What are coronaviruses?
What does "novel" mean?
Who is at risk for infection?
Are pregnant women at higher risk for severe disease?
Are children getting infected? What is the pediatric inflammatory syndrome?
What are the symptoms of COVID-19?
Do people with COVID-19 lose their sense of smell or taste?
What does cough etiquette mean?
Is there a vaccine?
Where does International SOS get its information?
How does COVID-19 spread?
Can a person with no symptoms spread the infection?
Can I get re-infected with COVID-19?
When can someone who has had COVID-19 stop isolating?
Does COVID-19 spread through the air or air-conditioning?
Can the virus be transmitted through packages shipped from an area with COVID-19?
Is protective equipment needed to handle a package shipped from an area with COVID-19?
Can COVID-19 spread through bank notes and coins?
What about pets and other animals?
Can I get infected with COVID-19 from food?
What can I do to protect myself?
Should I wear a face mask?
Should I wear a face shield?
What is the difference between quarantine and isolation?
What environmental measures can be taken?
Should we stop face-to-face meetings?
Where can I find guidance for my workplace?
Coronaviruses are a large family of viruses, some of which can infect people. Some cause mostly mild illness, such as the strains responsible for some common colds. Others can potentially also lead to severe, or even fatal, disease - such as Middle East Respiratory Syndrome Coronavirus (MERS-CoV), which continues to circulate in some parts of the world. The Severe Acute Respiratory Syndrome (SARS) outbreak was caused by a coronavirus. It caused severe and fatal disease, however, is no longer in circulation. The natural reservoir for coronaviruses is thought to be animal hosts. New strains emerge from this reservoir, infect an 'intermediate' host, and from there infect people. The viruses may then be capable of being transmitted from one person to another. Some are efficient at human-to-human transmission, while others are not.
Novel means new. In this case, the 2019-novel coronavirus was given a new name SARS-CoV-2 as of 12 February, reflecting that the new virus is related to the SARS coronavirus seen in 2002. The virus is a previously-unidentified strain of coronavirus. It is responsible for the outbreak of pneumonia which began in Wuhan, China in December 2019. The disease caused by the virus has been called COVID-19, or Coronavirus Disease-2019.
The disease can move from person to person, but it is not yet known how easily or sustainably it spreads. Scientists are studying the data as it becomes available. The initial cases reported having visited a seafood/animal market, which may have been a source of exposure. However now the main way the disease is spreading is from person to person.
Some people have had a mild illness and recovered. Others have had more severe infections. Critical and fatal cases have occurred. Preliminary evidence indicates that people with underlying medical conditions, elderly people and those with compromised immune systems may be at higher risk for severe illness.
So far there is little information about whether pregnant women are more likely to have a severe infection than other healthy adults. A review of 28 pregnant women in China who were infected with COVID-19 found that they did not have a more severe illness than non-pregnant women, and none of their babies were infected. A systematic review of 9 studies found that women with COVID-19 had no difference in risk for severe illness than that of the general population however, some were less symptomatic. Adverse birth outcomes such as preterm birth and low birthweight appeared to be slightly higher. A United States Center for Disease Prevention (CDC) study of 8,207 pregnant women in the US found that COVID-19 affects especially Hispanic pregnant women and, that pregnant women are more likely to be hospitalised and develop severe disease but not to die. A Pan American Health Organization/World Health Organization (PAHO/WHO) Epidemiological Alert states "Recently published results and studies based on COVID-19 surveillance data have indicated an increased risk among pregnant women of presenting with severe forms of COVID-19 and, therefore, of being hospitalized and admitted to intensive care units (ICU)".
The Royal College of Obstetricians & Gynaecologists state "There is no evidence that pregnant women are more likely to get seriously ill from coronavirus but pregnant women have been included in the list of people at moderate risk (clinically vulnerable) as a precaution". The European Centre for Disease Prevention and Control state "There is limited scientific evidence on the severity of illness in pregnant women after COVID-19 infection. It seems that pregnant women appear to experience similar clinical manifestations as non-pregnant women who have progressed to COVID-19 pneumonia [...]". The United States Centers for Disease Prevention and Control state "pregnant people might be at an increased risk for severe illness from COVID-19 compared to non-pregnant people. Additionally, there may be an increased risk of adverse pregnancy outcomes, such as preterm birth, among pregnant people with COVID-19”. See their Frequently Asked Questions and Answers: Coronavirus Disease 2019 (COVID-19) and Pregnancy for more information.
Early in the outbreak, it seemed as if young children were not getting the disease very commonly and, if they were infected, they might have mild or no symptoms. Studies so far show that people under 18 years old account for 2 percent or fewer of known COVID-19 cases. This could be because, in general, children have shown no symptoms or milder symptoms than adults and so their infections may be going undetected. Symptoms in children can include cold-like symptoms, such as fever, runny nose, and cough. Vomiting and diarrhea have also been reported more commonly among children than adults who have COVID-19.
In late April, pediatricians in New York began noting an increase in inflammatory/shock type serious illness among children - some of whom had COVID-19. As information was shared more widely, and monitoring increased, other states and countries started reporting similar occurrences among children. This syndrome is still very rare, and has not yet definitively been linked to coronavirus. Follow the Latest News story for updated developments in this emerging field of information.
The illness is still being studied. So far, we know that common symptoms include fever, headache, chills (including "rigors" - chills with shaking), fatigue, cough, sore throat, muscle aches, shortness of breath and difficulty breathing. These symptoms are not limited to COVID-19. Respiratory illnesses and pneumonia caused by other organisms (including bacteria) and other viruses (such as influenza) can also cause these symptoms. Other less common symptoms of COVID-19 include nausea and diarrhoea. Loss of the sense of smell and taste has also been described. Conjunctivitis (pink eyes due to inflammation of the lining of the eyeball) and rashes have also been reported in some cases.
It is capable of causing severe illness, with kidney problems, neurological and cardiovascular complications, and multi-organ failure, which can be fatal. It is possible that people with underlying health conditions are at higher risk for severe disease.
Several groups of doctors, particularly those who work in the ears/nose/throat field, have reported that some people who lost their sense of smell or taste and tested positive for the disease even without other symptoms. Though a reduced ability to taste to smell can be common in people with a ‘stuffy nose’ (nasal congestion) attributed with seasonal allergies and other medical conditions, these COVID-19 patients often reported the change in senses without any stuffy nose. The medical groups reporting this information suggested that it might be useful for people who lose their sense of taste or smell to self-isolate for at least 7 days to prevent spreading the virus – which they can do even if they have no other symptoms. They also suggested these symptoms might be added to COVID-19 screening tools used by clinicians to determine who should be tested and advised to self-isolate. The World Health Organization is investigating the situation and has not yet made a formal declaration on any changes to protocol based on these symptoms.
Cough etiquette, or respiratory hygiene, is a measure taken to reduce person-to-person transmission of infected droplets. Individuals should distance themselves, cover their mouth and nose with a tissue when coughing and sneezing. It is important that tissues are disposed of correctly (in nearest waste bin) after use and that hands are washed immediately with soap and water or alcohol based hand sanitizer (containing 60-85% alcohol).
No. It may take months or years for a vaccine to be developed. Research and testing is underway.
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While the first cases in Wuhan may have 'jumped' from an animal or environmental source to people, the spread now is from person to person. Infectious particles are expelled when talking, coughing and sneezing. People who are sick, as well as those who do not have any symptoms, can spread the disease. Others are infected via contact (direct or indirect) with these contaminated particles, or by inhaling them.
People who are infected can spread the disease for about two days before they have developed symptoms. People are probably most infectious at the time symptoms first start, even if these symptoms are only mild. Therefore it is very important for contacts of COVID-19 cases to quarantine themselves at home, and minimise contact with others for 14 days after exposure even if they do not have any symptoms.
The data around re-infected cases is emerging. It is likely that persons who have recovered from COVID-19 are immune, and cannot be re-infected, for some period of time. It is not known if this protective immunity lasts for months or years. It is also likely that those testing positive for antibodies (from infection or immunisation) are protected against infection but this has not been confirmed in a trial. Note that a person’s antibody test may be positive for a period of time but may revert to negative should their immunity wane. We would expect this to correlate with a loss of protective immunity but this has not been studied.
The immune response to COVID-19 is not yet fully understood. Virus particles can persist in body fluids for long periods and may lead to a positive test although the person might not be infectious. False positive tests can also occur. Alternatively, it is also possible that the virus particles may reactivate under certain conditions.
Different locations have different guidance and regulations about when someone with COVID-19 can be released from isolation. In some locations, for people to be released from hospital, two negative tests 48 hours apart are required. Most locations require no fever and no other symptoms (or at least an improvement of other symptoms), for at least two days. Always follow your local guidance.
In mid-June, the World Health Organization published Criteria for releasing COVID-19 patients from isolation in which they advise "it appears safe to release patients from isolation based on clinical criteria [...] that patients’ symptoms have been resolved for at least three days before release from isolation, with a minimum time in isolation of 13 days since symptom onset."
CDC published a recommendation on duration of isolation and precautions as follows:
- "For most persons with COVID-19 illness, isolation and precautions can generally be discontinued 10 days after symptom onset and resolution of fever for at least 24 hours, without the use of fever-reducing medications, and with improvement of other symptoms.
- A limited number of persons with severe illness may produce replication-competent virus beyond 10 days that may warrant extending duration of isolation and precautions for up to 20 days after symptom onset; consider consultation with infection control experts.
- For persons who never develop symptoms, isolation and other precautions can be discontinued 10 days after the date of their first positive RT-PCR test for SARS-CoV-2 RNA."
COVID-19 is spread through droplets from an infected person to someone who is in close unprotected contact. There is increasing evidence that airborne transmission occurs. In the hospital setting, patients are currently managed in special 'negative pressure' rooms if available, and healthcare workers will take 'airborne precautions' when performing certain procedures.
The Federation of European Heating, Ventilation and Air Conditioning Associations REHVA experts provide guidance on COVID-19 for building services to prevent spread of SARS-CoV-2, with Frequently Asked Questions including the use of UV sterilisation of air.
For more information, WHO has published Q&A on ventilation and air conditioning in public spaces and buildings and COVID-19.
This coronavirus is primarily spreading to people who are in close unprotected direct contact with an infected person. The United States CDC advises "Although the virus can survive for a short period on some surfaces, it is unlikely to be spread from domestic or international mail, products or packaging. However, it may be possible that people can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads."
The World Health Organization in its 6 April 2020 interim guidance on ‘Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages’ does not recommend any type of mask is used, and gloves are only needed if they are ordinarily required to protect against mechanical hazards. “To date, there are no data to suggest that contact with goods or products shipped from countries affected by the COVID-19 outbreak have been the source of COVID-19 infection in humans.”
Theoretically, cash, like any other frequently handled object, could become contaminated with the virus that causes COVID-19. People could potentially transfer the virus to their eyes / nose / mouth via their hands after handling cash. However the main way the disease is spreading is through direct contact with infected people. In 2006, the European Center for Disease Prevention and Control issued a report that in part looked at the risk of bank notes as a potential vehicle for influenza transmission. It concluded that for the general public “handling banknotes and coins is not practically avoidable and will confer no discernible increased risk compared with handling almost any other communal object used in daily life; and compared with exposure to respiratory droplets (coughs and sneezes) and communal hard surfaces and fittings (hand rails, escalator hand belts, door handles, etc.) the ability of money to transmit influenza will pretty much pale into insignificance compared with what else is going on in society at the time. The overwhelmingly important issue will be compliance with frequent handwashing and 'no-touch-face' advice.” Individuals who frequently handle money might have an increased risk and are advised to avoid licking their fingers while counting, and not to touch their face during and after handling money."Again these risks would be significantly reduced across a wide range of occupations by compliance with hand hygiene regimens and 'no-touch-face' advice."
Some animals have tested positive for the virus following close contact with humans who were likely infected. So far, the data shows cats are the most commonly infected domestic animals. They can develop symptoms, and in a lab setting infected cats were able to spread the disease on to other cats. Pet cats have been found infected in Belgium, Hong Kong, China and and the United States. Tigers and lions at a zoo in New York were infected by a human caregiver. Several dogs have also tested positive. The United States Center for Disease Control and Prevention (CDC) issued guidelines for pet owners, including limiting a pet's exposure to people outside its household and reducing their contact with humans who have COVID-19. The World Organisation for Animal Heath's FAQ on pets and other animals is available here. They state, "Currently, there is no evidence to suggest that animals infected by humans are playing a role in the spread of COVID-19. Human outbreaks are driven by person to person contact." There is no evidence that poultry, pigs or other livestock animals can be easily infected. Note that tests used on animals are different than those used to detect human infections.
There is no evidence of COVID-19 transmission through food to date, and per the United Nations Food and Agricultural Organization (FAO) and the United States CDC. General food hygiene measures should be observed, especially washing hands thoroughly before preparing or eating food.
There are currently no medications that are proven to be consistently effective in the prevention or treatment of COVID-19. Patients receive supportive care, aimed at relieving their symptoms and preventing complications while they recover. This can include the use of mechanical ventilation if required.
Studies are underway to see if new or existing medications may be effective. These medications are generally available only on prescriptions, have significant side effects and potentially can cause serious adverse events. They should not be used except under the guidelines of local authorities or within hospital settings. The drugs being trialled include:
- Remdesivir: an experimental antiviral medication which has been used to treat Ebola virus.
- Chloroquine: oral prescription medication used for malaria prevention or treatment in areas where malaria remains sensitive.
- Hydroxychloroquine: oral prescription medication used for treatment of rheumatoid arthritis.
- Lopinavir-Ritonavir: antiviral medication used against HIV
Solidarity is the World Health Organization's (WHO) multi-country clinical study for potential treatments for COVID-19, established to hasten the search for effective treatments. At least 45 countries are participating. The trial tests four different drugs or combinations – chloroquine; remdesivir; a combination of the two drugs lopinavir and ritonavir; and those two drugs plus interferon beta. The trial started on 27 March 2020 and the first patient was enrolled in Oslo University Hospital, Norway. More information on the medications being tested is available here. Note that as of 25 May, WHO stopped using hydroxychloroquine in their trial due to safety concerns. A review of the data on risks and benefits is underway.
United States Centers for Disease Control and Prevention Information for Clinicians on Therapeutic Options for COVID-19 Patients
Note that French Ministry of Health on 14 March advised against the use "non-steroidal anti-inflammatory drugs (NSAIDS)" (such as ibuprofen) as they may make the disease worse. Several other authorities have stated there isn't sufficient evidence for this position. See the European Medicines Agency statement 18 March, the United States Food and Drug Administration statement 19 March, and World Health Organization Tweet 19 March. On 19 April, WHO stated the outcome of their review of available literature indicates "there is no evidence of severe adverse events, acute health care utilization, long-term survival, or quality of life in patients with COVID-19, as a result of the use of NSAIDs."
Nevertheless all agree that paracetamol / acetaminophen can be used if required to relieve fever, mild pain and headache.
The antiviral medication Tamiflu (oseltamivir) is not effective against COVID-19. Tamiflu is used to treat influenza.
Some authorities have recommended alternative treatments for COVID-19. However, there is no evidence to confirm or disprove the effectiveness and safety of alternative treatments.
Certain medical facilities in China have been designated by the Department of Health as “fever clinics”. These fever clinics manage any patients who suffer from fever and respiratory symptoms. Other facilities are mandated to refer any patients with fever and respiratory symptoms to these dedicated fever clinics.
If you are sick but do not have a fever or respiratory symptoms, then you can be treated in the non-fever clinic facilities.
International SOS advises its members in China who are suffering from symptoms of illness to call the Assistance Centre for advice before seeking care at a medical facility.
Avoid potential exposure. Practice good hygiene measures and safe food practices.
- Avoid direct contact with animals (live or dead) and their environment. Do not touch surfaces that may be contaminated with droppings.
- Keep some distance from people who are obviously sick.
- Maintain good personal hygiene. Wash your hands frequently with soap and water. Carry hand sanitiser for use when soap and water are not readily available. Some authorities are advising hand sanitisers containing 60-85% alcohol. Avoid touching your face.
- Ensure food, including eggs, is thoroughly cooked.
- Do not travel if you are sick. Note that some locations have implemented screening, and travellers may face quarantine and testing.
If your location has guidelines for the public, please follow them.
In some locations, authorities are requiring people to wear a mask when in public places. You must comply with any official directives. In late March 2020, Austria, Czech Republic, and Slovakia made it mandatory for people to wear a mask or use a cloth to cover their mouth and nose when in public places.
The US Centers for Disease Control and Prevention updated their advice on 3 April. “CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission.” This will not be enforced in the United States, it can be done on a voluntary basis.
In other locations, authorities are asking only people who are sick, or if they can't, those in close contact with them, to use a face mask to cover their coughs and sneezes while they are seeking medical attention. Other authorities encourage groups at higher risk for severe complications e.g. older adults or those with underlying illness, to consider wearing a mask. Some authorities have advised to use masks while travelling or working in public places to reduce the chances of droplet transmission.
While surgical face masks may stop people touching their mouth, they do not stop them breathing in the virus, nor the virus entering the eyes. They will also catch some of the droplets that are coughed and sneezed out.
Fitted respirators, such as ‘P2’, 'P3' or ‘N95’ masks, require training and fitting. These are generally not being recommended for use by the public. They may be recommended to be used by those in close contact with infected people, such as healthcare workers or family members caring for sick relatives.
The World Health Organization updated its interim guidance on 6 June to advise "the general public should be encouraged to use medical and non-medical masks in areas with known or suspected community transmission”.
To prevent getting infected with COVID-19 : Covering nose and mouth to prevent infection in the general public isn’t “proven” by scientific standards to work. The potential problems – you need to protect infection through your eyes as well, the mask won’t stop droplets that land anywhere else on your face, and if you aren’t meticulous you can transfer virus from the mask to your eyes / nose / mouth or contaminate other people. Potential upside – we do know that used properly, appropriate personal protective equipment does stop healthcare workers being infected.
BOTTOM LINE – most important is to avoid exposure (stay at home as much as possible),don’t touch your face, wash your hands. If you must go out in public – keep 2 metres away from other people, avoid crowded places, keep any essential face to face interactions as short as possible. Covering your eyes, nose and mouth when you are face to face with others might help prevent infection but you MUST be sure to handle those coverings as ‘contaminated’ items when you take them off – remove carefully, wash your hands, dispose or clean and disinfect in a safe manner. Same goes for your clothes.
To prevent spread of virus to others: All authorities recommend a mask for sick people when they are seeking healthcare / when in healthcare facilities. We are learning that people with COVID-19 that have no symptoms/ minimal symptoms (such as a sore throat), may be able to transmit the virus to others through the infectious droplets they create when they talk. The potential problems – masks are in short supply and if the general public uses them, then the healthcare workers that need them most miss out. They may give a ‘false sense of security’ that being out in public is risk free if everyone is using a mask. Potential upside: As people may not know if they are infected and potentially spreading virus, it might reduce the risk of spreading COVID-19 if everyone were to cover their mouth when in public
BOTTOM LINE – most important is to stay at home as much as possible and not expose others to any virus you might have . If you must go out in public – keep 2 metres away from people, avoid crowded places, keep any essential face to face interactions as short as possible. Covering your mouth with a mask / cloth when you speak may help reduce the risk that you are spreading virus, but you MUST be sure to handle the mask / cloth as ‘contaminated’ items when you take them off – remove carefully, wash your hands, dispose or clean and disinfect in a safe manner.
The effectiveness of wearing a face shield to reduce the spray of droplets onto other people, is not fully understood. The US Centers for Disease Control and Prevention (CDC) “does not recommend use of face shields for normal everyday activities or as a substitute for cloth face coverings.” In their recent interim guidance, the World Health Organization (WHO) advise “In the context of non-medical mask shortage, face shields may be considered as an alternative noting that they are inferior to masks with respect to prevention of droplet transmission.”
Under certain circumstances, such as continued close contact with people, individuals may choose to wear a face shield as well as a mask. If face shields are used without a mask, it is important that the shield covers the sides of the face and below the chin. Disposable face shields should only be used once.
Quarantine is the separation and monitoring of people who have been exposed to an infected person (or have been to an outbreak area) to see if they become ill. This separation helps reduce the risk that the quarantined person will spread the disease. Quarantine generally requires a person to remain in a nominated place or at home for a certain period of time after exposure to a disease. The duration of quarantine will vary depending on the estimated incubation period. For COVID-19, early estimates indicate a quarantine duration of 14 days.
Isolation is the separation of people who are ill with a potentially contagious disease from those who are healthy.
Environmental measures aim at reducing transmission of infection and include the routine cleaning of frequently used surfaces and objects; minimising shared objects; and good ventilation. Frequently touched surfaces and objects should be washed with water and detergent, followed by a dilute household bleach solution. These objects /surfaces may include desks, phones, keyboards, doorknobs and toilets. Laundry should be washed according to detergent manufacturer’s instructions at the warmest specified temperature. Shared objects should be kept to a minimum including such things as drinking glasses, eating utensils, towels and linen. Good air ventilation is important in rooms where people gather regularly.
A traveller has recently returned from an affected location. What should they do?
If there are local procedures in place from the local health authorities, these must be followed. Many locations are requiring travellers from some or all locations to quarantine themselves for 14 days.
If there are no requirements, anyone who has been in an affected location should monitor their health for 14 days. If symptoms develop, seek medical care according to the local procedure. When travelling to medical care, consider wearing a mask, use private transport, avoid contact with others as much as possible. Ensure you provide your travel and potential exposure history to the medical facility.
If there are local restrictions on gatherings, you must comply with these. Any activity that involves gathering people in close proximity in an enclosed space risks spreading the virus and in the event that someone is confirmed infected, there are potentially large numbers of contacts who must self-quarantine for 14 days. Non-essential meetings are best postponed, or carried out via remote video link if possible.
Where can I find guidance for my workplace?
The International Chamber of Commerce has also published Coronavirus Guidelines for Business.
Many local authorities also provide guidance:
Hong Kong Centre For Health Protection Guidance includes a section for Businesses & Workplace
United States Centers for Disease Control and Prevention Resources for Businesses and Employers