious disease*”.ti,ab. “acute respiratory disease*”.ti,ab. “influenza like
illness”.ti,ab. Exp Pandemics/ Pandemic*.ti,ab. “respiratory disease”.ti,ab.
Intervention terms
("aerosols"[All Fields] OR "aerosolic"[All Fields] OR "aerosolization"[All Fields] OR "aerosolizations"[All Fields] OR "aerosolize"[All
Fields] OR "aerosolized"[All Fields] OR "aerosolizer"[All Fields] OR "aerosolizes"[All Fields] OR "aerosolizing"[All Fields] OR
"aerosols"[MeSH Terms] OR "aerosols"[All Fields] OR "aerosol"[All Fields]) OR (("airborn"[All Fields] OR "airborne"[All Fields]) AND
("precaution"[All Fields] OR "precautions"[All Fields]))) AND (y_1[Filter])
6.6.2 Cleaning in the community

Search terms
1. exp Health facilities/ or exp hospitals/ or exp Nursing Homes/ or Homes for the Aged/ or assisted living facilities/
2. exp Health Personnel/ or exp Health Occupations/
3. ((medical or health or healthcare) adj3 (facility or facilities or centre* or center* or office* or setting*)).ti,ab,kf.
4. ((medical or health care or healthcare) adj (worker* or staff or employee* or personnel or occupation*)).ti,ab,kf.
(hospital* or ward* or physician* or doctor* or surgeon* or surgical or surger* or dentist* or dental or nurs* or infirmar* or
5.
hospice* or Clinic or Clinics or "Old Age Homes" or "Old Age Home").ti,ab,kf.
6. ((longterm care or long term care) adj3 (home* or facility or facilities or residence* or housing* or setting*)).ti,ab,kf.
7. Pharmacies/ not Health facilities/
8. (Caregivers/ or Pharmacists/) not (Health Personnel/ or Health Occupations/)
9. or/1-6
10. or/7-8
11. 9 not 10
12. Disinfection/ or exp Disinfectants/ or exp Detergents/ or Fumigation/ or Decontamination/
13. exp chlorine compounds/ or hypochlorous acid/ or sodium hypochlorite/
14. Quaternary Ammonium Compounds/ or Bleaching Agents/ or Hydrogen Peroxide/
15. exp ethanol/ or exp ethanolamines/ or 2-Propanol/
16. methylene blue/
((sanitation or sanitary or housekeep* or janitor*) adj3 (worker* or staff or employee* or personnel or occupation* or
17.
team* or department*)).ti,ab,kf.
(brush or brushing or clean* or disinfect* or decontaminat* or fogging or fog or fogger* or fumigat* or mist or misting or
18.
sanitis* or sanitiz* or scrub or scrubbing or spray* or wipe or wiping).ti,ab,kf.
19. (detergent* or soap* or methylene blue or ethanol or bleach* or chlorin* or hypochlorit* or hydrogen peroxide or
169 of 209
glutaraldehyde or formaldehyde or aldehyde or dihydrogen dioxide or hydrogen dioxide or hydroperoxide or quaternary

ammonium or quaternary bisammonium or quaternized amine or hypochlorous acid).ti,ab,kf.
20. (antiseptic* or iodine or ethanolamin* or isopropanol or isopropyl or propanol or 2propanol).ti,ab,kf.
21. or/12-20
22. (cisplatin/ or exp Hydrochloric acid/) not (chlorine compounds/ or hypochlorous acid/ or sodium hypochlorite/)
23. 21 not 22
(hand wash* or hand hygiene or hand sanitisation or hand sanitization or hand disinfection or hand decontamination or
skin disinfection or skin decontamination or skin wash* or skin hygiene or skin sanitisation or skin sanitization or hands or
24.
eczema* or mouth or oral* or nose or handwash* or skinwash* or mouthwash* or nosewash* or nasal* or topical* or
ultraviolet or ultra violet or UV or UVC or UVGI or actinic).ti.
((PPE or "personal protective equipment" or mask* or facemask* or respirator or respirators or N95 or N99 or KN95 or
FFP2 or FFP3 or "Filtering face piece" or "Filtering face pieces" or "Filtering facepiece" or "Filtering facepieces" or
25.
"respiratory protective device" or "respiratory protective devices") adj2 (disinfect* or decontaminat* or sanitiz* or sanitis*
or clean* or wash*)).ti.
((PPE or "personal protective equipment" or mask* or facemask* or respirator or respirators or N95 or N99 or KN95 or
26. FFP2 or FFP3 or "Filtering face piece" or "Filtering face pieces" or "Filtering facepiece" or "Filtering facepieces" or
"respiratory protective device" or "respiratory protective devices") not (surface* or touch* or high touch or high traffic or
170 of 209
environment* or material* or object or objects or building* or floor* or counter* or bed or beds or equipment* or room or
rooms or space* or door* or chair* or wheelchair* or washroom* or bathroom* or elevator* or toilet* or contact time* or
wood* or plastic* or metal* or fog* or fumigat* or mist or misting or spray*)).ti.
27. 24 or 25 or 26
28. 23 not 27
29. limit 28 to covid-19
30. 11 and 29
31. limit 30 to (meta analysis or "systematic review")
32. randomized controlled trial.pt.
33. controlled clinical trial.pt.
34. randomized.ab.
35. placebo.ab.
36. randomly.ab.
37. trial.ab.
38. groups.ab.
39. or/32-38
40. exp animals/ not humans.sh.
41. 39 not 40 [adapted from the Cochrane HSSS RCT filter]
42. 30 and 41
exp cohort studies/ or exp epidemiologic studies/ or exp clinical trial/ or exp evaluation studies as topic/ or exp statistics
43.
as topic/
44. ((time and factors) or program or survey* or ci or cohort or comparative stud* or evaluation studies or follow-up*).mp.
45. (control and (group* or study)).mp.
46. or/43-45
47. (animals/ not humans/) or comment/ or editorial/ or exp review/ or meta analysis/ or consensus/ or exp guideline/
48. hi.fs. or case report.mp.
49. or/47-48
50. 46 not 49 [NRS filter by Waffenschmidt et al. 2020]
51. 30 and 50
52. 31 or 42 or 51
53. exp Animals/ not Humans/
54. 52 not 53
55. (comment or editorial or newspaper article).pt.
56. 54 not 55
((sanitation or sanitary or housekeep* or janitor*) adj (worker* or staff or employee* or personnel or occupation* or team*
57.
or department*)).ti,ab,kw.
58. (clean* or disinfect* or decontaminat* or sanitis* or sanitiz*).ti,ab,kw.
59. (mist or misting or scrub or scrubbing or spray* or wipe or wiping).ti,ab. not scrub typhus.mp.
60. (brush or brushing or fogging or fogger* or fumigat*).ti,ab.
(detergent* or soap* or methylene blue or ethanol or bleach* or chlorin* or hypochlorit* or hydrogen peroxide or
61. glutaraldehyde or formaldehyde or aldehyde or dihydrogen dioxide or hydrogen dioxide or hydroperoxide or quaternary
ammonium or quaternary bisammonium or quaternized amine or hypochlorous acid).ti,ab,kw.
62. (antiseptic* or iodine or ethanolamin* or isopropanol or isopropyl or propanol or 2propanol).ti,ab,kw.
(hand* or skin* or eczema* or mouth* or oral* or nose* or nasal* or intranasal* or inhal* or nebuli* or throat* or gargl* or
63.
topical* or ultraviolet or ultra violet or UV or UVC or UVGI or actinic).ti,kw.
(PPE or "personal protective equipment" or mask* or facemask* or respirator or respirators or N95 or N99 or KN95 or
64. FFP2 or FFP3 or "Filtering face piece" or "Filtering face pieces" or "Filtering facepiece" or "Filtering facepieces" or
"respiratory protective device" or "respiratory protective devices").ti,kw. or exp mask/ or exp respiratory protection/ or
171 of 209
protective equipment/
65. drinking/ or exp alcoholism/ or exp drug dependence/ or exp addiction/
66. 63 or 64 or 65
67. disinfection/
68. decontamination/
69. fumigation/
70. exp disinfectant agent/ or 2 propanol/ or alcohol/ or formaldehyde/ or glutaraldehyde/ or hypochlorite sodium/ or iodine/
71. detergent/
72. chlorine/ or chlorine derivative/
73. hypochlorous acid/
74. quaternary ammonium derivative/ or benzalkonium/ or benzalkonium chloride/ or tetrylammonium/
75. bleaching agent/ or hydrogen peroxide/
76. ethanolamine derivative/ or ethanolamine/
77. methylene blue/
78. or/57-62,67-77
79. 78 not 66
81. exp health care facility/ or assisted living facility/ or exp hospital/ or nursing home/
82. home for the aged/
83. exp health care personnel/
84. medical profession/
85. ((medical or health or healthcare) adj3 (facility or facilities or centre* or center* or office* or setting*)).ti,ab,kw.
86. ((medical or health care or healthcare) adj (worker* or staff or employee* or personnel or occupation*)).ti,ab,kw.
(hospital* or physician* or doctor* or surgeon* or surgical or surger* or dentist* or dental or nurs* or infirmar* or hospice*
87.
or Clinic or Clinics or "Old Age Homes" or "Old Age Home").ti,ab,kw.
88. ((longterm care or long term care) adj3 (home* or facility or facilities or residence* or housing* or setting*)).ti,ab,kw.
89. exp "pharmacy (shop)"/ not health care facility/
(exp pharmacist/ or exp health educator/) not (paramedical personnel/ or health care personnel/ or health practitioner/ or
90.
paramedical profession/ or medical profession/)
91. or/81-88
92. 89 or 90
93. 91 not 92
94. 80 and 93
95. limit 94 to "systematic review"
randomized controlled trial/ or controlled clinical trial/ or randomization/ or exp intermethod comparison/ or double-blind
96.
procedure/
97. human experiment/
(random$ or crossover or cross over or volunteer or volunteers or placebo or allocated or assigned or (open adj
98.
label)).ti,ab.
99. (compare or compared or comparison).ti.
((evaluated or evaluate or evaluating or assessed or assess) and (compare or compared or comparing or
100.
comparison)).ab.
101. ((double or single or doubly or singly) adj (blind or blinded or blindly)).ti,ab.
102. parallel group$1.ti,ab.
((assign$ or match or matched or allocation) adj5 (alternate or group$1 or intervention$1 or patient$1 or subject$1 or
103.
participant$1)).ti,ab.
104. (controlled adj7 (study or design or trial)).ti,ab.
105. trial.ti.
172 of 209
106. or/96-105
107. (Systematic review not (trial or study)).ti.
108. (random cluster adj3 sampl$).ti,ab.
109. (review.ab. and review.pt.) not trial.ti.
110. (databases adj4 searched).ab.
111. "we searched".ab. and (review.ti. or review.pt.)
112. "update review".ab.
113. Random field$.ti,ab.
114. (nonrandom$ not random$).ti,ab.
(random$ adj sampl$ adj7 (cross section$ or questionnaire$1 or survey$ or database$1)).ti,ab. not (comparative study/
115.
or controlled study/ or randomi?ed controlled.ti,ab. or randomly assigned.ti,ab.)
Cross-sectional study/ not (randomized controlled trial/ or controlled clinical trial/ or controlled study/ or randomi?ed
116.
controlled.ti,ab. or control group$1.ti,ab.)
117. (((case adj control$) and random$) not randomi?ed controlled).ti,ab.
(rat or rats or mouse or mice or swine or porcine or murine or sheep or lambs or pigs or piglets or rabbit or rabbits or cat
118.
or cats or dog or dogs or cattle or bovine or monkey or monkeys or trout or marmoset$1).ti. and animal experiment/
119. Animal experiment/ not (human experiment/ or human/)
120. ("cochrane database of systematic reviews" or "cochrane database of systematic reviews online").jn.
121. or/107-120
122. 106 not 121 [Cochrane Embase RCT filter 2022 revision (Glanville et al. 2019)]
123. 94 and 122
Clinical article/ or controlled study/ or major clinical study/ or prospective study/ or cohort.mp. or compared.mp. or
124.
groups.mp. or multivariate.mp. [NRS filter by Furlan et al. 2006 for Embase]
125. 94 and 124
126. 95 or 123 or 125
127. exp animal/ not exp human/
128. 126 not 127
129. editorial.pt.
130. 128 not 129
131. 1 or 2 or 85 or 86 or 87 or 88
132. 131 not 10
133. 12 or 13 or 14 or 15 or 16 or 57 or 58 or 59 or 60 or 61 or 62
134. 133 not 27
(nCoV* or 2019nCoV or 19nCoV or COVID19* or COVID or SARS-COV-2 or SARSCOV-2 or SARS-COV2 or
135.
SARSCOV2 or coronavirus* or corona virus* or betacoronavirus* or CoV or HCoV).mp.
136. limit 135 to yr="2019 -Current" [COVID-19 filter adapted from CADTH Search Strings]
137. 132 and 134 and 136
138. 56 use medall
139. 130 use emczd
140. 137 use cctr
141. 137 use coch
142. 138 or 139 or 140 or 141
143. remove duplicates from 142
6.6.3 Cleaning in the health-care facility

Search terms
173 of 209
exp Health facilities/ or exp hospitals/ or exp Nursing Homes/ or Homes for the Aged/ or assisted living
1.
facilities/
2. exp Health Personnel/ or exp Health Occupations/
((medical or health or healthcare) adj3 (facility or facilities or centre* or center* or office* or
3.
setting*)).ti,ab,kf.
((medical or health care or healthcare) adj (worker* or staff or employee* or personnel or
4.
occupation*)).ti,ab,kf.
(hospital* or ward* or physician* or doctor* or surgeon* or surgical or surger* or dentist* or dental or
5.
nurs* or infirmar* or hospice* or Clinic or Clinics or "Old Age Homes" or "Old Age Home").ti,ab,kf.
((longterm care or long term care) adj3 (home* or facility or facilities or residence* or housing* or
6.
setting*)).ti,ab,kf.
7. Pharmacies/ not Health facilities/
8. (Caregivers/ or Pharmacists/) not (Health Personnel/ or Health Occupations/)
9. or/1-6
10. or/7-8
11. 9 not 10
12. Disinfection/ or exp Disinfectants/ or exp Detergents/ or Fumigation/ or Decontamination/
13. exp chlorine compounds/ or hypochlorous acid/ or sodium hypochlorite/
14. Quaternary Ammonium Compounds/ or Bleaching Agents/ or Hydrogen Peroxide/
15. exp ethanol/ or exp ethanolamines/ or 2-Propanol/
16. methylene blue/
174 of 209
((sanitation or sanitary or housekeep* or janitor*) adj3 (worker* or staff or employee* or personnel or

17.
occupation* or team* or department*)).ti,ab,kf.
(brush or brushing or clean* or disinfect* or decontaminat* or fogging or fog or fogger* or fumigat* or
18.
mist or misting or sanitis* or sanitiz* or scrub or scrubbing or spray* or wipe or wiping).ti,ab,kf.
(detergent* or soap* or methylene blue or ethanol or bleach* or chlorin* or hypochlorit* or hydrogen
peroxide or glutaraldehyde or formaldehyde or aldehyde or dihydrogen dioxide or hydrogen dioxide or
19.
hydroperoxide or quaternary ammonium or quaternary bisammonium or quaternized amine or
hypochlorous acid).ti,ab,kf.
20. (antiseptic* or iodine or ethanolamin* or isopropanol or isopropyl or propanol or 2propanol).ti,ab,kf.
21. or/12-20
(cisplatin/ or exp Hydrochloric acid/) not (chlorine compounds/ or hypochlorous acid/ or sodium
22.
hypochlorite/)
23. 21 not 22
(hand wash* or hand hygiene or hand sanitisation or hand sanitization or hand disinfection or hand
decontamination or skin disinfection or skin decontamination or skin wash* or skin hygiene or skin
24. sanitisation or skin sanitization or hands or eczema* or mouth or oral* or nose or handwash* or
skinwash* or mouthwash* or nosewash* or nasal* or topical* or ultraviolet or ultra violet or UV or UVC
or UVGI or actinic).ti.
((PPE or "personal protective equipment" or mask* or facemask* or respirator or respirators or N95 or
N99 or KN95 or FFP2 or FFP3 or "Filtering face piece" or "Filtering face pieces" or "Filtering facepiece"
25.
or "Filtering facepieces" or "respiratory protective device" or "respiratory protective devices") adj2
(disinfect* or decontaminat* or sanitiz* or sanitis* or clean* or wash*)).ti.
((PPE or "personal protective equipment" or mask* or facemask* or respirator or respirators or N95 or
or "Filtering facepieces" or "respiratory protective device" or "respiratory protective devices") not
26. (surface* or touch* or high touch or high traffic or environment* or material* or object or objects or
building* or floor* or counter* or bed or beds or equipment* or room or rooms or space* or door* or
chair* or wheelchair* or washroom* or bathroom* or elevator* or toilet* or contact time* or wood* or
plastic* or metal* or fog* or fumigat* or mist or misting or spray*)).ti.
27. 24 or 25 or 26
28. 23 not 27
30. 11 and 29
31. limit 30 to (meta analysis or "systematic review")
32. randomized controlled trial.pt.
33. controlled clinical trial.pt.
34. randomized.ab.
35. placebo.ab.
36. randomly.ab.
37. trial.ab.
38. groups.ab.
39. or/32-38
40. exp animals/ not humans.sh.
41. 39 not 40 [adapted from the Cochrane HSSS RCT filter]
42. 30 and 41
exp cohort studies/ or exp epidemiologic studies/ or exp clinical trial/ or exp evaluation studies as topic/
43.
or exp statistics as topic/
((time and factors) or program or survey* or ci or cohort or comparative stud* or evaluation studies or
44.
follow-up*).mp.
45. (control and (group* or study)).mp.
175 of 209
46. or/43-45
(animals/ not humans/) or comment/ or editorial/ or exp review/ or meta analysis/ or consensus/ or exp
47.
guideline/
48. hi.fs. or case report.mp.
49. or/47-48
50. 46 not 49 [NRS filter by Waffenschmidt et al. 2020]
51. 30 and 50
52. 31 or 42 or 51
54. 52 not 53
56. 54 not 55
((sanitation or sanitary or housekeep* or janitor*) adj (worker* or staff or employee* or personnel or
57.
occupation* or team* or department*)).ti,ab,kw.
58. (clean* or disinfect* or decontaminat* or sanitis* or sanitiz*).ti,ab,kw.
59. (mist or misting or scrub or scrubbing or spray* or wipe or wiping).ti,ab. not scrub typhus.mp.
60. (brush or brushing or fogging or fogger* or fumigat*).ti,ab.
(detergent* or soap* or methylene blue or ethanol or bleach* or chlorin* or hypochlorit* or hydrogen
peroxide or glutaraldehyde or formaldehyde or aldehyde or dihydrogen dioxide or hydrogen dioxide or
61.
hydroperoxide or quaternary ammonium or quaternary bisammonium or quaternized amine or
hypochlorous acid).ti,ab,kw.
62. (antiseptic* or iodine or ethanolamin* or isopropanol or isopropyl or propanol or 2propanol).ti,ab,kw.
(hand* or skin* or eczema* or mouth* or oral* or nose* or nasal* or intranasal* or inhal* or nebuli* or
63.
throat* or gargl* or topical* or ultraviolet or ultra violet or UV or UVC or UVGI or actinic).ti,kw.
(PPE or "personal protective equipment" or mask* or facemask* or respirator or respirators or N95 or
64.
or "Filtering facepieces" or "respiratory protective device" or "respiratory protective devices").ti,kw. or
exp mask/ or exp respiratory protection/ or protective equipment/
65. drinking/ or exp alcoholism/ or exp drug dependence/ or exp addiction/
66. 63 or 64 or 65
67. disinfection/
68. decontamination/
69. fumigation/
exp disinfectant agent/ or 2 propanol/ or alcohol/ or formaldehyde/ or glutaraldehyde/ or hypochlorite
70.
sodium/ or iodine/
71. detergent/
72. chlorine/ or chlorine derivative/
73. hypochlorous acid/
74. quaternary ammonium derivative/ or benzalkonium/ or benzalkonium chloride/ or tetrylammonium/
75. bleaching agent/ or hydrogen peroxide/
76. ethanolamine derivative/ or ethanolamine/
77. methylene blue/
78. or/57-62,67-77
79. 78 not 66
81. exp health care facility/ or assisted living facility/ or exp hospital/ or nursing home/
82. home for the aged/
83. exp health care personnel/
176 of 209
84. medical profession/

((medical or health or healthcare) adj3 (facility or facilities or centre* or center* or office* or
85.
setting*)).ti,ab,kw.
((medical or health care or healthcare) adj (worker* or staff or employee* or personnel or
86.
occupation*)).ti,ab,kw.
(hospital* or physician* or doctor* or surgeon* or surgical or surger* or dentist* or dental or nurs* or
87.
infirmar* or hospice* or Clinic or Clinics or "Old Age Homes" or "Old Age Home").ti,ab,kw.
((longterm care or long term care) adj3 (home* or facility or facilities or residence* or housing* or
88.
setting*)).ti,ab,kw.
89. exp "pharmacy (shop)"/ not health care facility/
(exp pharmacist/ or exp health educator/) not (paramedical personnel/ or health care personnel/ or
90.
health practitioner/ or paramedical profession/ or medical profession/)
91. or/81-88
92. 89 or 90
93. 91 not 92
94. 80 and 93
95. limit 94 to "systematic review"
randomized controlled trial/ or controlled clinical trial/ or randomization/ or exp intermethod
96.
comparison/ or double-blind procedure/
97. human experiment/
(random$ or crossover or cross over or volunteer or volunteers or placebo or allocated or assigned or
98.
(open adj label)).ti,ab.
99. (compare or compared or comparison).ti.
((evaluated or evaluate or evaluating or assessed or assess) and (compare or compared or comparing
100.
or comparison)).ab.
101. ((double or single or doubly or singly) adj (blind or blinded or blindly)).ti,ab.
102. parallel group$1.ti,ab.
((assign$ or match or matched or allocation) adj5 (alternate or group$1 or intervention$1 or patient$1
103.
or subject$1 or participant$1)).ti,ab.
104. (controlled adj7 (study or design or trial)).ti,ab.
105. trial.ti.
106. or/96-105
107. (Systematic review not (trial or study)).ti.
108. (random cluster adj3 sampl$).ti,ab.
109. (review.ab. and review.pt.) not trial.ti.
110. (databases adj4 searched).ab.
111. "we searched".ab. and (review.ti. or review.pt.)
112. "update review".ab.
113. Random field$.ti,ab.
114. (nonrandom$ not random$).ti,ab.
(random$ adj sampl$ adj7 (cross section$ or questionnaire$1 or survey$ or database$1)).ti,ab. not
115.
(comparative study/ or controlled study/ or randomi?ed controlled.ti,ab. or randomly assigned.ti,ab.)
Cross-sectional study/ not (randomized controlled trial/ or controlled clinical trial/ or controlled study/ or
116.
randomi?ed controlled.ti,ab. or control group$1.ti,ab.)
117. (((case adj control$) and random$) not randomi?ed controlled).ti,ab.
(rat or rats or mouse or mice or swine or porcine or murine or sheep or lambs or pigs or piglets or
118. rabbit or rabbits or cat or cats or dog or dogs or cattle or bovine or monkey or monkeys or trout or
marmoset$1).ti. and animal experiment/
119. Animal experiment/ not (human experiment/ or human/)
177 of 209
120. ("cochrane database of systematic reviews" or "cochrane database of systematic reviews online").jn.
121. or/107-120
122. 106 not 121 [Cochrane Embase RCT filter 2022 revision (Glanville et al. 2019)]
123. 94 and 122
Clinical article/ or controlled study/ or major clinical study/ or prospective study/ or cohort.mp. or
124.
compared.mp. or groups.mp. or multivariate.mp. [NRS filter by Furlan et al. 2006 for Embase]
125. 94 and 124
126. 95 or 123 or 125
128. 126 not 127
129. editorial.pt.
130. 128 not 129
131. 1 or 2 or 85 or 86 or 87 or 88
132. 131 not 10
133. 12 or 13 or 14 or 15 or 16 or 57 or 58 or 59 or 60 or 61 or 62
134. 133 not 27
(nCoV* or 2019nCoV or 19nCoV or COVID19* or COVID or SARS-COV-2 or SARSCOV-2 or SARS-
135.
COV2 or SARSCOV2 or coronavirus* or corona virus* or betacoronavirus* or CoV or HCoV).mp.
137. 132 and 134 and 136
138. 56 use medall
139. 130 use emczd
140. 137 use cctr
141. 137 use coch
142. 138 or 139 or 140 or 141
178 of 209
6.6.4 UV
Search terms
1. Ultraviolet Rays/ or Ultraviolet Therapy/
2. (ultraviolet or ultra violet or UV or UVGI or UVC).ti,ab,kf.
3. (actinic adj3 (ray* or radiat* or irradiat*)).ti,ab,kf.
4. (germicid* adj3 lamp*).ti,ab,kf.
5. or/1-4
8. 6 not 7
10. 8 not 9
11. exp ultraviolet radiation/
12. ultraviolet germicidal irradiation/
13. ultraviolet irradiation/
14. ultraviolet phototherapy/
15. (ultraviolet or ultra violet or UV or UVGI or UVC).ti,ab,kw.
16. (actinic adj3 (ray* or radiat* or irradiat*)).ti,ab,kw.
17. (germicid* adj3 lamp*).ti,ab,kw.
18. or/11-17
21. 19 not 20
22. editorial.pt.
23. 21 not 22
24. (ultraviolet or ultra violet or UV or UVGI or UVC).mp.
25. (actinic adj3 (ray* or radiat* or irradiat*)).mp.
26. (germicid* adj3 lamp*).mp.
27. or/24-26
(nCoV* or 2019nCoV or 19nCoV or COVID19* or COVID or SARS-COV-2 or SARSCOV-2 or SARS-COV2 or SARSCOV2 or
28. SARS coronavirus 2 or Severe Acute Respiratory Syndrome Coronavirus 2 or Severe Acute Respiratory Syndrome Corona
Virus 2).mp.
29. (longCOVID* or postCOVID* or postcoronavirus* or postSARS*).mp.
30. ((Wuhan or Hubei) adj5 pneumonia).mp.
31. (coronavirus* or corona virus* or betacoronavirus* or CoV or HCoV).mp.
32. 28 or 29 or 30 or 31
34. 27 and 33
35. 10 use medall
36. 23 use emczd
37. 34 use cctr
38. 34 use coch
39. 35 or 36 or 37 or 38
179 of 209
6.6.5 Dead body management

Outcome terms
Intervention terms
"cadaver"[Title/Abstract] OR "corpse"[Title/Abstract] OR "dead"[Title/Abstract] OR "death"[Title/Abstract] OR "remains"[Title/
Abstract] OR "mortem"[Title/Abstract] OR "postmortem"[Title/Abstract] OR "post-mortem"[Title/Abstract] OR "deceased"[Title/
Abstract] OR "passed away"[Title/Abstract] OR "cremation"[Title/Abstract] OR "cremated"[Title/Abstract] OR "buried"[Title/Abstract]
OR "embalming"[Title/Abstract] OR "burial"[Title/Abstract] OR "grave"[Title/Abstract])
180 of 209
6.6.6 Glove use in community

Outcome terms
Intervention terms
glove* OR surgical glove* OR protective glove*
Setting terms
"Community Health Worker*"[Mesh] OR "Community Health Center*"[Mesh] OR "Community Health Centre*"[Mesh] OR
"Community Health Nurs*"[Mesh] OR "Community Health Service*"[Mesh] OR "Community Pharmacy Service*"[Mesh] OR
181 of 209
"Hospital*, Community"[Mesh] OR "Nurses, Community Health"[Mesh] OR “community setting*” OR “Community health program*”
OR “community health programme*” OR “community” OR “community outreach” OR “community level” OR “outpatient” OR
“community-based*” OR “community based*” OR “visiting nurse*” OR “health visitor*” OR “mobile clinic*” OR “ambulatory care” OR
“community medicine” OR “community care” OR “community” OR “village health worker*” OR “health post*”
6.6.7 Laundry
Outcome terms
Intervention terms
"Laundry"[Title/Abstract] OR "Laundering"[Title/Abstract] OR ("bedded"[All Fields] OR "bedding and linens"[MeSH Terms] OR
("bedding"[All Fields] AND "linens"[All Fields]) OR "bedding and linens"[All Fields] OR "bedding"[All Fields] OR "beddings"[All
Fields]) OR "Hospital laundry"[Title/Abstract] OR "laundry management"[Title/Abstract] OR "linen handling"[Title/Abstract] OR
"linen"[Title/Abstract])
182 of 209
6.6.8 Mask use during physical activity

Search terms
1. masks/ or n95 respirators/
2. Respiratory Protective Devices/
(mask or masks or masking or masked or facemask* or respirator or respirators or N95 or N99 or KN95 or FFP2 or FFP3 or
3. "Filtering face piece" or "Filtering face pieces" or "Filtering facepiece" or "Filtering facepieces" or "respiratory protective
device" or "respiratory protective devices").ti,ab,kf.
4. or/1-3
5. exp Exercise/
(exercis* or physical activit* or workout or running or walking or weight lifting or body building or weightlifting or bodybuilding
or jogging or stretching or yoga or pilates or aerobics or sport or sports or boxing or wrestling or volleyball or badminton or
6.
tennis or squash or racquetball or martial art* or athlete* or athletic* or basketball or cycling or bicycling or football or soccer
or hockey or baseball or softball or rugby or cricket or skating or dancing or golf or rowing or bowling).ti,ab,kf.
7. exp Sports/ or exp Athletes/
8. (gym* or arena* or ((fitness or recreation*) adj5 (club* or center* or centre* or facility or facilities or class or classes))).ti,ab,kf.
9. (track adj5 field).ti,ab,kf.
10. or/5-9
11. 4 and 10
14. 12 not 13
183 of 209

16. 14 not 15
17. exp mask/
18. exp respiratory protection/
(mask or masks or masking or masked or facemask* or respirator or respirators or N95 or N99 or KN95 or FFP2 or FFP3 or
19. "Filtering face piece" or "Filtering face pieces" or "Filtering facepiece" or "Filtering facepieces" or "respiratory protective
device" or "respiratory protective devices").ti,ab,kw.
20. or/17-19
21. exp physical activity/
22. exp exercise/
(exercis* or physical activit* or workout or running or walking or weight lifting or body building or weightlifting or bodybuilding
or jogging or stretching or yoga or pilates or aerobics or sport or sports or boxing or wrestling or volleyball or badminton or
23.
tennis or squash or racquetball or martial art* or athlete* or athletic* or basketball or cycling or bicycling or football or soccer
or hockey or baseball or softball or rugby or cricket or skating or dancing or golf or rowing or bowling).ti,ab,kw.
24. exp "sports and sport related phenomena"/ or exp sport facility/ or exp sports medicine/
25. exp athlete/
(gym* or arena* or ((fitness or recreation*) adj5 (club* or center* or centre* or facility or facilities or class or
26.
classes))).ti,ab,kw.
27. (track adj5 field).ti,ab,kw.
28. or/21-27
29. 20 and 28
32. 30 not 31
33. editorial.pt.
34. 32 not 33
35. 1 or 2 or 19
36. 5 or 7 or 23 or 26 or 27
37. 35 and 36
Virus 2).mp.
42. 38 or 39 or 40 or 41
44. 37 and 43
45. 16 use medall
46. 34 use emczd
47. 44 use cctr
48. 44 use coch
49. 45 or 46 or 47 or 48
184 of 209
6.6.9 Mask fit
Search Terms
exp Masks /exp Protective Device /exp Respiratory Protective Devices /Mask.ti,ab. /Facemask*.ti,ab. /Respirator.ti,ab.
/FFP2.ti,ab. /exp N95 Respirators /N95.ti,ab. /N99.ti,ab. /N100.ti,ab. /R95.ti,ab. /P2.ti,ab. /P95.ti,ab. /P99.ti,ab.
/P100.ti,ab. /PARP.ti,ab. /FFR.ti,ab. /'medical mask*'.ti,ab. /'surgical mask*'.ti,ab. /'cloth mask*'.ti,ab. /PPE.ti,ab. /
'personal protection equipment'.ti,ab. /exp Personal Protective Equipment /Fit.ti,ab. /Fitting.ti,ab. /Fit-tested.ti,ab. /Fit-
testing.ti,ab. /Size.ti,ab. /Sized.ti,ab. /Sizing.ti,ab. /Loose.ti,ab. /Ill-fitting.ti,ab. /Leak.ti,ab. /Leakage.ti,ab.
/Secure.ti,ab. /Secured.ti,ab. /Fasten.ti,ab. /Fastened.ti,ab. /Attached.ti,ab. /Insecure.ti,ab. /Unsecure.ti,ab
/Unattached.ti,ab /Detached.ti,ab /Unfastened.ti,ab. /Slack.ti,ab. /Oversized.ti,ab. /exp Virus Diseases/ /exp
Respiratory Tract Infections/ /'respiratory infection*'.ti,ab. /'respiratory virus*'.ti,ab. /'respiratory tract infections'.ti,ab. /exp
Pneumonia/ /exp COVID-19/ /exp SARS-CoV-2/ /exp Coronavirus/ /Coronavirus*.ti,ab. /'Coronavirus infection*'.ti,ab.
/2019-nCoV.ti,ab. /2019 ncov.ti,ab. /nCov.ti,ab. /Covid19.ti,ab. /SARSCoV-2.ti,ab. /'novel coronavirus'.ti,ab. /'novel
corona virus'.ti,ab. /covid*.ti,ab. /'severe acute respiratory syndrome'.ti,ab. /'coronavirus 2'.ti,ab. /'coronavirus disease'.ti,ab.
/'corona virus disease'.ti,ab. /'new coronavirus'.ti,ab. /'new corona virus'.ti,ab. /'new coronaviruses'.ti,ab /'novel
coronaviruses'.ti,ab. /Sars.ti,ab. /'sars corona virus'.ti,ab. /'respiratory infectious disease*'.ti,ab. /'acute respiratory
disease*'.ti,ab. /'influenza like illness'.ti,ab. /exp Pandemics/ /Pandemic*.ti,ab. /'respiratory disease'.ti,ab. /bracers.ti,ab.
/'double masking'.ti,ab. /'respiratory protection program'.ti,ab.
6.6.10 Physical distancing

Search terms
1 physical distancing/ 9392
185 of 209
2 (distancing or ((physical* or social* or intervention* or measure* or strategies or strategy or policy or policies or contact) adj5
distance*)).mp. 98182
3 1 or 2 98182
4 ((distance* or distant*) adj (learning or education)).mp. 7710
5 3 not 4 97480
6 (metre or metres or meter or meters or feet or foot or ft or yard* or centimeter* or centimetre* or cm or cms or 1m or 2m or "1
m" or "2 m" or "≥1m" or "≥2m" or "≤1m" or "≤2m" or ">1m" or ">2m" or "<1m" or "<2m" or "
7 ((compare or compared or comparison or comparing or versus or vs or "vs." or assess or assessed or assessing or evaluate or
evaluated or evaluating or measuring or ascertain* or optimum or optimal or ideal or best or minimum or short or shorter or shorten* or
shortest or long or longer or longest or length* or close or closer or closest or far or farther or farthest or further or furthest or small or
smaller or smallest or large or larger or largest or differ* or increasing or decreasing or exposure) adj5 (distance or
distances)).ti,ab,kf. 208318
8 6 or 7 5694865
9 5 and 8 33250
10 (predicter* or predictor* or predictive or ((risk or protective or multiple) adj3 factor*) or (risk adj3 (analysis or analyses or
assessment or evaluation or model*))).ti,ab,kf. or Risk Factors/ 4907279
11 5 and 10 7907
12 exp Disease Transmission, Infectious/ or transmission/ or communicable disease control/ or infection control/ 456188
186 of 209
13 (tm or pc).fs. 2937579

14 (transmission or transmissibility or transmit* or prevent* or spread* or containment).ti,ab,kf. 5727049
15 or/12-14 7766059
16 11 and 15 2729
17 9 or 16 35446
18 limit 17 to covid-19 5762
19 limit 18 to (meta analysis or "systematic review") 157
20 randomized controlled trial.pt. 1138501
21 controlled clinical trial.pt. 188275
22 randomized.ab. 2059666
23 placebo.ab. 896240
24 randomly.ab. 1204675
25 trial.ab. 2068182
26 groups.ab. 6397283
27 or/20-26 9555987
28 exp animals/ not humans.sh. 36234151
29 27 not 28 4923557
30 18 and 29 1490
31 exp cohort studies/ or exp epidemiologic studies/ or exp clinical trial/ or exp evaluation studies as topic/ or exp statistics as
topic/ 13109232
32 ((time and factors) or program or survey* or ci or cohort or comparative stud* or evaluation studies or follow-up*).mp.
15180580
33 (control and (group* or study)).mp. 6317732
34 or/31-33 25111022
35 (animals/ not humans/) or comment/ or editorial/ or exp review/ or meta analysis/ or consensus/ or exp guideline/
14617907
36 hi.fs. or case report.mp. 3620143
37 or/35-36 18035109
38 34 not 37 20747473
39 18 and 38 3611
40 19 or 30 or 39 4111
41 exp animals/ not humans/ 17316537
42 40 not 41 4109
43 (comment or editorial or newspaper article).pt. 2160773
44 42 not 43 4101
45 social distancing/ 12183
46 (distancing or ((physical* or social* or intervention* or measure* or strategies or strategy or policy or policies or contact) adj5
distance*)).ti,ab. 87355
47 45 or 46 93398
48 ((distance* or distant*) adj (learning or education)).mp. 7710
49 47 not 48 92712
50 (metre or metres or meter or meters or feet or foot or ft or yard* or centimeter* or centimetre* or cm or cms or 1m or 2m or "1
m" or "2 m" or "≥1m" or "≥2m" or "≤1m" or "≤2m" or ">1m" or ">2m" or "<1m" or "<2m" or "
51 ((compare or compared or comparison or comparing or versus or vs or "vs." or assess or assessed or assessing or evaluate or
evaluated or evaluating or measuring or ascertain* or optimum or optimal or ideal or best or minimum or short or shorter or shorten* or
shortest or long or longer or longest or length* or close or closer or closest or far or farther or farthest or further or furthest or small or
smaller or smallest or large or larger or largest or differ* or increasing or decreasing or exposure) adj5 (distance or distances)).ti,ab.
207648
52 50 or 51 5666290
53 49 and 52 32733
54 (predicter* or predictor* or predictive or ((risk or protective or multiple) adj3 factor*) or (risk adj3 (analysis or analyses or
assessment or evaluation or model*))).ti,ab. or risk factor/ 4976315
187 of 209
55 49 and 54 7508
56 exp disease transmission/ or exp nosocomial transmission/ or exp pathogen transmission/ or communicable disease control/ or
infection control/ 450246
57 (transmission or transmissibility or transmit* or spread* or containment).ti,ab,kw. 1852448
58 56 or 57 2112218
59 55 and 58 1557
60 53 or 59 34025
61 limit 60 to covid-19 4961
62 limit 61 to "systematic review" 1529
63 randomized controlled trial/ or controlled clinical trial/ or randomization/ or exp intermethod comparison/ or double-blind
procedure/ 2035290
64 human experiment/ 593123
65 (random$ or crossover or cross over or volunteer or volunteers or placebo or allocated or assigned or (open adj label)).ti,ab.
5570375
66 (compare or compared or comparison).ti. 1194113
67 ((evaluated or evaluate or evaluating or assessed or assess) and (compare or compared or comparing or
comparison)).ab. 4614752
68 ((double or single or doubly or singly) adj (blind or blinded or blindly)).ti,ab. 749260
69 parallel group$1.ti,ab. 90999
70 ((assign$ or match or matched or allocation) adj5 (alternate or group$1 or intervention$1 or patient$1 or subject$1 or
participant$1)).ti,ab. 812120
71 (controlled adj7 (study or design or trial)).ti,ab. 1173263
72 trial.ti. 1029826
73 or/63-72 11241401
74 (Systematic review not (trial or study)).ti. 414473
75 (random cluster adj3 sampl$).ti,ab. 2728
76 (review.ab. and review.pt.) not trial.ti. 2116515
77 (databases adj4 searched).ab. 101404
78 "we searched".ab. and (review.ti. or review.pt.) 82456
79 "update review".ab. 229
80 Random field$.ti,ab. 5958
81 (nonrandom$ not random$).ti,ab. 35836
82 (random$ adj sampl$ adj7 (cross section$ or questionnaire$1 or survey$ or database$1)).ti,ab. not (comparative study/ or
controlled study/ or randomi?ed controlled.ti,ab. or randomly assigned.ti,ab.) 18817
83 Cross-sectional study/ not (randomized controlled trial/ or controlled clinical trial/ or controlled study/ or randomi?ed
controlled.ti,ab. or control group$1.ti,ab.) 745980
84 (((case adj control$) and random$) not randomi?ed controlled).ti,ab. 38693
85 (rat or rats or mouse or mice or swine or porcine or murine or sheep or lambs or pigs or piglets or rabbit or rabbits or cat or cats
or dog or dogs or cattle or bovine or monkey or monkeys or trout or marmoset$1).ti. and animal experiment/ 1165072
86 Animal experiment/ not (human experiment/ or human/) 2450145
87 ("cochrane database of systematic reviews" or "cochrane database of systematic reviews online").jn. 55180
88 or/74-87 5770138
89 73 not 88 10231673
90 61 and 89 1632
91 Clinical article/ or controlled study/ or major clinical study/ or prospective study/ or cohort.mp. or compared.mp. or groups.mp.
or multivariate.mp. 24730657
92 case control study/ 521560
93 91 or 92 24878612
94 61 and 93 2375
95 62 or 90 or 94 3110
96 exp animal/ not exp human/ 10823124
97 95 not 96 3107
188 of 209
98 editorial.pt. 1357916
99 97 not 98 3099
100 1 or 46 91600
101 100 not 4 90919
102 52 and 101 32697
103 54 and 101 7311
104 12 or 13 or 57 4754501
105 103 and 104 1873
106 102 or 105 34205
107 (nCoV* or 2019nCoV or 19nCoV or COVID19* or COVID or SARS-COV-2 or SARSCOV-2 or SARS-COV2 or SARSCOV2 or
coronavirus* or corona virus* or betacoronavirus* or CoV or HCoV).mp. 677814
108 limit 107 to yr="2019 -Current" 645253
109 106 and 108 3674
110 44 use medall 1146
111 99 use emczd 1114
112 109 use cctr 81
113 109 use coch 0
114 110 or 111 or 112 or 113 2341
115 remove duplicates from 114 1879
189 of 209
6.6.11 Operating Rooms

Outcome terms
Setting terms
("operating rooms"[MeSH Terms] OR ("operating"[All Fields] AND "rooms"[All Fields]) OR "operating rooms"[All Fields] OR
("operating"[All Fields] AND "room"[All Fields]) OR "operating room"[All Fields] OR “operating theatre”[All Fields] OR “operating
suite”[All Fields] OR ("theater"[All Fields] OR "theaters"[All Fields] OR "theatre"[All Fields] OR "theatres"[All Fields]) OR
("surgery"[MeSH Subheading] OR "surgery"[All Fields] OR "surgical procedures, operative"[MeSH Terms] OR ("surgical"[All Fields]
AND "procedures"[All Fields] AND "operative"[All Fields]) OR "operative surgical procedures"[All Fields] OR "general
surgery"[MeSH Terms] OR ("general"[All Fields] AND "surgery"[All Fields]) OR "general surgery"[All Fields] OR "surgery s"[All
Fields] OR "surgerys"[All Fields] OR "surgeries"[All Fields]) OR ("operability"[All Fields] OR "operable"[All Fields] OR "operate"[All
Fields] OR "operated"[All Fields] OR "operates"[All Fields] OR "operating"[All Fields] OR "operation s"[All Fields] OR
"operational"[All Fields] OR "operative"[All Fields] OR "operatively"[All Fields] OR "operatives"[All Fields] OR "operator"[All Fields]
OR "operator s"[All Fields] OR "operators"[All Fields] OR "surgery"[MeSH Subheading] OR "surgery"[All Fields] OR "operations"[All
Fields] OR "surgical procedures, operative"[MeSH Terms] OR ("surgical"[All Fields] AND "procedures"[All Fields] AND
"operative"[All Fields]) OR "operative surgical procedures"[All Fields] OR "operation"[All Fields]) OR ("surgical procedures,
operative"[MeSH Terms] OR ("surgical"[All Fields] AND "procedures"[All Fields] AND "operative"[All Fields]) OR "operative surgical
procedures"[All Fields] OR "surgical"[All Fields] OR "surgically"[All Fields] OR "surgicals"[All Fields])) AND (y_1[Filter])
Intervention terms-cleaning
"clean"[All Fields] OR "cleaned"[All Fields] OR "cleaning"[All Fields] OR "cleanings"[All Fields] OR "cleanness"[All Fields] OR
"cleans"[All Fields] OR ("clean"[All Fields] OR "cleaned"[All Fields] OR "cleaning"[All Fields] OR "cleanings"[All Fields] OR
"cleanness"[All Fields] OR "cleans"[All Fields]) OR "sterile"[All Fields] OR "sterility"[All Fields] OR "sterilant"[All Fields] OR
"sterilants"[All Fields] OR "sterilely"[All Fields] OR "steriles"[All Fields] OR "sterilisation"[All Fields] OR "sterilization"[MeSH Terms]
OR ("sterilization"[All Fields] OR "sterilization"[All Fields] OR "sterilization"[MeSH Terms] OR "sterilisations"[All Fields] OR
"sterilised"[All Fields] OR "steriliser"[All Fields] OR "sterilisers"[All Fields] OR "sterilising"[All Fields] OR "sterilities"[All Fields] OR
"sterilise"[All Fields] OR "sterilize"[All Fields] OR "sterilizations"[All Fields] OR "sterilized"[All Fields] OR "sterilizer"[All Fields] OR
"sterilizers"[All Fields] OR "sterilizes"[All Fields] OR "sterilizing"[All Fields]) OR "decontaminant"[All Fields] OR "decontaminants"[All
Fields] OR "decontaminated"[All Fields] OR "decontaminates"[All Fields] OR "decontamination"[MeSH Terms] OR
"decontamination"[All Fields] OR "decontaminate"[All Fields] OR "decontaminating"[All Fields] OR "decontaminations"[All Fields]
OR "decontaminative"[All Fields] OR "disinfect"[All Fields] OR "disinfectable"[All Fields] OR "disinfectants"[Pharmacological Action]
OR "disinfectants"[MeSH Terms] OR "disinfectants"[All Fields] OR "disinfectant"[All Fields] OR "disinfected"[All Fields] OR
"disinfecting"[All Fields] OR "disinfection"[MeSH Terms] OR "disinfection"[All Fields] OR "disinfections"[All Fields] OR
"disinfective"[All Fields] OR "disinfects"[All Fields] OR “terminal cleaning”[All Fields] OR “terminal disinfection”[All Fields] AND
(y_1[Filter])
190 of 209
6.6.12 Waste Management

Outcome terms
Intervention terms
("waste"[All Fields] OR "waste s"[All Fields] OR "wastes"[All Fields] OR "medical waste"[All Fields] OR "biomedical waste"[All
Fields] OR "infectious waste"[All Fields] OR "healthcare waste"[All Fields] OR "hazardous waste"[All Fields] OR "contaminated
waste"[All Fields] OR "disposal"[All Fields] OR "disposals"[All Fields] OR "dispose"[All Fields] OR "disposed"[All Fields] OR
"disposer"[All Fields] OR "disposers"[All Fields] OR "disposes"[All Fields] OR "disposing"[All Fields]) AND (2020:2023[pdat]
191 of 209
6.6.13 Ventilation
Outcome terms
Intervention terms
("filtrate"[All Fields] OR "filtrated"[All Fields] OR "filtrates"[All Fields] OR "filtrating"[All Fields] OR "filtration"[MeSH Terms] OR
"filtration"[All Fields] OR "filtrations"[All Fields] OR ("recirculate"[All Fields] OR "recirculated"[All Fields] OR "recirculates"[All Fields]
OR "recirculating"[All Fields] OR "recirculation"[All Fields] OR "recirculations"[All Fields]) OR ("ventilated"[All Fields] OR
"ventilates"[All Fields] OR "ventilating"[All Fields] OR "ventilation"[MeSH Terms] OR "ventilation"[All Fields] OR "ventilate"[All
Fields] OR "ventilations"[All Fields] OR "ventilator s"[All Fields] OR "ventilators, mechanical"[MeSH Terms] OR ("ventilators"[All
Fields] AND "mechanical"[All Fields]) OR "mechanical ventilators"[All Fields] OR "ventilator"[All Fields] OR "ventilators"[All Fields]
OR "ventillation"[All Fields]) OR "HVAC"[All Fields] OR (("mechanical"[All Fields] OR "mechanically"[All Fields] OR
"mechanicals"[All Fields] OR "mechanics"[MeSH Terms] OR "mechanics"[All Fields] OR "mechanic"[All Fields]) AND ("drug delivery
systems"[MeSH Terms] OR ("drug"[All Fields] AND "delivery"[All Fields] AND "systems"[All Fields]) OR "drug delivery systems"[All
Fields] OR "system"[All Fields] OR "system s"[All Fields] OR "systems"[All Fields])) OR "Airconditioning"[All Fields] OR
(("ventilated"[All Fields] OR "ventilates"[All Fields] OR "ventilating"[All Fields] OR "ventilation"[MeSH Terms] OR "ventilation"[All
192 of 209
Fields] OR "ventilate"[All Fields] OR "ventilations"[All Fields] OR "ventilator s"[All Fields] OR "ventilators, mechanical"[MeSH Terms]
OR ("ventilators"[All Fields] AND "mechanical"[All Fields]) OR "mechanical ventilators"[All Fields] OR "ventilator"[All Fields] OR
"ventilators"[All Fields] OR "ventillation"[All Fields]) AND ("setting"[All Fields] OR "setting s"[All Fields] OR "settings"[All Fields])) OR
(("respiration, artificial"[MeSH Terms] OR ("respiration"[All Fields] AND "artificial"[All Fields]) OR "artificial respiration"[All Fields] OR
("mechanical"[All Fields] AND "ventilation"[All Fields]) OR "mechanical ventilation"[All Fields]) AND ("drug delivery systems"[MeSH
Terms] OR ("drug"[All Fields] AND "delivery"[All Fields] AND "systems"[All Fields]) OR "system"[All Fields] OR "system s"[All
Fields] OR "systems"[All Fields])) OR (("indoor"[All Fields] OR "indoors"[All Fields]) ("airflow"[All Fields] OR "airflows"[All Fields])
6.6.14 HEPA Filter

Search terms
1. air filters/
2. Air Ionization/
3. Ventilation/
(HVAC or HEPA or MERV or CADR or HRV or ERV or "Heating ventilation and air conditioning" or "High Efficiency
4. Particulate Air" or "High Efficiency Particulate Arrestance" or "Minimum Efficiency Reporting Value" or "Clean Air Delivery
Rate" or "Heat Recovery Ventilator" or "Energy Recovery Ventilator").ti,ab,kf.
5. (ventilation adj3 (unit* or system* or technolog* or vents or equipment or device*)).ti,ab,kf.
193 of 209
(air adj3 (cleaner* or cleaning or filter* or filtering or filtration or purifier* or purifying or purification or ultraviolet or ultra violet
6.
or UV or UVGI or UVC or actinic or ioni?er* or ioni?ing or ioni?ation or ozone or ozoni?er* or ozoni?ation)).ti,ab,kf.
7. (ion generator* or electrostatic precipitator*).mp.
8. or/1-7
9. air pollutants/ or air pollutants, occupational/
10. air pollution/ or air pollution, indoor/
11. Air/ or Air Microbiology/
12. Aerosols/ or Inhalation Exposure/
13. or/9-12
14. filtration/
15. Ultraviolet Rays/ or Ultraviolet Therapy/
16. or/14-15
17. 13 and 16
18. 8 or 17
21. 19 not 20
23. 21 not 22
24. exp air filter/ or hepa filter/ or air cleaning system/
25. room ventilation/
(HVAC or HEPA or MERV or CADR or HRV or ERV or "Heating ventilation and air conditioning" or "High Efficiency
26. Particulate Air" or "High Efficiency Particulate Arrestance" or "Minimum Efficiency Reporting Value" or "Clean Air Delivery
Rate" or "Heat Recovery Ventilator" or "Energy Recovery Ventilator").ti,ab,kw.
27. (ventilation adj3 (unit* or system* or technolog* or vents or equipment or device*)).ti,ab,kw.
(air adj3 (cleaner* or cleaning or filter* or filtering or filtration or purifier* or purifying or purification or ultraviolet or ultra violet
28.
or UV or UVGI or UVC or actinic or ioni?er* or ioni?ing or ioni?ation or ozone or ozoni?er* or ozoni?ation)).ti,ab,kw.
29. (ion generator* or electrostatic precipitator*).mp.
30. or/24-29
31. air pollution/ or air pollutant/ or air pollution control/ or indoor air pollution/
32. exp air/ or ambient air/ or workroom air/
33. aerosol/
34. 31 or 32 or 33
35. filtration/
36. exp ultraviolet radiation/ or ultraviolet germicidal irradiation/ or ultraviolet irradiation/
37. 35 or 36
38. 34 and 37
39. 30 or 38
42. 40 not 41
43. editorial.pt.
44. 42 not 43
45. 1 or 2 or 3 or 7 or 26 or 27 or 28
46. 17 or 45
Virus 2).mp.
194 of 209

51. 47 or 48 or 49 or 50
53. 46 and 52
54. 23 use medall
55. 44 use emczd
56. 53 use cctr
57. 53 use coch
58. 54 or 55 or 56 or 57
195 of 209
References
1. From emergency response to long-term COVID-19 disease management: sustaining gains made during the COVID-19 pandemic.
Geneva: World Health Organization; 2023. Website
2. Ending the COVID-19 emergency and transitioning from emergency phase to longer-term disease management: guidance on calibrating
the response, 4 September 2023. Geneva: World Health Organization; 2023. Website
3. Convention on the Rights of the Child: the children's version. New York: UNICEF; 1990. Website
4. Use of SARS-CoV-2 antigen-detection rapid diagnostic tests for COVID-19 self-testing: interim guidance, 9 March 2022. Geneva: World
Health Organization; 2022. Website
5. WHO COVID-19 Case definition. Geneva: World Health Organization; 2022. Website
6. Natural Ventilation for Infection Control in Health-Care Settings. Geneva: World Health Organization; 2009. Website
7. Roadmap to improve and ensure good indoor ventilation in the context of COVID-19. Geneva: World Health Organization; 2021.
Website
8. Infection prevention and control of epidemic-and pandemic prone acute respiratory infections in health care. Geneva: World Health
Organization; 2014. Website
9. Transmission-based precautions for the prevention and control of infections: aide-memoire. Geneva: World Health Organization; 2022.
Website
10. A GLOSSARY OF TERMS FOR COMMUNITY HEALTH CARE AND SERVICES FOR OLDER PERSONS. Geneva: World Health
11. Standard precautions for the prevention and control of infections: aide-memoire. Geneva: World Health Organization; 2022. Website
12. Standard precautions: Environmental cleaning and disinfection. Geneva: World Health Organization; OpenWHO; 2020. Website
13. Isolation Precautions. Centers for Disease Control and Prevention; Atlanta 2007. Website
14. Technical specifications of personal protective equipment for COVID-19. Geneva: World Health Organization; 2020. Website
15. WHO guidelines on hand hygiene in health care : a summary. Geneva: World Health Organization; 2009. Website
16. Standard precautions: Waste management. Geneva: World Health Organization; OpenWHO; Website
17. The world health report: 2006: working together for health. Geneva: World Health Organization; 2006. Website
18. COVID-19: occupational health and safety for health workers: interim guidance, 2 February 2021. Geneva: World Health Organization;
2021. Website
19. Hierarchy of Controls. National Institute for Occupational Safety and Health National Institute for Occupational Safety and Health;
2023. Website
196 of 209
20. COVID-19: occupational health and safety for health workers: interim guidance, 2 February 2021. Geneva: World Health Organization;
2021. Website
21. Infection prevention and control: Website. Geneva: World Health Organization; Website
22. ASTM standards & COVID-19. West Conshohocken (PA): ASTM International; 2021. Website
23. Directorate General of Drug Administration (DGDA). Dhaka: Ministry of Health & Family Welfare, Government of the People's Republic
of Bangladesh; 2021. Website
24. European Committee for Standardization. Brussels: Cen; 2021. Website
25. WHO guidance on research methods for health emergency and disaster risk management. Geneva: World Health Organization; 2021.
Website
26. Screening: when is it appropriate and how can we get it right?. World Health Organization: Regional Office for Europe 2020. Website
27. World Health Organization. “Crafting the mosaic”: A framework for resilient surveillance for respiratory viruses of epidemic and
pandemic potential. Geneva: World Health Organization; 2022. Website
28. Statement on the fifteenth meeting of the IHR (2005) Emergency Committee on the COVID-19 pandemic. Geneva: World Health
29. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014. Website
30. Schumemann H, Brożek J, Guyatt G, Oxman A. GRADE Handbook. Grading of Recommendations Assessment, Development and
Evaluation, Grade Working Group. GRADEPro Website
31. Guidelines for declaration of interests (WHO experts). Geneva: World Health Organization; 2021. Website
32. Chou R, Dana T, Jungbauer R,, Weeks C, McDonagh MS. Masks for prevention of respiratory virus infections, including SARS-CoV-2,
in health care and community settings: a living rapid review. Ann Intern Med. 2020;173(7):542-55. Pubmed Journal
33. Chou R, Dana T, Jungbauer R. Update Alert 8: Masks for Prevention of Respiratory Virus Infections, Including SARS-CoV-2, in Health
Care and Community Settings. Annals of internal medicine 2022;175(9):W108-W109 Pubmed Journal
34. Tricco A, Langlois E, Straus S. Rapid reviews to strengthen health policy and systems: a practical guide. World Health Organization;
Geneva 2017. Website
35. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-
disciplinary health research. BMC medical research methodology 2013;13:117 Pubmed Journal
36. Chou R, Dana T, Buckley DI,, Selph S, Fu R, Totten AM. Epidemiology of and risk factors for coronavirus infection in health care
workers: a living rapid review. Ann Intern Med. 2020;173(2):120-36. Pubmed Journal
37. Chou R, Dana T, Buckley DI,, Selph S, Fu R, Totten AM. Update alert 10: epidemiology of and risk factors for coronavirus infection in
health care workers. Ann Intern Med. 2022;175(1):W8-W9. Pubmed Journal
38. Ford N, Holmer HK, Chou R,, Villeneuve PJ, Baller A, et al. Mask use in community settings in the context of COVID-19: a systematic
review of ecological data. EClinicalMedicine. 2021;38::101024 Pubmed Journal
197 of 209
39. Dewidar O, Lotfi T, Langendam M, Parmelli E, Saz Parkinson Z, Solo K, et al. Which actionable statements qualify as good practice
statements In Covid-19 guidelines? A systematic appraisal. BMJ evidence-based medicine 2022;27(6):361-369 Pubmed Journal
40. Andrews JC, Schünemann Hj Fau - Oxman AD, Oxman Ad Fau - Pottie K, Pottie K Fau - Meerpohl JJ, Meerpohl Jj Fau - Coello PA,
Coello Pa Fau - Rind D, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation's
direction and strength. J Clin Epidemiol 2013;66(7):726-35 Pubmed Journal
41. Guyatt GH, Alonso-Coello P, Schünemann HJ,, Djulbegovic B, Nothacker M, et al. Guideline panels should seldom make good practice
statements: guidance from the GRADE Working Group. J Clin Epidemiol. 2016;80::3-7. Pubmed Journal
42. Lotfi T, Hajizadeh A, Moja L,, Akl EA, Piggott T, et al. A taxonomy and framework for identifying and developing actionable statements
in guidelines suggests avoiding informal recommendations. J Clin Eidemiol. 2021;141::161-71. Pubmed Journal
43. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level.
44. Allegranzi B, Bagheri Nejad S, Combescure C,, Graafmans W, Attar H, et al. Burden of endemic health-care-associated infection in
developing countries: systematic review and meta-analysis. Lancet. 2011;377(9761):228-41. Pubmed Journal
45. Interim practical manual: supporting national implementation of the WHO guidelines on core components of infection prevention and
control programmes. Geneva: World Health Organization; 2017. Website
46. Improving infection prevention and control at the health facility: interim practical manual supporting implementation of the WHO
guidelines on core components of infection prevention and control programmes. Geneva: World Health Organization; 2018. Website
47. Core competencies for infection prevention and control professionals. World Health Organization; Geneva 2020. Website
48. Chain of Infection Components. National Institute for Occupational Safety and Health; 2022. Website
49. Casadevall A, Pirofski LA. Host-pathogen interactions: basic concepts of microbial commensalism, colonization, infection, and disease.
Infection and immunity 2000;68(12):6511-8 Pubmed
50. Occupational safety and health in public health emergencies: a manual for protecting health workers and responders. World Health
Organization; Geneva 2018. Website
51. The COVID-19 Clinical CARE Pathway. World Health Organization; Geneva 2022. Website
52. Living guidance for clinical management of COVID-19: living guidance, 13 January 2023. Geneva: World Health Organization; Website
53. CONTACT AND DROPLET PRECAUTIONS - COVID-19 PERSONAL PROTECTIVE EQUIPMENT (PPE). Geneva: World Health
54. Antigen-detection in the diagnosis of SARS-CoV-2 infection: interim guidance, 6 October 2021. Geneva: World Health Organization;
2021. Website
55. Diagnostic testing for SARS-CoV-2. Geneva: World Health Organization; 2020. Website
56. Herstein JJ, Degarege A, Stover D, Austin C, Schwedhelm MM, Lawler JV, et al. Characteristics of SARS-CoV-2 Transmission among
Meat Processing Workers in Nebraska, USA, and Effectiveness of Risk Mitigation Measures. Emerging infectious diseases
2021;27(4):1032-1038 Pubmed Journal
198 of 209
57. Eykelbosh A. Physical barriers for COVID-19 infection prevention and control in commercial settings. National Collaborating Centre for
Environmental Health; Vancouver 2020. Website
58. van den Berg P, Schechter-Perkins EM, Jack RS, Epshtein I, Nelson R, Oster E, et al. Effectiveness of 3 Versus 6 ft of Physical
Distancing for Controlling Spread of Coronavirus Disease 2019 Among Primary and Secondary Students and Staff: A Retrospective,
Statewide Cohort Study. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
2021;73(10):1871-1878 Pubmed Journal
59. Source Control: CDC. Center for Disease Control and Prevention; Atlanta Website
60. Considerations for implementing and adjusting public health and social measures in the context of COVID-19. Geneva: World Health
61. Lan F-Y, Christophi CA, Buley J,, Iliaki E, Bruno-Murtha LA, et al. Effects of universal masking on Massachusetts healthcare workers'
COVID-19 incidence. Occup Med (Lond). 2020;70(8):606-9. Pubmed Journal
62. Seidelman JL, Lewis SS, Advani SD,, Akinboyo IC, Epling C, et al. Universal masking is an effective strategy to flatten the severe
acute respiratory coronavirus virus 2 (SARS-CoV-2) healthcare worker epidemiologic curve. Infect Control Hosp Epidemiol.
2020;41(12):1466-7. Pubmed Journal
63. Wang DD, O'Neill WW, Zervos MJ,, McKinnon JE, Allard D, et al. Association between implementation of a universal face mask policy
for healthcare workers in a health care system and SARS-CoV-2 positivity testing rate in healthcare workers. J Occup Environ Med.
2021;63(6):476-81. Pubmed Journal
64. Temkin E, Schwaber MJ, Vaturi A,, Nadir E, Zilber R, et al. Effect of a national policy of universal masking and uniform criteria for
severe acute respiratory coronavirus virus 2 (SARS-CoV-2) exposure on hospital staff infection and quarantine. Infect Control Hosp
Epidemiol. 2021;3 May 2021::1-7. Pubmed Journal
65. Wang X, Ferro EG, Zhou G,, Hashimoto D, Bhatt DL. Association between universal masking in a health care system and SARS-
CoV-2 positivity among health care workers. JAMA. 2020;324(7):703-4. Pubmed Journal
66. Ribeiro AI, Triguero-Mas M, Jardim Santos C, Gómez-Nieto A, Cole H, Anguelovski I, et al. Exposure to nature and mental health
outcomes during COVID-19 lockdown. A comparison between Portugal and Spain. Environment international 2021;154:106664 Pubmed
Journal
67. Setiawan HW, Pratiwi IN, Nimah L, Pawanis Z, Bakhtiar A, Fauzinigtyas R, et al. Challenges for Healthcare Workers Caring for
COVID-19 Patients in Indonesia: A Qualitative Study. Inquiry : a journal of medical care organization, provision and financing
2021;58:469580211060291 Pubmed Journal
68. Broom J, Broom A, Williams Veazey L, Burns P, Degeling C, Hor S, et al. "One minute it's an airborne virus, then it's a droplet virus,
and then it's like nobody really knows…": Experiences of pandemic PPE amongst Australian healthcare workers. Infection, disease &
health 2022;27(2):71-80 Pubmed Journal
69. Candido G, Tortù C, Seghieri C, Tartaglia R, Baglioni C, Citti P, et al. Physical and stressful psychological impacts of prolonged
personal protective equipment use during the COVID-19 pandemic: A cross-sectional survey study. Journal of infection and public health
2023;16(8):1281-1289 Pubmed Journal
70. Hoernke K, Djellouli N, Andrews L, Lewis-Jackson S, Manby L, Martin S, et al. Frontline healthcare workers' experiences with personal
protective equipment during the COVID-19 pandemic in the UK: a rapid qualitative appraisal. BMJ open 2021;11(1):e046199 Pubmed
Journal
71. Markkanen P, Brouillette N, Quinn M, Galligan C, Sama S, Lindberg J, et al. "It changed everything": The safe Home care qualitative
study of the COVID-19 pandemic's impact on home care aides, clients, and managers. BMC health services research 2021;21(1):1055
Pubmed Journal
199 of 209
72. Romeu-Labayen M, Tort-Nasarre G, Alvarez B, Subias-Miquel M, Vázquez-Segura E, Marre D, et al. Spanish nurses' experiences with
personal protective equipment and perceptions of risk of contagion from COVID-19: A qualitative rapid appraisal. Journal of clinical nursing
2022;31(15-16):2154-2166 Pubmed Journal
73. Venesoja A, Grönman K, Tella S, Hiltunen S, Koljonen K, Butylina S, et al. Healthcare Workers' Experiences and Views of Using
Surgical Masks and Respirators, and Their Attitudes on the Sustainability: A Semi-Structured Survey Study during COVID-19. Nursing
reports (Pavia, Italy) 2021;11(3):615-628 Pubmed Journal
74. Global analysis of health care waste in the context of COVID-19. Geneva: World Health Organization 2022. Website
75. Hospital Respiratory Protection Program Toolkit. The National Institute for Occupational Safety and Health (NIOSH) Website
76. Appendix A to §1910.134—fit testing procedures (mandatory) Part I. OSHA-accepted fit test protocols. Washington (DC): United States
Department of Labor; 2004. Website
77. Blachere FM, Lemons AR, Coyle JP, Derk RC, Lindsley WG, Beezhold DH, et al. Face mask fit modifications that improve source
control performance. American journal of infection control 2022;50(2):133-140 Pubmed Journal
78. Brooks JT, Beezhold DH, Noti JD, Coyle JP, Derk RC, Blachere FM, et al. Maximizing Fit for Cloth and Medical Procedure Masks to
Improve Performance and Reduce SARS-CoV-2 Transmission and Exposure, 2021. MMWR. Morbidity and mortality weekly report
2021;70(7):254-257 Pubmed Journal
79. Clapp PW, Sickbert-Bennett EE, Samet JM, Berntsen J, Zeman KL, Anderson DJ, et al. Evaluation of Cloth Masks and Modified
Procedure Masks as Personal Protective Equipment for the Public During the COVID-19 Pandemic. JAMA internal medicine
2021;181(4):463-469 Pubmed Journal
80. Ingabire J, McKenney H, Sebesta C, Badhiwala K, Kemere C, Kapur S, et al. Evaluation of Aerosol Particle Leak and Standard
Surgical Mask Fit With 3 Elastomeric Harness Designs. JAMA network open 2022;5(1):e2145811 Pubmed Journal
81. Fletcher JJ, Feucht EC, Hahn PY,, McGoff TN, Dehart DJ, et al. Healthcare-acquired coronavirus disease 2019 (COVID-19) is less
symptomatic than community-acquired disease among healthcare workers. Infect Control Hosp Epidemiol. 2021;1-7. Pubmed Journal
82. Haller S, Güsewell S, Egger T,, Scanferla G, Thoma R. Impact of respirator versus surgical masks on SARS-CoV-2 acquisition in
healthcare workers: a prospective multicentre cohort. Antimicrob Resist Infect Control. 2022;11(1):27 Pubmed Journal
83. Sims MD, Maine GN, Childers KL,, Podolsky RH, Voss DR, et al. Coronavirus disease 2019 (COVID-19) seropositivity and
asymptomatic rates in healthcare workers are associated with job function and masking. Clin Infect Dis. 2021;73(Suppl 2):S154-62.
Pubmed Journal
84. Piapan L, De Michieli P, Ronchese F,, Rui F, Mauro M, et al. COVID-19 outbreak in healthcare workers in hospitals in Trieste, north-
east Italy. J Hosp Infect. 2020;106(3):626-8. Pubmed Journal
85. Venugopal U, Jilani N, Rabah S,, Shariff MA, Jawed M, et al. SARS-CoV-2 seroprevalence among health care workers in a New York
City hospital: a cross-sectional analysis during the COVID-19 pandemic. Int J Infect Dis. 2021;102::63-9. Pubmed Journal
86. Loeb M, Bartholomew A, Hashmi M, Tarhuni W, Hassany M, Youngster I, et al. Medical Masks Versus N95 Respirators for Preventing
COVID-19 Among Health Care Workers : A Randomized Trial. Annals of internal medicine 2022;175(12):1629-1638 Pubmed Journal
87. Priority medical devices list for the COVID-19 response and associated technical specifications. Geneva: World Health Organization;
2020. Website
88. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory
infections to healthcare workers: a systematic review. PloS one 2012;7(4):e35797 Pubmed Journal
200 of 209
89. WASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities. Second edition.
90. Kwok CS, Dashti M, Tafuro J, Nasiri M, Muntean E-A, Wong N, et al. Methods to disinfect and decontaminate SARS-CoV-2: a
systematic review of in vitro studies. Therapeutic advances in infectious disease 2021;8:2049936121998548 Pubmed Journal
91. Tyan K, Levin A, Avalos-Pacheco A, Plana D, Rand EA, Yang H, et al. Considerations for the Selection and Use of Disinfectants
Against SARS-CoV-2 in a Health Care Setting. Open forum infectious diseases 2020;7(9):ofaa396 Pubmed Journal
92. Essential environmental health standards in health care. Geneva: World Health Organization; 2008. Website
93. Aide-memoire: environmental cleaning, waste and linen management. In: Infection prevention and control: guidance to action tools.
94. Disinfectant Use and Coronavirus (COVID-19) | United States Environmental Protection Agency. United States Environmental
Protection Agency Website
95. Safe managment of wastes from health-care activities, 2nd edition. World Health Organization; Geneva 2014. Website
96. Environmental cleaning and infection prevention and control in health care facilities in low- and middle-income countries. World Health
Organization; Geneva 2023. Website
97. Fujita R, Kurosu H, Norizuki M, Ohishi T, Zamoto-Niikura A, Iwaki M, et al. Potential risk of SARS-CoV-2 infection among people
handling linens used by COVID-19 patients before and after washing. Scientific reports 2022;12(1):14994 Pubmed Journal
98. Rani S. A review of the management and safe handling of bodies in cases involving COVID-19. Medicine, science, and the law
2020;60(4):287-293 Pubmed Journal
99. WHO guideline on the use of safety-engineered syringes for intramuscular, intradermal and subcutaneous injections in health care
settings. Geneva: World Health Organization; 2016. Website
100. Immunization in practice: a practical guide for health staff, 2015 update. Geneva: World Health Organization; 2015. Website
101. Aide-mémoire for a national strategy for the safe and appropriate use of injections. Geneva: World Health Organization; 2000.
Website
102. Glove use information leaflet. Geneva: World Health Organization; 2009. Website
103. Interim recommendations for the use of mRNA COVID-19 vaccines. Geneva: World Health Organization; 2023. Website
104. Pittet D, Ducel G. Infectious risk factors related to operating rooms. Infection control and hospital epidemiology 1994;15(7):456-62
Pubmed
105. Mayworm D. Keeping Your OR Clean: Five guidelines for controlling the environment to help prevent contamination and infections.
Association of periOperative Registered Nurses: Denver; 2007. Website
106. Infection Prevention and Control (IPC) Protocol for Adult Surgical Procedures During the COVID-19 Pandemic. 2022. Journal
Website
107. Glasbey JC, Nepogodiev D, Simoes JFF, Omar O, Li E, Venn ML, et al. Elective Cancer Surgery in COVID-19-Free Surgical
Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study. Journal of clinical oncology :
201 of 209
official journal of the American Society of Clinical Oncology 2021;39(1):66-78 Pubmed Journal
108. Decontamination and reprocessing of medical devices for health care facilities: aide-memoire. Geneva: World Health Organization;
2022. Website
109. Kitazawa A. Infection Prevention and Control at Home. Japan Medical Association journal : JMAJ 2015;58(1-2):27-30 Pubmed
110. Dyer AH, Fallon A, Noonan C, Dolphin H, O'Farrelly C, Bourke NM, et al. Managing the Impact of COVID-19 in Nursing Homes and
Long-Term Care Facilities: An Update. Journal of the American Medical Directors Association 2022;23(9):1590-1602 Pubmed Journal
111. Stratil JM, Biallas RL, Burns J, Arnold L, Geffert K, Kunzler AM, et al. Non-pharmacological measures implemented in the setting of
long-term care facilities to prevent SARS-CoV-2 infections and their consequences: a rapid review. The Cochrane database of systematic
reviews 2021;9(9):CD015085 Pubmed Journal
112. Estabrooks CA, Ewa V, Keefe J, Straus SE. The predictable crisis of covid-19 in Canada's long term care homes. BMJ (Clinical
research ed.) 2023;382:e075148 Pubmed Journal
113. How to implement seasonal influenza vaccination of health workers: an introduction manual for national immunization programme
managers and policy makers. Geneva: World Health Organization; 2019. Website
114. Abbas M, Robalo Nunes T, Martischang R, Zingg W, Iten A, Pittet D, et al. Nosocomial transmission and outbreaks of coronavirus
disease 2019: the need to protect both patients and healthcare workers. Antimicrobial Resistance & Infection Control 2021;10(1):7 Journal
Website
115. Mutambudzi M, Niedzwiedz C, Macdonald EB, Leyland A, Mair F, Anderson J, et al. Occupation and risk of severe COVID-19:
prospective cohort study of 120 075 UK Biobank participants. Occupational and Environmental Medicine 2021;78(5):307-314 Journal
Website
116. Shbaklo NA-O, Lupia TA-O, De Rosa FA-O, Corcione S.. Infection Control in the Era of COVID-19: A Narrative Review. Antibiotics
2021;10(10) Pubmed Journal
117. Brown CS, Clare K, Chand M, Andrews J, Auckland C, Beshir S, et al. Snapshot PCR surveillance for SARS-CoV-2 in hospital staff in
England. The Journal of infection 2020;81(3):427-434 Pubmed Journal
118. Arons MM, Hatfield KM, Reddy SC, Kimball A., James A., Jacobs JR, et al. Presymptomatic SARS-CoV-2 Infections and
Transmission in a Skilled Nursing Facility. N Engl J Med 2020;382(22):2081-2090
119. Moghadas SM, Fitzpatrick MC, Sah P, Pandey A, Shoukat A, Singer BH, et al. The implications of silent transmission for the control of
COVID-19 outbreaks. Proceedings of the National Academy of Sciences of the United States of America 2020;117(30):17513-17515
Pubmed Journal
120. Kalish HA-O, Klumpp-Thomas CA-O, Hunsberger S., Baus HA, Fay MA-O, Siripong NA-O, et al. Undiagnosed SARS-CoV-2
seropositivity during the first 6 months of the COVID-19 pandemic in the United States. Sci Transl Med 2021;13(601):22 Pubmed Journal
121. Jones TA-O, Biele GA-O, Mühlemann BA-O, Veith TA-O, Schneider JA-O, Beheim-Schwarzbach J., et al. Estimating infectiousness
throughout SARS-CoV-2 infection course. Science 2021;373(6551):25 Pubmed Journal
122. Hakki S, Zhou J, Jonnerby J, Singanayagam A, Barnett JL, Madon KJ, et al. Onset and window of SARS-CoV-2 infectiousness and
temporal correlation with symptom onset: a prospective, longitudinal, community cohort study. The Lancet. Respiratory medicine
2022;10(11):1061-1073 Pubmed Journal
123. Blann AD, Heitmar R. SARS-CoV-2 and COVID-19: A Narrative Review. British journal of biomedical science 2022;79:10426 Pubmed
Journal
202 of 209
124. Jamison DA, Anand Narayanan S., Trovão NS, Guarnieri JW, Topper MJ, Moraes-Vieira PM, et al. A comprehensive SARS-CoV-2
and COVID-19 review, Part 1: Intracellular overdrive for SARS-CoV-2 infection. Journal Website
125. World Health Organization. Recommendations for national SARS-CoV-2 testing strategies and diagnostic capacities. Geneva, World
126. Public health surveillance for COVID-19: interim guidance. World Health Organization; Geneva 2022. Website
127. Contact tracing and quarantine in the context of COVID-19: interim guidance, 6 July 2022. Geneva: World Health Organization 2022.
Website
128. World Health Organization. WHO policy brief: COVID-19 testing, 14 September 2022. Geneva: World Health Organization; 2022.
Website
129. Framework and toolkit for infection prevention and control in outbreak preparedness, readiness and response at the national level.
130. Framework and toolkit for infection prevention and control in outbreak preparedness, readiness and response at the health care
facility level. World Health Organization; Geneva 2022. Website
131. Defining collaborative surveillance: a core concept for strengthening the global architecture for health emergency preparedness,
response, and resilience (HEPR). World Health Organization; Geneva 2023. Website
132. WHO policy brief: Maintaining infection prevention and control measures for COVID-19 in health care facilities, 14 September 2022.
133. WHO policy brief: COVID-19 surveillance, 11 April 2023. Geneva: World Health Organization; 2023. Website
134. Strategic preparedness, readiness and response plan to end the global COVID-19 emergency in 2022. Geneva: Word Health
135. Coronavirus disease (COVID-19) weekly epidemiological update and weekly operational update. Geneva: World Health Organization;
2023. Website
136. Roberge RJ. Face shields for infection control: a review. J Occup Environ Hyg. 2016;13(4):235-42. Pubmed Journal
137. Abaluck J, Kwong LH, Styczynski A,, Haque A, Kabir MD, et al. The impact of community masking on COVID-19: a cluster
randomized trial in Bangladesh. Science. 2022;375(6577) Pubmed Journal
138. Bundgaard H, Bundgaard JS, Raaschou-Pedersen DET,, von Buchwald C, Todsen T, et al. Effectiveness of adding a mask
recommendation to other public health measures to prevent SARS-CoV-2 infection in Danish mask wearers: a randomized controlled trial.
Ann Intern Med. 2021;174(3):335-43. Pubmed Journal
139. Andrejko KL, Pry JM, Myers JF, Fukui N, DeGuzman JL, Openshaw J, et al. Effectiveness of Face Mask or Respirator Use in Indoor
Public Settings for Prevention of SARS-CoV-2 Infection - California, February-December 2021. MMWR. Morbidity and mortality weekly
report 2022;71(6):212-216 Pubmed Journal
140. Doung-Ngern P, Suphanchaimat R, Panjangampatthana A,, Janekrongtham C, Ruampoom D, et al. Case-control study of use of
personal protective measures and risk for SARS-CoV-2 infection, Thailand. Emerg Infect Dis. 2020;26(11):2607-16. Pubmed Journal
141. Gonçalves MR, Dos Reis RCP, Tólio RP, Pellanda LC, Schmidt MI, Katz N, et al. Social Distancing, Mask Use, and Transmission of
Severe Acute Respiratory Syndrome Coronavirus 2, Brazil, April-June 2020. Emerging infectious diseases 2021;27(8):2135-2143 Pubmed
203 of 209
Journal
142. Lio CF, Cheong HH, Lei CI, Lo IL, Yao L, Lam C, et al. Effectiveness of personal protective health behaviour against COVID-19. BMC
public health 2021;21(1):827 Pubmed Journal
143. Rebmann T, Loux TM, Arnold LD, Charney R, Horton D, Gomel A. SARS-CoV-2 Transmission to Masked and Unmasked Close
Contacts of University Students with COVID-19 - St. Louis, Missouri, January-May 2021. MMWR. Morbidity and mortality weekly report
2021;70(36):1245-1248 Pubmed Journal
144. Sharif N, Alzahrani KJ, Ahmed SN, Opu RR, Ahmed N, Talukder A, et al. Protective measures are associated with the reduction of
transmission of COVID-19 in Bangladesh: A nationwide cross-sectional study. PloS one 2021;16(11):e0260287 Pubmed Journal
145. Sugimura M, Chimed-Ochir O, Yumiya Y, Ohge H, Shime N, Sakaguchi T, et al. The Association between Wearing a Mask and
COVID-19. International journal of environmental research and public health 2021;18(17) Pubmed Journal
146. Tjaden AH, Gibbs M, Runyon M, Weintraub WS, Taylor YJ, Edelstein SL, et al. Association between Self-reported Masking Behavior
and SARS-CoV-2 Infection Wanes from Pre-Delta to Omicron-Predominant Periods - North Carolina COVID-19 Community Research
Partnership (NC-CCRP). American journal of infection control 2022. Pubmed Journal
147. van den Broek-Altenburg EM, Atherly AJ, Diehl SA,, Gleason KM, Hart VC, et al. Jobs, housing, and mask wearing: cross-sectional
study of risk factors for COVID-19. JMIR Public Health Surveill. 2021;7(1) Pubmed Journal
148. Wang YU, Tian H, Zhang L,, Zhang M, Guo D, et al. Reduction of secondary transmission of SARS-CoV-2 in households by face
mask use, disinfection and social distancing: a cohort study in Beijing, China. BMJ Glob Health. 2020;5(5) Pubmed Journal
149. Hale T, Angrist N, Goldszmidt R, Kira B, Petherick A, Phillips T, et al. A global panel database of pandemic policies (Oxford COVID-19
Government Response Tracker). Nature human behaviour 2021;5(4):529-538 Pubmed Journal
150. Face masks and coverings for the general public: Behavioural knowledge, effectiveness of cloth coverings and public messaging. The
Royal Society 2020. Website
151. Tsang PM, Prost A. Boundaries of solidarity: a meta-ethnography of mask use during past epidemics to inform SARS-CoV-2
suppression. BMJ global health 2021;6(1) Pubmed Journal
152. Machida M, Nakamura I, Saito R,, Nakaya T, Hanibuchi T, et al. Incorrect use of face masks during the current COVID-19 pandemic
among the general public in Japan. Int J Environ Res Public Health. 2020;17(18):6484 Pubmed Journal
153. Milton DK, Fabian MP, Cowling B,, Grantham ML, McDevitt JJ. Influenza virus aerosols in human exhaled breath: particle size,
culturability, and effect of surgical masks. PLoS Pathog. 2013;9(3) Pubmed Journal
154. Chen Y-J, Qin G, Chen J,, Xu J-L, Feng D-Y, et al. Comparison of face-touching behaviors before and during the coronavirus disease
2019 pandemic. JAMA Netw Open. 2020;3(7):e2016924 Pubmed Journal
155. Shiraly R, Shayan Z, McLaws M-L. Face touching in the time of COVID-19 in Shiraz, Iran. Am J Infect Control. 2020;48(12):1559-61.
Pubmed Journal
156. Betsch C, Korn L, Sprengholz P,, Felgendreff L, Eitze S, Schmid P. Social and behavioral consequences of mask policies during the
COVID-19 pandemic. Proc Natl Acad Sci U S A . 2020;117(36):21851-3. Pubmed Journal
157. Cowling BJ, Ali ST, Ng T,, Tsang TK, Li JCM, Fong MW. Impact assessment of non-pharmaceutical interventions against coronavirus
disease 2019 and influenza in Hong Kong: an observational study. Lancet Public Health. 2020;5(5):e279-88. Pubmed Journal
204 of 209
158. Bakhit M, Krzyzaniak N, Scott A,, Clark J, Glasziou P, Del Mar C. Downsides of face masks and possible mitigation strategies: a
systematic review and meta-analysis. BMJ Open. 2021;11(2):e044364 Pubmed Journal
159. Kunstler B, Newton S, Hill H, Ferguson J, Hore P, Mitchell BG, et al. P2/N95 respirators & surgical masks to prevent SARS-CoV-2
infection: Effectiveness & adverse effects. Infection, disease & health 2022;27(2):81-95 Pubmed Journal
160. Kisielinski K, Giboni P, Prescher A, Klosterhalfen B, Graessel D, Funken S, et al. Is a Mask That Covers the Mouth and Nose Free
from Undesirable Side Effects in Everyday Use and Free of Potential Hazards?. International journal of environmental research and public
health 2021;18(8) Pubmed Journal
161. Balestracci B, La Regina M, Di Sessa D, Mucci N, Angelone FD, D'Ecclesia A, et al. Patient safety implications of wearing a face
mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations. Internal and emergency
medicine 2022. Pubmed Journal
162. Thatiparthi A, Liu J, Martin A, Wu JJ. Adverse Effects of COVID-19 and Face Masks: A Systematic Review. The Journal of clinical
and aesthetic dermatology 2021;14(9 Suppl 1):S39-S45 Pubmed
163. Giacalone S, Minuti A, Spigariolo C,, Passoni E, Nazzaro G. Facial dermatoses in the general population due to wearing of personal
protective masks during the COVID-19 pandemic: first observations after lockdown. Clin Exp Dermatol. 2021;46(2):368-9. Pubmed Journal
164. Matusiak Ł, Szepietowska M, Krajewski P,, Białynicki‐Birula R, Szepietowski JC. Inconveniences due to the use of face masks during
the COVID‐19 pandemic: a survey study of 876 young people. Dermatol Ther. 2020;33(4):e13567 Pubmed Journal
165. Hüfner K, Hofer A, Sperner-Unterweger B. On the difficulties of building therapeutic relationships when wearing face masks. J
Psychosom Res. 2020;138(110226):110226 Pubmed Journal
166. Crume B. The silence behind the mask: my journey as a deaf pediatric resident amid a pandemic. Acad Pediatr. 2020;21(1):1-2.
Pubmed Journal
167. Cowling BJ, Chan K-H, Fang V,, Cheng CKY, Fung ROP, et al. Facemasks and hand hygiene to prevent influenza transmission in
households: a cluster randomized trial. Ann Intern Med. 2009;151(7):437-46. Pubmed Journal
168. Allison MA, Guest‐Warnick G, Nelson D,, Pavia AT, Srivastava R, et al. Feasibility of elementary school children’s use of hand gel and
facemasks during influenza season. Influenza Other Respir Viruses. 2010;4(4):223-9. Pubmed Journal
169. Canini L, Andréoletti L, Ferrari P,, D'Angelo R, Blanchon T, et al. Surgical mask to prevent influenza transmission in households: a
cluster randomized trial. PloS One. 2010;5(11) Pubmed Journal
170. Uchida M, Kaneko M, Hidaka Y,, Yamamoto H, Honda T, et al. Effectiveness of vaccination and wearing masks on seasonal influenza
in Matsumoto City, Japan, in the 2014/2015 season: An observational study among all elementary schoolchildren. Prev Med Rep.
2017;5::86-91. Pubmed Journal
171. Zand AD, Heir AV. Environmental impacts of new coronavirus outbreak in Iran with an emphasis on waste management sector. J
Mater Cycles Waste Manag. 2021;23(1):240-7. Pubmed Journal
172. Coronavirus disease (COVID-19) advice for the public: when and how to use masks. Geneva: World Health Organization; 2020.
Website
173. Scott N, Saul A, Spelman T,, Stoove M, Pedrana A, et al. The introduction of a mandatory mask policy was associated with
significantly reduced COVID-19 cases in a major metropolitan city. PloS One. 2021;16(7) Pubmed Journal
174. Aydin O, Emon B, Cheng S,, Hong L, Chamorro LP, Saif MTA. Performance of fabrics for home-made masks against the spread of
COVID-19 through droplets: a quantitative mechanistic study. Extreme Mech Lett. 2020;40. Pubmed Journal
205 of 209
175. Fischer EP, Fischer MC, Grass D,, Henrion I, Warren WS, Westman E. Low-cost measurement of face mask efficacy for filtering
expelled droplets during speech. Sci Adv. 2020;6(36) Pubmed Journal
176. Infection prevention and control (IPC) in health-care facilities in the event of a surge or resurgence in cases of COVID-19. Geneva:
World Health Organization; 2021. Website
177. Lustig SR, Biswakarma JJH, Rana D, Tilford SH, Hu W, Su M, et al. Effectiveness of Common Fabrics to Block Aqueous Aerosols of
Virus-like Nanoparticles. ACS nano 2020;14(6):7651-7658 Pubmed Journal
178. Lee S-A, Hwang D-C, Li H-Y, Tsai C-F, Chen C-W, Chen J-K. Particle Size-Selective Assessment of Protection of European Standard
FFP Respirators and Surgical Masks against Particles-Tested with Human Subjects. Journal of healthcare engineering 2016;2016 Pubmed
Journal
179. Bull FC, Al-Ansari SS, Biddle S,, Borodulin K, Buman MP, Cardon G. World Health Organization 2020 guidelines on physical activity
and sedentary behaviour. Br J Sports Med. 2020;54(24):1451-62. Pubmed Journal
180. Advice on the use of masks for children in the community in the context of COVID-19. Geneva: World Health Organization; 2020.
Website
181. Mask use in the context of COVID-19: interim guidance, 1 December 2020. Geneva: World Health Organization; 2020. Website
182. Version 1.0 of the COVID-19 infection prevention and control living guideline: mask use in community settings. Geneva: World Health
183. Bialek S, Gierke R, Hughes M,, McNamara LA, Pilishvili T, Skoff T. Coronavirus disease 2019 in children - United States, February
12-April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(14):422-6. Pubmed Journal
184. COVID-19 in children and the role of school settings in transmission – second update. Stockholm: European Centre for Disease
Prevention and Control; 2021. Website
185. Divala T, Sakala M, Chirombo J, Baggaley R, Sacks JA, Johnson C. Use of SARS-CoV-2 antigen-detection rapid diagnostic tests for
COVID-19 self-testing: interim guidance, 9 March 2022: web annex D: global survey on COVID-19 self-testing using SARS-CoV-2 Ag-
RDTs. Geneva: World Health Organization; 2022. Website
186. Fontanet A, Tondeur L, Grant R,, Temmam S, Madec Y, et al. SARS-CoV-2 infection in schools in a northern French city: a
retrospective serological cohort study in an area of high transmission, France, January to April 2020. Euro Surveill. 2021;26(15):2001695
Pubmed Journal
187. Goldstein E, Lipsitch M, Cevik M. On the effect of age on the transmission of SARS-CoV-2 in households, schools, and the
community. J Infect Dis. 2020;223(3):362-9. Pubmed Journal
188. Ladhani SN, Amin-Chowdhury Z., Davies H,, Aiano F, Hayden I, et al. COVID-19 in children: analysis of the first pandemic peak in
England. Arch Dis Child. 2020;105(12):1180-5. Pubmed Journal
189. Ladhani SN, Ireland G, Baawuah F,, Beckmann J, Okike IO, et al. SARS-CoV-2 infection, antibody positivity and seroconversion rates
in staff and students following full reopening of secondary schools in England: a prospective cohort study, September–December 2020.
EClinicalMedicine. 2021;37::100948 Pubmed Journal
190. Li X, Xu W, Dozier M,, He Y, Kirolos A, et al. The role of children in the transmission of SARS-CoV2: updated rapid review. J Glob
Health. 2020;10(2):021101 Pubmed Journal
191. Ludvigsson JF. Children are unlikely to be the main drivers of the COVID-19 pandemic: a systematic review. Acta Paediatr.
2020;109(8):1525-30. Pubmed Journal
206 of 209
192. Lu Y, Li Y, Deng W,, Liu M, He Y, et al. Symptomatic infection is associated with prolonged duration of viral shedding in mild
coronavirus disease 2019: a retrospective study of 110 children in Wuhan. Pediatr Infect Dis J. 2020;39(7):e95-9. Pubmed Journal
193. National COVID-19 surveillance reports, including weekly summary of findings monitored through various COVID-19 surveillance
systems. London: Public Health England; 2020. Website
194. Stringhini S, Wisniak A, Piumatti G,, Azman AS, Lauer SA, et al. Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Geneva,
Switzerland (SEROCoV-POP): a population-based study. Lancet. 2020;396(10247):313-9. Pubmed Journal
195. Torres JP, Piñera C, De La Maza V,, Lagomarcino AJ, Simian D, et al. Severe acute respiratory syndrome coronavirus 2 antibody
prevalence in blood in a large school community subject to a coronavirus disease 2019 outbreak: a cross-sectional study. Clin Infect Dis.
2020;73(2):e458-65. Pubmed Journal
196. Viner RM, Mytton OT, Bonell C,, Melendez-Torres GJ, Ward J, et al. Susceptibility to SARS-CoV-2 infection among children and
adolescents compared with adults: a systematic review and meta-analysis. JAMA Pediatr. 2021;175(2):143-56. Pubmed Journal
197. Enhancing response to Omicron SARS-CoV-2 variant. World Health Organization; Geneva 2022. Website
198. Chadeau-Hyam M, Wang H, Eales O,, Haw D, Bodinier B, et al. REACT-1 study round 14: High and increasing prevalence of SARS-
CoV-2 infection among school-aged children during September 2021 and vaccine effectiveness against infection in England. medRxiv
[preprint]. 2021. Journal
199. Elliot P, Bodineier B, Ealse O,, Wang H, Haw D. Rapid increase in Omicron infections in England during December 2021: REACT-1
study. London: Imperial College London; 2021. Website
200. Munday J, Jarvis C, Gimma A,, Wong K, Van Zandvoort K, et al. Contact matrices estimated from the CoMix social contact survey.
London: London School of Hygiene and tropical Medicine; 2021. Website
201. Kleynhans J, Tempia S, Wolter N,, von Gottberg A, Bhiman J, et al. SARS-CoV-2 seroprevalence in a rural and urban household
cohort during first and second waves of infections, South Africa, July 2020–March 2021. Emerg Infect Dis. 2021;27(12):3020-9. Pubmed
Journal
202. Weekly epidemiological update on COVID-19; 19-October-2021. Geneva: World Health Organization; 2021. Website
203. Real-time assessment of community transmission findings. London: Imperial College London; 2021. Website
204. COVID-19 SeroHub. Washington (DC): National Institutes of Health; 2021. Website
205. Thompson HA, Mousa A, Dighe A,, Fu H, Arnedo-Pena A, et al. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
setting-specific transmission rates: a systematic review and meta-analysis. Clin Infect Dis. 2021;73(3):e754-64. Pubmed Journal
206. Zhu Y, Bloxham CJ, Hulme KD,, Sinclair JE, Tong ZWM, et al. A meta-analysis on the role of children in severe acute respiratory
syndrome coronavirus 2 in household transmission clusters. Clin Infect Dis. 2021;72(12):e1146-53. Pubmed Journal
207. Mickells GE, Figueroa J, West K,, Wood A, McElhanon BO. Adherence to masking requirement during the COVID-19 pandemic by
early elementary school children. J Sch Health. 2021;91(7):555-61. Pubmed Journal
208. Budzyn SE, Panaggio MJ, Parks S,, Papazian M, Magid J, Barrios LC. Pediatric COVID-19 cases in counties with and without school
mask requirements—United States, July 1-September 4, 2021. MMWR Morb Mortal Wkly Rep. 2021;70:1377-8. Pubmed Journal
209. Chernozhukov V, Kasahara H, Schrimpf P. The association of opening K–12 schools with the spread of COVID-19 in the United
States: county-level panel data analysis. Proc Natl Acad Sci U S A. 2021;118(42):e2103420118 Pubmed Journal
207 of 209
210. Doyle T, Kendrick K, Troelstrup T,, Gumke M, Edwards J, et al. COVID-19 in primary and secondary school settings during the first
semester of school reopening—Florida, August-December 2020. MMWR Morb Mortal Wkly Rep. 2021;70(12):437-41. Pubmed Journal
211. Falk A, Benda A, Falk P,, Steffen S, Wallace Z, Hoeg TB. COVID-19 cases and transmission in 17 K-12 schools—Wood County,
Wisconsin, August 31-November 29, 2020. MMWR Morb Mortal Wkly Rep. 2021;70(4):136-40. Pubmed Journal
212. Gettings J, Czarnik M, Morris E,, Haller E, Thompson AM, et al. Mask use and ventilation improvements to reduce COVID-19
incidence in elementary schools—Georgia, November 16–December 11, 2020. MMWR Morb Mortal Wkly Rep. 2021;70:779-84. Pubmed
Journal
213. Jordan I, de Sevilla MF, Fumado V,, Bassat Q, Bonet-Carne E, et al. Transmission of SARS-CoV-2 infection among children in
summer schools applying stringent control measures in Barcelona, Spain. Clin Infect Dis. 2021;74(1):66-73. Pubmed Journal
214. McCullough JM, Dale AP, Gue M,, Eller B, Cullen T, Scott SE. Association between K–12 school mask policies and school-associated
COVID-19 outbreaks— Maricopa and Pima Counties, Arizona, July–August 2021. MMWR Morb Mortal Wkly Rep. 2021;70(39):1372-3.
Pubmed Journal
215. Nelson SB, Dugdale CM, Bilinski A,, Cosar D, Pollock NR, Ciaranello A. Prevalence and risk factors for in-school transmission of
SARS-CoV-2 in Massachusetts K-12 public schools, 2020-2021. medRxiv [preprint]. 2021. Journal
216. Yuan H, Reynolds C, Ng S,, Yang W. Factors affecting the transmission of SARS-CoV-2 in school settings. Influenza Other Respir
Viruses. 2022. Pubmed Journal
217. Zimmerman KO, Akinboyo IC, Brookhart M,, Boutzoukas AE, McGann KA, et al. Incidence and secondary transmission of SARS-
CoV-2 infections in schools. Pediatrics. 2021;147(4):e2020048090 Pubmed Journal
218. Assathiany R, Salinier C, Béchet S,, Dolard C, Kochert F, et al. Face masks in young children during the COVID-19 pandemic:
parents' and pediatricians' point of view. Front Pediatr. 2021 2021;9(579):676718 Journal
219. Lo C-H, Nguyen LH, Drew DA,, Warner ET, Joshi AD, et al. Race, ethnicity, community-level socioeconomic factors, and risk of
COVID-19 in the United States and the United Kingdom. EClinicalMedicine. 2021;38:101029 Pubmed Journal
220. Sze S, Pan D, Nevill CR,, Gray LJ, Martin CA, et al. Ethnicity and clinical outcomes in COVID-19: a systematic review and meta-
analysis. EClinicalMedicine. 2020;29:100630 Pubmed Journal
221. Aronu AE, Chinawa JM, Nduagubam OC,, Ossai EN, Chinawa AT, Igwe WC. Maternal perception of masking in children as a
preventive strategy for COVID-19 in Nigeria: A multicentre study. PLoS One. 2020;15(11) Pubmed Journal
222. Smith J, Culler A, Scanlon K. Impacts of blood gas concentration, heart rate, emotional state, and memory in school-age children with
and without the use of facial coverings in school during the COVID-19 pandemic. FASEB J. 2021;35(S1) Journal
223. Betsch C., Korn L., Felgendreff L., Eitze S., Thaiss H.. School opening during the SARS-CoV-2 pandemic: Public acceptance of
wearing fabric masks in class. Public Health Pract (Oxf) 2021;2:100115 Pubmed Journal
224. Chen X, Ran LI, Liu Q,, Hu Q, Du X, Tan X. Hand hygiene, mask-wearing behaviors and its associated factors during the COVID-19
epidemic: a cross-sectional study among primary school students in Wuhan, China. Int J Environ Res Public Health. 2020;17(8):2893
Pubmed Journal
225. Theuring S, Thielecke M, van Loon W,, Hommes F, Hülso C, et al. SARS-CoV-2 infection and transmission in school settings during
the second COVID-19 wave: a cross-sectional study, Berlin, Germany, November 2020. Euro Surveill. 2021;26(34):2100184 Pubmed
Journal
226. Volpp KG, Kraut BH, Ghosh S,, Neatherlin J. Minimal SARS-CoV-2 transmission after implementation of a comprehensive mitigation
208 of 209
strategy at a school—New Jersey, August 20-November 27, 2020. MMWR Morb Mortal Wkly Rep. 2021;70(11):377-81. Pubmed Journal
227. Ammann P, Ulyte A, Haile SR,, Puhan MA, Kriemler S, Radtke T. Perceptions towards mask use in school children during the SARS-
CoV-2 pandemic: the Ciao Corona study. medRxiv [preprint]. 2021. Journal
228. Ayran G, Köse S, Sarıalioğlu A,, Çelebioğlu A. Hand hygiene and mask-wearing behaviors and the related factors during the COVID
19 pandemic: a cross-sectional study with secondary school students in Turkey. J Pediatr Nurs. 2022;62::98-105. Pubmed Journal
229. Convention on the Rights of Persons with Disabilities. Article 2. New York (NY): United Nations; 2008. Website
230. Infection prevention and control - Hand Hygiene. [Website] Geneva: World Health Organization; Website
231. Hand hygiene for all. United Nations Children's Fund: New York; 2020. Website
232. Coronavirus disease (COVID-19): Cleaning and disinfecting surfaces in non-health care settings. [Website] Geneva: World Health
233. Ikiz E, Maclaren VW, Alfred E, Sivanesan S. Impact of COVID-19 on household waste flows, diversion and reuse: The case of multi-
residential buildings in Toronto, Canada. Resources, conservation, and recycling 2021;164:105111 Pubmed Journal
234. Global Research and Innovations Forum: Building the world’s resilience against future outbreaks and pandemics. Geneva: World
209 of 209

WHO 2019 NCoV IPC Guideline 2023.4 Eng

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Infection prevention and

control in the context of

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

1. Executive summary ..................................................................................................................................................................................... 6

1.1 Definitions .......................................................................................................................................................................................... 6

1.2 Abbreviations ................................................................................................................................................................................... 12

1.3 Background ....................................................................................................................................................................................... 13

3. Part 1: Health-care settings ....................................................................................................................................................................... 26

3.1 Background ....................................................................................................................................................................................... 26

3.1.1 What is an IPC programme? ................................................................................................................................................. 26

3.1.2 IPC principles ........................................................................................................................................................................ 26

3.1.3 Standard precautions ............................................................................................................................................................ 29

3.1.4 Transmission-based precautions ........................................................................................................................................... 29

3.2.1 Screening and patient placement ........................................................................................................................................... 30

3.2.2 Ventilation ............................................................................................................................................................................... 31

3.2.3 Physical barriers ..................................................................................................................................................................... 34

3.2.4 Physical distancing ................................................................................................................................................................ 37

3.2.5 Mask use for source control .................................................................................................................................................. 38

3.2.6 PPE selection and use .......................................................................................................................................................... 50

3.2.6.1 PPE technical specifications ....................................................................................................................................... 57

3.2.7 Aerosol-generating procedures (AGPs) ................................................................................................................................. 60

3.3 Water, sanitation, hygiene, and waste management ....................................................................................................................... 65

3.3.1 Environmental cleaning ......................................................................................................................................................... 66

3.3.2 Waste management .............................................................................................................................................................. 70

3.3.3 Handling of linens and laundry ............................................................................................................................................... 73

3.4 Safe dead body management .......................................................................................................................................................... 75

3.5 Special settings ................................................................................................................................................................................. 77

3.5.2 Operating theatres .................................................................................................................................................................. 78

3.5.3 Home-care settings ............................................................................................................................................................... 83

3.5.4 Long-term care facilities ........................................................................................................................................................ 85

3.6.3 Risk assessment and management of exposure ................................................................................................................ 100

4. Part 2: Mitigation measures in the community ....................................................................................................................................... 103

4.1 Introduction to public health and social measures .......................................................................................................................... 103

4.2 Mask use......................................................................................................................................................................................... 104

4.2.1 Mask use in the community ................................................................................................................................................. 104

4.2.1.1 Type of mask used by the general public .................................................................................................................... 113

4.2.1.2 Mask use during physical activity ................................................................................................................................ 119

4.2.2 Mask use by children ............................................................................................................................................................ 122

4.2.2.1 Introduction .............................................................................................................................................................. . 123

4.2.2.2 Age-specific recommendations ................................................................................................................................ 126

4.2.2.3 Special populations ................................................................................................................................................... 134

4.2.2.4 Implementation considerations for use of masks in schools ..................................................................................... 136

4.3 Glove use ....................................................................................................................................................................................... 136

4.4 Caring for persons with COVID-19 in the home.............................................................................................................................. 139

4.5 Water, sanitation, hygiene, and waste management ...................................................................................................................... 140

4.5.1 Environmental Cleaning ...................................................................................................................................................... 141

4.5.2 Waste Management ............................................................................................................................................................ 143

4.5.3 Handling of linens and laundry ............................................................................................................................................. 144

4.6 Safe dead body management ........................................................................................................................................................ 145

5. Acknowledgements .................................................................................................................................................................................. 147

5.3 Systematic review teams ............................................................................................................................................................... 151

6. Annexes ................................................................................................................................................................................................... 152

6.1 Annex 1: Research Gaps ............................................................................................................................................................... 152

6.5 Annex 5: Results of rapid qualitative evidence synthesis ............................................................................................................... 167

6.6 Annex 6: Search Strategies ........................................................................................................................................................... 169

6.6.1 Airborne Precautions ............................................................................................................................................................ 169

6.6.2 Cleaning in the community .................................................................................................................................................. 169

6.6.3 Cleaning in the health-care facility ....................................................................................................................................... 173

6.6.4 UV......................................................................................................................................................................................... 179