Author: COVID-19 NEWS

1. Background and Purpose
Globally, health systems have been challenged by the overwhelming demands of the COVID-19 pandemic. Resources and staff are being diverted to test and provide treatment for people with presumed or diagnosed COVID-19, and supplies are limited. Some healthcare services are being compromised in order to meet the demands of caring for COVID-19 patients, and many people fear accessing healthcare facilities due to fear of acquiring the virus.  These fears may be worsened by misinformation.1 During the Ebola outbreak in West Africa in 2014–2015, increased morbidity and mortality in other diseases (e.g., measles, malaria, HIV/AIDS, and TB) were seen due to reduction in access to and utilization of healthcare services, and deaths from these diseases outnumbered deaths from Ebola.2 It is important to ensure continuity of essential health services in order to prevent illness and death from non-COVID-19 illnesses.  This will likely require adaptations to service delivery models and settings.3,4 In addition, infection prevention and control measures to reduce the risk of exposure to COVID-19 among patients and healthcare workers (HCW) should be integrated into all healthcare settings.5
The purpose of this document is to provide ministries of health, public health authorities, and implementing partners with a framework for implementing strategies to reduce preventable illness and death during the COVID-19 pandemic in persons with non-COVID-19 illness and injury, particularly in low-resource settings.
2. Activities to mitigate the impact of COVID-19 on health services
National and sub-national public health authorities play a critical role in determining how to mitigate the impact of COVID-19 on persons needing essential non-COVID-19 services in a variety of healthcare settings. Specific areas of focus for national and sub-national authorities could include:
Prioritizing locations for targeted interventions to reduce the impact of COVID-19 on other diseases. This could be based on COVID-19 prevalence, as well as burden of non-COVID-19 diseases or the need for services (i.e. immunization services), and population size.
Developing targeted communications and educational materials for use in all healthcare settings on:
COVID-19 symptoms, prevention, and transmission among patients and healthcare workers
Infection prevention and control (IPC) for both healthcare workers and patients

Developing methods to facilitate access to facility and community-based healthcare services by service providers, patients, and their supporters during periods of movement restriction.
Maintaining adequate supplies and commodities to provide services and reduce risk of exposure of patients and HCWs to COVID-19 at all service delivery points:
Ensuring adequate supply and use of personal protective equipment (PPE), hand hygiene supplies (soap and water or hand sanitizer with at least 60% alcohol), as well as cleaning and disinfecting supplies.
Forecasting and ordering for multi-month dispensing of medications (e.g., 3- or 6-month dispensing) for chronically ill patients who are stable to reduce length of time between clinic contacts. Use telehealth to monitor and support patients between in-person visits.
Establishing, staffing, and supplying community isolation centers for mild-to-moderately ill COVID-19 patients to isolate and recover.
Planning for and purchasing supplies needed to move essential non-COVID-19 services into makeshift clinics in areas most heavily affected by COVID-19. Coordinating with IPC focal persons for IPC considerations and requirements in such settings.

Ensuring monitoring plans track service delivery occurring outside of healthcare facilities in order to track retention in health programs, including those for chronic disease, antenatal care (ANC), and immunization services.
3. Modification of service delivery to maintain essential non-COVID-19 services
Modify Service Access
Determine which essential services will continue and which need to be paused or referred to another clinic due to burden of COVID-19 patients.
Screen patients for symptoms of or exposure to COVID-19 before they get to the health facility; consider using telehealth platforms to screen patients before they come to the health facility and to make referrals, if needed.
Triage and test patients for COVID-19, including, where possible, touchless temperature checks.
Ensure hand hygiene (all people entering and exiting facility should wash hands with soap and water or use hand sanitizer with 60% alcohol), appropriate use of PPE, and regular cleaning and disinfection, especially of frequently touched surfaces and shared objects.
Ensure use of a medical mask for all patients with respiratory symptoms or other symptoms suggestive of COVID-19 and encourage the use of masks for other patients.5
Modify Clinic Space:
Separate patients by maintaining at least a distance of about 2 arm lengths (about 2 meters) when possible (e.g., move waiting areas outside) and limiting the number of people in the facility at a time, especially in small spaces such as pharmacies and hallway waiting areas.
Consider altering and repurposing clinic space or designating certain facilities for COVID-19 care while others are designated for essential non-COVID-19 services.
Modify underused spaces in facilities that have access to improved water sources (water supplied through a household connection, public standpipe, borehole well, protected dug well, protected spring, or rainwater collection) and good ventilation (e.g., operates properly and increases circulation of outdoor air as much as possible) for use as isolation areas for presumptive or positive COVID-19 patients.
Ensure separate spaces that allow for physical distancing are available for assessment of acutely ill persons and delivery of essential non-COVID-19 services.
Modify Service Delivery:
Minimize patient contacts with HCW and other patients to reduce risk of exposure or infection:
Lengthen time between appointments for stable, healthy patients.
Use telemedicine visits (either video, phone calls, SMS (short message service)) for screening, follow-up, and refilling prescriptions.
Implement 3- or 6-month dispensing of medication for healthy, stable patients.

Provide staggered appointments to reduce the number of people in waiting areas and implement and enforce an appointment scheduling system to decongest clinics.
Provide fast-track services for acute and chronic patients to reduce contact with multiple providers (e.g., charts pulled, medications ready, patient only sees provider if needed, one provider sees patient through all services).
Limit number of visitors who may accompany patient to clinic or community-based services.
Relocate services—each community and healthcare facility will need to determine which of the following options best fits their circumstances and available resources.3,4,7 Decisions may vary based on the number of COVID-19 cases in the community.
Health facilities with few presumptive or positive COVID-19 patients may designate an area within the facility where COVID-19 patients can be isolated.
In sites where there is a higher burden of COVID-19 cases, the facility may consider:
Moving essential non-COVID-19 services outside of the facility into community spaces, (e.g., a vacant school, church, or community center) to reduce risk of exposure at facilities, ensure these patients remain in care and on treatment as some may fear getting sick if they return to the clinic, and reduce crowding at clinics so they are better able to care for COVID-19 patients.
Moving services for COVID-19 patients with mild or moderate symptoms to community isolation centers to maintain space in facilities for essential non-COVID-19 services.

Promoting home-based care for COVID-19 patients with mild or moderate symptoms who can safely isolate at home.

Offer multiple “no-contact” drug pick-up options for patients with chronic illnesses:
Scheduled medicine pick-up at community or clinic pharmacies, or community pick-up points (e.g. houses of worship or schools). Consider adaptations to minimize in-person contact and exposure risk. Alternative modes of communication may include telemedicine calls, SMS, or social media.
Implement 3- or 6-month dispensing of medication for healthy, stable patients.

Maintain routine contact with stable patients. Provide more frequent contact to new patients and patients at risk for loss to follow-up.
Shift and share tasks as needed:
Re-assign staff from less busy services to assist with essential services.
Work with the Ministry of Health (MOH) and local HCW societies to determine how task shifting can best be used to provide essential services.

Ensure HCWs are appropriately trained in provision of care for patients with COVID-19, and that clear guidance/ operating procedures exist for training on transmission of COVID-19, donning and doffing personal protective equipment, etc.
Links to Disease Specific Recommendations:
Additional Resources:
https://www.jhpiego.org/wp-content/uploads/2020/06/Jhpiego-Operational-Guidance-for-Continuity-of-Essential-Services-Final.pdfpdf iconexternal icon

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Background
SARS-CoV-2 infection is transmitted predominately by respiratory droplets generated when people cough, sneeze, sing, talk, or breathe. CDC recommends community use of masks, specifically non-valved multi-layer cloth masks, to prevent transmission of SARS-CoV-2. Masks are primarily intended to reduce the emission of virus-laden droplets (“source control”), which is especially relevant for asymptomatic or presymptomatic infected wearers who feel well and may be unaware of their infectiousness to others, and who are estimated to account for more than 50% of transmissions.1,2  Masks also help reduce inhalation of these droplets by the wearer (“filtration for personal protection”). The community benefit of masking for SARS-CoV-2 control is due to the combination of these effects; individual prevention benefit increases with increasing numbers of people using masks consistently and correctly.
Source Control to Block Exhaled Virus
Multi-layer cloth masks block release of exhaled respiratory particles into the environment,3-6 along with the microorganisms these particles carry.7,8  Cloth masks not only effectively block most large droplets (i.e., 20-30 microns and larger)9 but they can also block the exhalation of fine droplets and particles (also often referred to as aerosols) smaller than 10 microns ;3,5 which increase in number with the volume of speech10-12 and specific types of phonation.13 Multi-layer cloth masks can both block up to 50-70% of these fine droplets and particles3,14  and limit the forward spread of those that are not captured.5,6,15,16 Upwards of 80% blockage has been achieved in human experiments that have measured blocking of all respiratory droplets,4 with cloth masks in some studies performing on par with surgical masks as barriers for source control.3,9,14
Filtration for Personal Protection
Studies demonstrate that cloth mask materials can also reduce wearers’ exposure to infectious droplets through filtration, including filtration of fine droplets and particles less than 10 microns. The relative filtration effectiveness of various masks has varied widely across studies, in large part due to variation in experimental design and particle sizes analyzed. Multiple layers of cloth with higher thread counts have demonstrated superior performance compared to single layers of cloth with lower thread counts, in some cases filtering nearly 50% of fine particles less than 1 micron .14,17-29 Some materials (e.g., polypropylene) may enhance filtering effectiveness by generating triboelectric charge (a form of static electricity) that enhances capture of charged particles18,30 while others (e.g., silk) may help repel moist droplets31 and reduce fabric wetting and thus maintain breathability and comfort.
Human Studies of Masking and SARS-CoV-2 Transmission
Data regarding the “real-world” effectiveness of community masking are limited to observational and epidemiological studies.
An investigation of a high-exposure event, in which 2 symptomatically ill hair stylists interacted for an average of 15 minutes with each of 139 clients during an 8-day period, found that none of the 67 clients who subsequently consented to an interview and testing developed infection. The stylists and all clients universally wore masks in the salon as required by local ordinance and company policy at the time.32
In a study of 124 Beijing households with > 1 laboratory-confirmed case of SARS-CoV-2 infection, mask use by the index patient and family contacts before the index patient developed symptoms reduced secondary transmission within the households by 79%.33
A retrospective case-control study from Thailand documented that, among more than 1,000 persons interviewed as part of contact tracing investigations, those who reported having always worn a mask during high-risk exposures experienced a greater than 70% reduced risk of acquiring infection compared with persons who did not wear masks under these circumstances.34
A study of an outbreak aboard the USS Theodore Roosevelt, an environment notable for congregate living quarters and close working environments, found that use of face coverings on-board was associated with a 70% reduced risk.35
Investigations involving infected passengers aboard flights longer than 10 hours strongly suggest that masking prevented in-flight transmissions, as demonstrated by the absence of infection developing in other passengers and crew in the 14 days following exposure.36,37
Seven studies have confirmed the benefit of universal masking in community level analyses: in a unified hospital system,38 a  German city,39 a U.S. state,40 a panel of 15 U.S. states and Washington, D.C.,41,42 as well as both Canada43 and the U.S.44 nationally. Each analysis demonstrated that, following directives from organizational and political leadership for universal masking, new infections fell significantly. Two of these studies42,44 and an additional analysis of data from 200 countries that included the U.S.45 also demonstrated reductions in mortality. An economic analysis using U.S. data found that, given these effects, increasing universal masking by 15% could prevent the need for lockdowns and reduce associated losses of up to $1 trillion or about 5% of gross domestic product.42
Conclusions
Experimental and epidemiological data support community masking to reduce the spread of SARS-CoV-2. The prevention benefit of masking is derived from the combination of source control and personal protection for the mask wearer. The relationship between source control and personal protection is likely complementary and possibly synergistic14, so that individual benefit increases with increasing community mask use. Further research is needed to expand the evidence base for the protective effect of cloth masks and in particular to identify the combinations of materials that maximize both their blocking and filtering effectiveness, as well as fit, comfort, durability, and consumer appeal. Adopting universal masking policies can help avert future lockdowns, especially if combined with other non-pharmaceutical interventions such as social distancing, hand hygiene, and adequate ventilation.

Links with this icon indicate that you are leaving the CDC website.The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
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COVID-19 Alert: Cases are Rising
COVID-19 cases, hospitalizations, and deaths across the United States are rising. As cold weather moves in, people spend more time indoors, and the holidays approach, take steps to slow the spread of COVID-19. Wear a mask, stay at least 6 feet apart, avoid crowds, and wash your hands often. The more steps you take, the more you are protected against COVID-19. View Cases in the U.S. and your state on the data tracker.

Background
SARS-CoV-2 infection is transmitted predominately by respiratory droplets generated when people cough, sneeze, sing, talk, or breathe. CDC recommends community use of masks, specifically non-valved multi-layer cloth masks, to prevent transmission of SARS-CoV-2. Masks are primarily intended to reduce the emission of virus-laden droplets (“source control”), which is especially relevant for asymptomatic or presymptomatic infected wearers who feel well and may be unaware of their infectiousness to others, and who are estimated to account for more than 50% of transmissions.1,2  Masks also help reduce inhalation of these droplets by the wearer (“filtration for personal protection”). The community benefit of masking for SARS-CoV-2 control is due to the combination of these effects; individual prevention benefit increases with increasing numbers of people using masks consistently and correctly.
Source Control to Block Exhaled Virus
Multi-layer cloth masks block release of exhaled respiratory particles into the environment,3-6 along with the microorganisms these particles carry.7,8  Cloth masks not only effectively block most large droplets (i.e., 20-30 microns and larger)9 but they can also block the exhalation of fine droplets and particles (also often referred to as aerosols) smaller than 10 microns ;3,5 which increase in number with the volume of speech10-12 and specific types of phonation.13 Multi-layer cloth masks can both block up to 50-70% of these fine droplets and particles3,14  and limit the forward spread of those that are not captured.5,6,15,16 Upwards of 80% blockage has been achieved in human experiments that have measured blocking of all respiratory droplets,4 with cloth masks in some studies performing on par with surgical masks as barriers for source control.3,9,14
Filtration for Personal Protection
Studies demonstrate that cloth mask materials can also reduce wearers’ exposure to infectious droplets through filtration, including filtration of fine droplets and particles less than 10 microns. The relative filtration effectiveness of various masks has varied widely across studies, in large part due to variation in experimental design and particle sizes analyzed. Multiple layers of cloth with higher thread counts have demonstrated superior performance compared to single layers of cloth with lower thread counts, in some cases filtering nearly 50% of fine particles less than 1 micron .14,17-29 Some materials (e.g., polypropylene) may enhance filtering effectiveness by generating triboelectric charge (a form of static electricity) that enhances capture of charged particles18,30 while others (e.g., silk) may help repel moist droplets31 and reduce fabric wetting and thus maintain breathability and comfort.
Human Studies of Masking and SARS-CoV-2 Transmission
Data regarding the “real-world” effectiveness of community masking are limited to observational and epidemiological studies.
An investigation of a high-exposure event, in which 2 symptomatically ill hair stylists interacted for an average of 15 minutes with each of 139 clients during an 8-day period, found that none of the 67 clients who subsequently consented to an interview and testing developed infection. The stylists and all clients universally wore masks in the salon as required by local ordinance and company policy at the time.32
In a study of 124 Beijing households with > 1 laboratory-confirmed case of SARS-CoV-2 infection, mask use by the index patient and family contacts before the index patient developed symptoms reduced secondary transmission within the households by 79%.33
A retrospective case-control study from Thailand documented that, among more than 1,000 persons interviewed as part of contact tracing investigations, those who reported having always worn a mask during high-risk exposures experienced a greater than 70% reduced risk of acquiring infection compared with persons who did not wear masks under these circumstances.34
A study of an outbreak aboard the USS Theodore Roosevelt, an environment notable for congregate living quarters and close working environments, found that use of face coverings on-board was associated with a 70% reduced risk.35
Investigations involving infected passengers aboard flights longer than 10 hours strongly suggest that masking prevented in-flight transmissions, as demonstrated by the absence of infection developing in other passengers and crew in the 14 days following exposure.36,37
Seven studies have confirmed the benefit of universal masking in community level analyses: in a unified hospital system,38 a  German city,39 a U.S. state,40 a panel of 15 U.S. states and Washington, D.C.,41,42 as well as both Canada43 and the U.S.44 nationally. Each analysis demonstrated that, following directives from organizational and political leadership for universal masking, new infections fell significantly. Two of these studies42,44 and an additional analysis of data from 200 countries that included the U.S.45 also demonstrated reductions in mortality. An economic analysis using U.S. data found that, given these effects, increasing universal masking by 15% could prevent the need for lockdowns and reduce associated losses of up to $1 trillion or about 5% of gross domestic product.42
Conclusions
Experimental and epidemiological data support community masking to reduce the spread of SARS-CoV-2. The prevention benefit of masking is derived from the combination of source control and personal protection for the mask wearer. The relationship between source control and personal protection is likely complementary and possibly synergistic14, so that individual benefit increases with increasing community mask use. Further research is needed to expand the evidence base for the protective effect of cloth masks and in particular to identify the combinations of materials that maximize both their blocking and filtering effectiveness, as well as fit, comfort, durability, and consumer appeal. Adopting universal masking policies can help avert future lockdowns, especially if combined with other non-pharmaceutical interventions such as social distancing, hand hygiene, and adequate ventilation.

Links with this icon indicate that you are leaving the CDC website.The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
You will be subject to the destination website’s privacy policy when you follow the link.
CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

For more information on CDC’s web notification policies, see Website Disclaimers.

Links with this icon indicate that you are leaving the CDC website.The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
You will be subject to the destination website’s privacy policy when you follow the link.
CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

For more information on CDC’s web notification policies, see Website Disclaimers.

Links with this icon indicate that you are leaving the CDC website.The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
You will be subject to the destination website’s privacy policy when you follow the link.
CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

For more information on CDC’s web notification policies, see Website Disclaimers.