Hand hygiene, cough etiquette, face masks, cleaning and laundry - Advice and information to the general public
How to prevent transmission
The SARS-CoV-2 virus that leads to COVID-19 disease is spread primarily via droplet and contact transmission, when the virus is transmitted from the respiratory tract of an infected person to a healthy person. Therefore, good hygiene is an important measure to limit transmission in the population.
Cough etiquette and social distancing are crucial to limiting droplet transmission, while hand hygiene, and especially avoiding touching the face with unclean hands, is important to prevent indirect contact transmission.
- Facts about coronavirus: The virus, transmission and disease
- Facts about infection control measures during the COVID-19 outbreak
Avoid touching your face with unclean hands. This will prevent indirect contact contamination from the hands to the eyes, mouth and respiratory tract.
When should hand hygiene be performed?
- Before cooking or eating food
- After using the toilet (or changing nappies)
- With visibly dirty hands
- After contact with bodily fluids (e.g., after wiping the nose)
- After contact with animals
- When you arrive at work / childcare centre / school
- After being in areas used by many people, including work / childcare centre / school
Hand wash or hand disinfection?
Both hand washing and alcohol-based hand disinfection are, in most cases, effective methods of hand hygiene.
Alcohol-based hand disinfection is less effective when hands are wet, visibly dirty or soiled with organic matter such as food or bodily fluids. Therefore, washing with soap and water is normally recommended as a method outside the healthcare service.
However, during the COVID-19 pandemic, hand hygiene is performed more frequently than usual. Alcohol-based hand disinfection is easily accessible and less irritating to the skin on the hands. Therefore, it can be a good alternative to hand washing when your skin is dry and not visibly dirty.
Follow the manufacturer's recommendations for how much to use and how long it takes to work.
NB: There is no need to perform both hand washing and hand disinfection – either is sufficient.
Effective hand washing, step by step:
Choice of disinfectant
During the ongoing COVID-19 pandemic, there is a great demand for hand disinfectants and many new products have come on the market in recent months. It is important that the products used are both effective, safe and skin friendly.
The Norwegian Institute of Public Health primarily recommends alcohol-based hand disinfection, based on ethanol or Isopropanol. Ethanol is less irritating to skin, eyes and mucous membranes and may therefore be preferred as a main ingredient. The alcohol concentration should be between 70-90 per cent v/v.
Hand disinfectants must comply with the requirements of the biocide regulations managed by the Norwegian Environment Agency. In connection with the COVID-19 pandemic, temporary reductions in the requirements for alcohol-based hand disinfectants sold in Norway have been granted.
Hand disinfectants with active ingredients other than alcohol are also available. Experience shows that many of these are less suitable as a means of hand disinfection due to limited efficacy, side effects and development of resistance. If you choose to use products with active substances other than alcohol, it is important to confirm that the product complies with the requirements of the biocide regulations.
Precautions with hand disinfection:
- Alcohol-based hand disinfectants can be harmful if swallowed. Consider safe use and placement in areas where children, people with mental disorders or who are mentally impaired or other groups are at increased risk of accidental ingestion.
- Alcohol-based hand disinfectants are flammable. Do not store or use in high temperatures or near open flames.
- Hands must be dry after using hand disinfectant before touching nearby objects. Cases have been reported where hands that are damp with disinfectant have touched metal objects and sparks have resulted.
How should you dry your hands?
You can dry your hands with disposable paper towels or warm air hand dryers. It is important that hand dryers are kept clean. They should be designed so that water does not collect at the bottom and then be blown out during use.
Hand towels can be used in private homes but should be changed regularly.
Warm air hand dryers should not be used in healthcare institutions. Read more about drying hands in the national hand hygiene guide in the health service.
How to prevent dry and sore hands?
Here is ome advice to prevent dry and sore skin on the hands due to frequent hand hygiene:
- Use skin-friendly soaps (perfume-free, pH <5.5) and use good quality paper towels to reduce drying out of the skin. At home, clean towels are a good option.
- Wash your hands in lukewarm water, not hot water.
- Wet your hands before applying soap.
- Rinse your hands thoroughly after washing so that all soap suds are washed away.
- Pat your hands with the paper towel / towel until they are completely dry, avoid rubbing hard.
- Use hand cream to prevent dry and sore skin, as often as needed (e.g., after hand washing).
- When using shared tubes (other than by people in the same household), it is important to ensure that the tube opening does not come into contact with skin or objects during use, to avoid contaminating the cream.
Use of disposable gloves
Transmission by hands wearing gloves happens in the same way as for hands without gloves. Therefore, we do not recommend the general use of disposable gloves, see Routine use of gloves for shop employees and customers is not recommended.
- Avoid coughing or sneezing directly onto others.
- Try to cough / sneeze into a paper tissue (carefully disposed of afterwards), or into the crook of your elbow if you do not have tissues available.
Use of face masks
In connection with the COVID-19 pandemic, research is ongoing on the effects of various infection control measures. The Norwegian Institute of Public Health constantly updates the scientific advice, according to the knowledge that is available. This also applies to recommendations on the use of medical face masks and non-medical face masks in the population.
It is important to differentiate between the following:
- Medical face masks: face masks produced for use in the healthcare services that meet current standards.
- Non-medical face masks: homemade or factory-made face masks of textiles or other materials. There are no standards or other legislation related to the production of the masks and the degree of protection is unknown.
Are non-medical face masks an effective measure to prevent transmission in the population?
The virus that causes COVID-19 disease is transmitted from the respiratory tract of a contagious person and comes into contact with the mucosa of the eyes, nose or mouth of another person. Experience shows that in some cases, the COVID-19 virus is not only transmitted by those who are ill and have symptoms, but also probably 1 to 2 days before the onset of disease (presymptomatic phase). However, it is believed that the infectivity is greatest among people with symptoms.
The use of non-medical face masks in the population is a measure that is considered to reduce the risk of infection from contagious people without symptoms (presymptomatic carriers).
The effect of medical face masks is well-documented when they are used correctly. However, there is considerable uncertainty about the effect of non-medical face masks. The research so far indicates that they are less effective than using medical face masks, and that there is great variation in the type of material and shape.
With high prevalence of COVID-19 in the community and large numbers of presymptomatic and asymptomatic carriers, widespread use of non-medical face masks in the community is likely to inhibit transmission from presymptomatic or asymptomatic carriers wearing face masks.
Recommendations from the NIPH
For every measure that is recommended, the expected benefit must be weighed against any disadvantages or costs incurred.
Based on the current epidemiological situation, the Norwegian Institute of Public Health considers that there is no scientific basis for recommending the general use of face masks in the population. The number of new COVID-19 cases in the population is currently falling, and the proportion of presymptomatic and asymptomatic carriers in the community is probably relatively low. However, the recommendations may change if there is a significant increase in transmission in all or part of the population.
If geographical areas or groups in the community with widespread transmission are identified by the NIPH, further measures may be necessary, such as the use of medical or non-medical face masks in some areas or situations.
The advice is in accordance with recommendations from the European Centre for Disease Control (ECDC) and the World Health Organisation (see knowledge base for further information).
Advice to those who choose to use non-medical face masks
If you choose to use a face mask, the following conditions are important:
- Do not buy face masks that needed in the healthcare services (Face mask class II or IIR, or respirator masks)
- Using a face mask does NOT replace other infection control advice such as hand hygiene and cough etiquette, staying home with respiratory tract symptoms and maintaining a distance of at least 1–2 metres from others.
- For the face mask to have optimal effect, it must sit tightly around the mouth, nose, and chin.
- Face masks have a limited effect and lifetime and must be changed regularly (when they become damp).
- Face masks are uncomfortable to wear and, as a rule, untrained people who wear face masks will frequently touch the face mask and the rest of their face. Avoid touching the front of a face mask that has been used. Avoid touching the front of the mask and then your eyes or face.
- Dispose of the used face mask with regular household waste and be careful to clean your hands after removing the mask.
Knowledge base and assessments
Use of face masks against COVID-19
A systematic review (currently not peer-reviewed) has searched for scientific articles on the effect of face masks to limit the spread of COVID-19 among people not diagnosed with COVID-19. (1). No scientific articles were found that had investigated this.
Some case studies on the benefits of face masks worn in public by people who have respiratory tract symptoms were found.
Comparing countries where the use of face masks is common with countries where it is not common as evidence for the effect of face masks in the population against COVID-19 may is not valid. Many factors influence the prevalence of COVID-19 in a country, and these must be controlled for if a comparison of the effect of face masks is to be made. In addition, countries have very different nuances in their recommendations on face mask use (2).
Use of face masks against other microbes transmitted via the respiratory tract
As there are no publications about this for COVID-19, we can search for publications that have evaluated this for other microbes transmitted from the respiratory tract. We must be careful about transferring results from studies for other respiratory microbes, as infectivity and other characteristics of the virus may differ.
A systematic review by Saunders-Hastings et al from 2017 reviewed articles that examined the effect of the use of personal protective equipment during the pandemic in 2009. It shows a confirmed protective effect of regular hand hygiene, but no certain effect of the use of face masks (3). A similar review by Cowling et al from 2010 concludes that there is scientific support for saying that face mask use among people with influenza during the 2009 pandemic helped to reduce the spread of infection, but that there are no scientific studies to show that face masks protect healthy people from infection (4).
An overview in Epistemonikos lists 23 systematic reviews that have looked at the use of face masks to prevent respiratory tract infections (5). Few of them have evaluated their use among people without symptoms outside of healthcare institutions and none show that face mask use protects healthy people from respiratory infections.
Recommendations from the European Centre of Disease Control (ECDC)
- Use of medical face masks should be reserved for healthcare workers
- Use of non-medical face masks can be considered in the population in epidemic situations where the proportion of asymptomatic carriers in the population is high, and then in the following situations:
- When people visit densely populated areas (shops, shopping centres, etc.)
- When using public transport
- In certain workplaces and for professions that involve close physical contact with many people, if there are no physical separations such as plexi glass barriers, and where working from home is not possible.
- The use of non-medical face masks is an additional measure and does not replace other established preventive measures such as social distancing, cough etiquette and hand hygiene, and avoiding contact with the face, mouth and nose. It is unknown to what extent non-medical face masks in the population help to reduce the spread of infection in addition to other measures.
- Correct use is critical to achieve any effect when using non.medical face masks.
- Recommendations must be viewed in the context of lack of knowledge, lack of equipment and possible negative consequences.
The ECDC points out that there are some important pitfalls to be aware of when recommending the use of non-medical face masks in the population:
- It must be ensured that medical face masks and respirators are prioritised for use in the healthcare service, especially when there is a lack of protective equipment.
- The use of non-medical face masks can provide false security and cause people to become complacent about other infection control recommendations such as social distancing, hand hygiene, cough etiquette and regulations concerning quarantine and isolation.
- There is a risk that incorrect use of face masks, particularly handling of used masks, and increased touching of the face may lead to an increased risk of transmission.
- ECDC: Using face masks in the community - Reducing COVID-19 transmission from potentially asymptomatic or pre-symptomatic people through the use of face masks
Recommendations from the World Health Organization (WHO)
On 6 April, the World Health Organization updated its recommendations for the use of medical face masks, and face masks for the population and in home-based services (7).
The WHO points out that some studies have found that face masks can help to prevent droplet transmission from people infected with COVID-19. They further emphasise that there is currently no evidence that healthy people using medical or non-medical face masks in the community protect themselves from infection. Like the ECDC, they emphasise that medical face masks should be reserved for the healthcare service and that the use of face masks among healthy people can lead to a false sense of security. In turn, this can lead to lower compliance with important infection control measures such as social distancing, cough etiquette and hand hygiene, and to increased touching the face.
The WHO concludes that there is no literature to support the general use of medical or non-medical face masks among healthy people. They provide further advice about which factors must be taken into account when assessing the introduction of recommendations for the use of non-medical face masks in a population.
Laundry and home cleaning
- In households where coronavirus infection has not been confirmed, normal cleaning can be performed.
- In households where infection has been confirmed: Clean surfaces that are touched by both the infected person and others daily, such as bathroom sinks, toilets, door handles and kitchen worktops. Ordinary detergents can be used. Towels and bedding used by the sick person must be washed on a minimum of 60 degrees, other textiles at the highest possible temperature. Clothes and textiles that have been in contact with the infected person should be kept separately from other objects before washing. Wash your hands after handling the used textiles.
Cleaning of common facilities
Although many places are closed, there are still many common facilities/areas , visited by a high number of people. These may be workplaces, transport, public toilets, catering establishments, shops and more. The SARS-CoV-2 virus (COVID-19) can easily be removed through manual cleaning with water and detergents.
As a general rule, ordinary cleaning procedures can be followed. However, local cleaning routines should be reviewed to see whether adjustments are necessary, for example, frequency and organisation. For more detailed information, see:
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SARS-CoV-2 is the name of the virus that is causing the outbreak of COVID-19 disease.
The virus is related to another coronavirus that caused the SARS outbreak in 2002/2003 but is not the same virus.