Management of Visitors to Healthcare Facilities in the Context of COVID-19: Non-US Healthcare Settings

1. Background

This document provides guidance to healthcare facilities on the management of visitors to reduce the risk of transmission of SARS-CoV-2, also known as COVID-19 virus, to visitors of patients with suspected or confirmed COVID-19. This document also considers preventing introduction of SARS-CoV2 into healthcare facilities by visitors during periods of community transmission; the risk of introduction into facilities increases as community transmission becomes more widespread. Facilities should establish policies and procedures for managing, screening, educating, and training all visitors.

2. Visitors to healthcare facilities should be limited in the context of the COVID-19 pandemic, regardless of known community transmission. If visitors are allowed:

• • Facilities should designate an entrance that visitors can use to access the healthcare facility.
  • Visitors who are noted by healthcare facility staff to have fever or other symptoms of acute respiratory illness (e.g., cough or shortness of breath) should be instructed to leave the facility and seek care if needed.
  • Facilities should encourage visitors to be aware of signs and symptoms of acute respiratory illness consistent with COVID-19 and not enter the facility if they have such signs and symptoms.
    • Visual alerts, such as signs and posters, should be placed at facility entrances and other strategic areas instructing visitors not to enter as a visitor if they have fever or respiratory symptoms.
    • Signage should include signs and symptoms pdf icon[236 KB, 1 Page] of COVID-19 and who to notify if visitors have symptoms.
  • Visitors are strongly discouraged from visiting patients who are at increased risk for severe illness from COVID-19. If visitors are allowed, facilities should follow national policies regarding the use of medical masks or face covers (e.g., homemade mask) by healthy visitors.¹

• Facilities should apply alternatives for direct interaction between visitors and patients, including setting up remote communications (e.g., telephone or internet connection) in the isolation area to allow for video or audio calls.
• Facilities should have staff members who are able to provide training and education to visitors. All visitors allowed to visit patients should be educated on:
  • Signs and symptoms of COVID-19 including instructions on who to notify if they develop symptoms.
  • Performing hand hygiene by washing hands with soap and water for at least 40 seconds or by using an alcohol-based hand rub with at least 60% ethanol or 70% isopropanol for at least 20 seconds. Facilities should provide adequate supplies for visitors to perform hand hygiene.
  • Following respiratory hygiene and cough etiquette (e.g., covering mouth and nose with a disposable tissue when coughing or sneezing) in the event an individual develops respiratory symptoms while visiting the facility. Facilities should provide adequate supplies for visitors to perform respiratory hygiene and should instruct visitors with cough or other respiratory symptoms to immediately leave the facility and seek care if needed.

3. Considerations during community transmission of COVID-19

• Thresholds should be established to determine when active screening of all visitors will be initiated.
• During active screening, all visitors should be assessed before entering the healthcare facility for symptoms of acute respiratory illness consistent with COVID-19. If a visitor has symptoms, they should not be allowed to enter the facility.
• During widespread community transmission of COVID-19, visitor access to healthcare facilities should be restricted. Only visitors essential for helping to provide patient care and/or caring for pediatric patients should be allowed. Facilities should consider requiring all essential visitors to wear a medical mask or face cover, according to national policies, to prevent COVID-19 transmission in the facility from pre-symptomatic or asymptomatic individuals.

4. When visiting COVID-19 patients is essential such as for pediatric patients and/or for basic patient care and feeding:

• Visitors to areas where patients with COVID-19 are isolated should be limited to essential visitors such as those helping to provide patient care and/or caring for pediatric patients. Limit to one visitor/caregiver² per patient with COVID-19 at a time.
• Visits should be scheduled to allow enough time for screening, education, and training of visitors.
• Visitors should be assessed to determine risks to their health. Visitors who are at high risk for severe illness from COVID-19, ³ such as older adults and those with underlying medical conditions, should be strongly discouraged.
• Movement of visitors in the healthcare facility should be restricted. Visitors should only visit the patient they are caring for and should not go to other locations in the facility.
• Facilities should provide education on appropriate personal protective equipment (PPE) use, hand hygiene, limiting surfaces touched, social distancing, and movement within the facility.
  • Training on PPE use should be conducted by a trained healthcare worker and include observations of the visitor to ensure correct donning and doffing of PPE and appropriate hand hygiene. Appropriate disposal of PPE should be ensured by facility staff.
  • Because patients with COVID-19 are on isolation precautions and PPE supplies are limited, facilities should enforce visitor restriction policies. PPE should not be shared among family members of a patient with COVID-19. If PPE is not available for visitors, and a visitor is essential for helping to provide patient care, follow PPE contingency plans.
• Facilities should make sure that visitors understand the potential risks associated with providing care to patients with COVID-19, especially for visitors at high risk for serious illness from COVID-19 and those who are primary caregivers and have extended contact with patients (e.g., parents or guardians of children).
• Visitors should not be present during aerosol-generating procedures or during collection of respiratory specimens.
• Facilities should consider the need to conduct active screening for visitors with potential exposure to SARS-CoV-2 due to a breach in infection prevention and control (IPC) protocol.

¹ Refer here for WHO advice on the use of masks in the context of COVID-19external icon

² Caregivers are defined as “parents, spouses, other family members or friends without formal healthcare training” per WHO interim guidance for home care for patients with suspected novel coronavirus (COVID-19) infection presenting with mild symptoms, and management of their contactsexternal icon.

³ Refer here for definition of individuals at high risk of COVID-19

5. References

Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings

WHO Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health careexternal icon

WHO Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19) pdf icon[841 KB, 7 Pages]external icon

Gopalakrishna G, Choo P, Leo YS, Tay BK, Lim YT, Khan AS, Tan CC. SARS transmission and hospital containment. Emerg Infect Dis. 2004 Mar;10(3):395-400.

Lee NE, Siriarayapon P, Tappero J, Chen KT, Shuey D, Limpakarnjanarat K, Chavavanich A, Dowell SF; SARS Mobile Response Team Investigators. Infection control practices for SARS in Lao People’s Democratic Republic, Taiwan, and Thailand: experience from mobile SARS containment teams, 2003. Am J Infect Control. 2004 Nov;32(7):377-83.

Mizumoto K, Kagaya K, Zarebski A, Chowell G. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020. Euro Surveill. 2020 Mar;25(10).

Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G, Wallrauch C, Zimmer T, Thiel V, Janke C, Guggemos W, Seilmaier M, Drosten C, Vollmar P, Zwirglmaier K, Zange S, Wölfel R, Hoelscher M. Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. N Engl J Med. 2020 Mar 5;382(10):970-971.

Weber DJ, Rutala WA, Fischer WA, Kanamori H, Sickbert-Bennett EE. Emerging infectious diseases: Focus on infection control issues for novel coronaviruses (Severe Acute Respiratory Syndrome-CoV and Middle East Respiratory Syndrome-CoV), hemorrhagic fever viruses (Lassa and Ebola), and highly pathogenic avian influenza viruses, A(H5N1) and A(H7N9). Am J Infect Control. 2016 May 2;44(5 Suppl):e91-e100.