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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 stop transmission via 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 touching contact points in areas used by many people, including work / childcare centre / school
- Before putting on a face mask and immediately after removing it
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 available 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.
For the best effect, 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 – one 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, like WHO and ECDC, 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.
Alcohol-based hand disinfectants have been used by the healthcare system in Norway for several decades. Even though some react with irritated skin, experience shows that alcohol-based disinfection is effective and is gentle to skin on the hands.
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. In order to be sold in Norway, these products, like alcohol-based hand disinfectants, must comply with the requirements of the biocide regulations. They must show documented effect according to ES-NS-1500. There is limited experience with clinical use of these products.
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 alcohol-based hand disinfectant have touched metal objects and sparks have resulted.
How should you dry your hands after washing them?
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.
In situations with increased risk of transmission and where it is difficult to keep distance, face masks can be recommended as part of the measures to reduce the risk of transmission. Follow the local recommendations for the areas you are staying in.
In this article, we distinguish between medical face masks and cloth face coverings.
- Medical face masks: disposable face masks produced for use in the healthcare service that meet current standards.
- Cloth face coverings: homemade or factory-produced cloth face coverings made of textiles or other washable materials. A European agreement document has been prepared with quality requirements for cloth face coverings for use in public spaces, including guidance about minimum requirements and test methods.
COVID-19 disease is transmitted when the SARS-CoV-2 virus from the respiratory tract of a contagious person comes into contact with the mucosa of the eyes, nose or mouth of another person. Experience from several countries shows that in some cases, the virus is not only transmitted by those who are sick and have symptoms, but also probably 1 to 2 days before the onset of disease (presymptomatic phase) and in some cases from contagious people without symptoms (asymptomatic carriers).
Medical face masks are primarily designed to prevent spread of infection from the person wearing the face mask to others. Face masks also have a protective effect for the wearer when used correctly. By using a face mask, you are protecting people near to you from being infected by you, if you are unknowingly infected with a respiratory virus. However, you also reduce the risk of being infected by others.
The research so far indicates that cloth face coverings are less effective than medical face masks, and that there is great variation in their effect depending on the type of material and fit.
NIPH’s recommendations for when face masks should be used outside the healthcare service
People arriving in Norway from areas with quarantine duty (red countries) must be quarantined for 10 days, and can use public transport from the airport, port or similar entry point to reach their quarantine accommodation. Anyone over the age of 12 years shall wear a face mask.
It is recommended that anyone who has confirmed or probable COVID-19 disease (in home isolation) should use a face mask when they are closer to other household members than 1 metre, if their health allows it. Alternatively, it is recommended that household members should use face masks when they are closer to the patient than 1 metre.
Use of face masks in areas with increased risk of transmission
In areas with little or no known transmission, general recommendations to use face masks are not introduced (although people are free to use them).
In areas with increased risk of transmission where the cases are not caused by known outbreaks or imported cases, face masks are recommended on public transport where it is not possible to maintain a distance of 1 metre.
Not everyone can use a face mask, for medical or other reasons. Children under 12-13 years are not recommended to use face masks. Children under 2 years should not use face masks as they can interfere with their ability to breathe. People who are unconscious or have a reduced state of consciousness, or for other reasons are unable to remove the face mask themselves, and people with pronounced breathing problems, should not wear a face mask. We emphasise that regardless of how much transmission there is in society, the most important measure is to be able to maintain at least 1 metre distance from others. Where this is impossible, the use of face masks can reduce the risk of transmission, but cannot replace distance as a measure.
The NIPH’s advice about face masks is largely in line with the recommendations of the European Institute of Infectious Disease Control (ECDC) and the World Health Organization (WHO).
Correct use of face masks
As the face mask sits close to the face, it is important to handle it with clean hands. For the face mask to have a good effect, it is important that it fits snugly around the edges and covers well over the mouth and nose. In this way, you ensure that as much of the air you breathe in and out is filtered through the face mask, and does not leak out on the sides.
Face masks can become contaminated during use, on the inside with respiratory secretions from your breath, on the outside with potential infectious agents from others. Therefore, touch used face masks as little as possible, and perform hand hygiene after touching them.
If you use cloth face coverings, store the clean ones separately from the used ones. Cloth face coverings can be washed with other clothes at 60 degrees.
Put on a face mask as follows:
- Perform hand hygiene.
- Put on the face mask with the lighter coloured side nearest the face.
- Fasten the face mask with the elastic around the ears, or around the head if it has a tie.
- Press the noseband down on each side of the bridge of the nose and pull the face mask firmly down under the chin.
- If you wear glasses, wear these on top of the face mask.
- Touch the face mask as little as possible during use
- Remove the face mask, preferably only touching the elastic / ties
- Dispose of the face mask as normal waste (keep the cloth face covering in a bag until it is washed).
- Perform hand hygiene.
Be tolerant about face mask use - both towards those who use them and those who do not.
Knowledge base on the use of face masks and cloth face coverings
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.
As there are no publications about this for COVID-19, we can search for publications that have evaluated the effect of cloth face coverings 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.
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).
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 is therefore difficult.
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.
A rapid review by the NIPH in June 2020 (6) used an Evidence to Decision (EtD) framework to evaluate knowledge and produce a recommendation. The knowledge was based on a structured review of the L·OVE COVID-19 database and a live map of COVID-19 research. We searched for ongoing overviews and studies in PROSPERO, the list of COVID-19 studies in the International Clinical Trials Registry Platform (ICTRP) updated 12th May 2020) and the ClinicalTrials.gov COVID-19 list. We also found some articles by checking the reference lists in identified articles and through personal contacts.
In the summary, it emerged that there is documentation that face masks can have a protective effect against the spread of respiratory tract infections in society, but the results are variable. Randomised studies performed outside healthcare institutions indicate that face masks have little protective effect.
Laboratory studies indicate that the effect is greater when face masks are used to prevent transmission from pre-symptomatic and asymptomatic contagious individuals, compared with when uninfected people use face masks to prevent themselves from becoming infected. Incorrect use of face masks reduces the effect, and there will therfore be a need for training tailored to different target groups to ensure effective use of face masks.
Recommendations from the European Centre of Disease Control (ECDC)
- Use of medical face masks type II and IIR should be reserved for healthcare workers
- Use of non-medical cloth face coverings 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 cloth face coverings 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 cloth face coverings.
- 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 cloth face coverings 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 cloth face coverings can cause a false sense of security, leading 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 cloth face coverings, particularly handling of used masks, and increased touching of the face may lead to an increased risk of transmission.
Recommendations from the World Health Organization (WHO)
On 5th June, the World Health Organization updated its recommendations for the use of face masks and cloth face coverings for COVID-19 (8).
Studies carried out on influenza-like diseases and coronavirus diseases except COVID-19, show that the use of cloth face coverings can prevent transmission to the surroundings from sick people with symptoms.
However there is limited knowledge about the use of cloth face coverings among healthy close contacts, other close contacts or participants in large gatherings being an effective measure to prevent transmission to the surroundings.
Currently, there is no direct evidence from studies of COVID-19 on the effect of use of cloth face coverings by healthy people in the population.
Several countries recommend the use of cloth face coverings by healthy people as a measure to prevent transmission to the surroundings. This measure is not supported by good studies of COVID-19. However, many factors should be considered, including studies on the evaluation of asymptomatic and pre-symptomatic transmission, experiences from countries that have introduced the use of cloth face coverings to the population, individual values and preferences and difficulties in keeping a safe distance.
The WHO concludes that to effectively prevent transmission of COVID-19 in areas with ongoing transmission in society, the authorities should consider recommending the use of cloth face coverings in certain situations as part of a comprehensive set of measures.
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.
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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.