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COVID-19: Recommendations for Prevention and Response

NOTE: For the latest, please visit UNC Gillings Coronavirus Portal.

This resource is intended to synthesize currently available evidence and guidance on SARS-CoV-2 virus and COVID-19 disease occurrence, transmission, and management in the context of water, sanitation, and hygiene (WaSH) and environmental health. In addition, it includes links to selected documents, guidance, and resources relevant to these topics for WaSH and environmental health practitioners, policy stakeholders, and researchers. It also provides links to selected online discussion forums and groups that may be relevant to these stakeholders.

This resource will be updated periodically and was last updated on July 27, 2020.

COVID-19 in Context

(Source 1

Coronavirus disease or COVID-19 is caused when a person becomes infected with the novel SARS-CoV-2 coronavirus. This illness originated in the Chinese city of Wuhan in late 2019 and has since spread throughout the world. Most people infected with the virus experience mild to moderate respiratory symptoms and require little to no special treatment to ensure their recovery although a proportion of those infected (especially those with underlying health conditions such as diabetes, cardiovascular disease, chronic respiratory disease, and certain cancers) can go on to develop serious illness that can be fatal if they do not promptly receive specialized care at a hospital. Below is a collection of information regarding the characteristics of the virus as they relate to the context of WaSH and environmental health. 

SARS-CoV-2 Transmission

(Sources 2, 3, 4

  • The main route of transmission for COVID-19 is thought to be through direct contact with large respiratory droplets emitted when an infected person coughs, talks, or sneezes.
  • People infected with COVID-19 can contaminate their immediate environment with the virus and there is evidence to indicate that SARS-COV-2 can be transmitted indirectly via contact with contaminated surfaces.
  • COVID-19 persistence on surfaces requires further characterization, but seems likely to behave like other coronaviruses. A study conducted by the National Institute of Allergy and Infectious diseases indicated that under controlled laboratory conditions (21-23°C and 40% relative humidity) viable SARS-CoV-2 virus was detected for up to 72 hours on plastic, 48 hours on stainless steel, and 24 hours on cardboard after application to these media. 
  • Limited information regarding SARS-CoV-2 susceptibility to disinfection is currently available, however a study conducted by researchers at the University of Hong Kong indicated the virus is susceptible to standard disinfection methods and materials. For all disinfectants tested except hand soap solution, addition of the substance at working concentration to 15 μL of SARS-CoV-2 culture rendered the virus undetectable after a 5-minute incubation period at 22° C under laboratory conditions. A recently published review of the susceptibility of other human coronaviruses found effective inactivation of HCoV (within 1 minute under ambient conditions) using common disinfectants such as 70% ethanol, 0.1% sodium hypochlorite, and hydrogen peroxide. 
  • WHO warns that airborne transmission of COVID-19 is possible in healthcare facilities when aerosol generating procedures (AGPs) are performed. While the potential for COVID-19 transmission via aerosols requires further investigation and cannot be ruled out in poorly ventilated indoor spaces, there is no credible evidence to indicate that this mode of transmission constitutes a significant source of exposure in other contexts at this time.
  • There have been no reports of fecal-oral transmission of COVID-19 to date.  While the risk of catching COVID-19 from the feces of an infected person appears to be low, there are conflicting reports regarding the persistence of live SARS-CoV-2 in feces.  Given that the COVID-19 virus is rapidly inactivated by chemical agents in the colon, this transmission pathway is likely of little significance to viral spread.
  • There has been no evidence of SARS-CoV-2 presence as infectious virus or survival in drinking water and no documented COVID-19 transmission through drinking or wastewater. The virus is likely to become inactivated significantly faster than non-enveloped human enteric viruses with known waterborne transmission and standard treatment methods and disinfection procedures are expected to be effective at mitigating any potential risk of infection from this pathway.
  • SARS-CoV-2 RNA is readily detectable in untreated wastewater and efforts are currently underway across the globe to assess COVID-19 sewage surveillance as a potentially important tool for monitoring population and community infection trends.

Recommendations for COVID-19 Prevention and Response

(Sources 4, 5, 6, 7, 8

Individuals:

  • Hand hygiene is an effective strategy to reduce the transmission of COVID-19. Access to sufficient quantities of water and soap, alcohol-based hand rub, and/or hygiene materials are needed to facilitate regular, effective handwashing.  
  • Limiting face-to-face contact with others in public spaces through social distancing and masking is vital for reducing SARS-CoV-2 transmission in these spaces. Masking provides a means of “source control” by reducing the number of particles emitted by people infected with COVID-19 as well as offering some measure of protection from personal exposure for those who are uninfected.  

Healthcare Facilities:

  • In order to protect healthcare workers in close contact with patients, it is important to characterize effective decontamination and disinfection methods for filtering facepiece respirators such as the N95 in order to enable their reuse and continued availability in times of shortage. 

WaSH and Environmental Health Implementers:

  • Access to safely managed sanitation services is crucial to ensuring potentially infectious waste is disposed of safely.  
  • COVID-19 highlights the importance of on-plot water and sanitation service delivery – the WaSH sector must continue to strive to provide on-plot service in order to mitigate risk of viral transmission posed by queuing and congregating at water points. 
  • Prioritize sustaining and expanding WaSH services in healthcare facilities (HCFs) and schools, as well as community WaSH infrastructure. Infection prevention and control is one of the eight pillars described in the WHO’s COVID-19 Strategic Preparedness and Response Plan.  

Health Systems Response:

  • In order to streamline coordinated crisis response, systems must be established to ensure cross-sectoral coordination and collaboration. Governments, NGOs, and the private sector must work together to mitigate the effects of the pandemic efficiently.  
  • In responding to COVID-19, policymakers and planners should consider investing in safely managed water and sanitation service delivery, as well as hygiene promotion and infrastructure, because these measures constitute “no-regrets” solutions proven to benefit overall public health while simultaneously mitigating risk associated with the transmission of other infectious diseases.  

Additional COVID-19 Hygiene Resources

(Sources 9, 10)

For Individuals 

Clean your hands often

  • Wash your hands often with soap and water for at least 20 seconds, especially after you have been in a public place, or after blowing your nose, coughing, or sneezing. 
  • If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry. 
  • Avoid touching your eyes, nose, and mouth with unwashed hands. 
  • Handwashing informational video: https://youtu.be/d914EnpU4Fo.

Avoid close contact 

  • Avoid close contact with people who are sick.
  • Stay home as much as possible.
  • Put distance between yourself and other people. 
  • Remember that some people without symptoms may be able to spread virus. 
  • Keeping distance from others is especially important for people who are at higher risk of getting very sick

Cover your mouth and nose with a cloth face cover when around others

  • You could spread COVID-19 to others even if you do not feel sick. 
  • Everyone should wear a cloth face cover when they have to go out in public, for example to the grocery store or to pick up other necessities. 
  • Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance. 
  • The cloth face cover is meant to protect other people in case you are infected. 
  • Do NOT use a facemask meant for a healthcare worker. 
  • Continue to keep about 6 feet between yourself and others. The cloth face cover is not a substitute for social distancing. 

Cover coughs and sneezes

  • If you are in a private setting and do not have on your cloth face covering, remember to always cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow. 
  • Throw used tissues in the trash. 
  • Immediately wash your hands with soap and water for at least 20 seconds following coughs and sneezes. If soap and water are not readily available, clean your hands with a hand sanitizer that contains at least 60% alcohol. 

For WaSH and Environmental Health Implementers 

  • Frequent and correct hand hygiene is one of the most important measures that can be used to prevent infection with the COVID-19 virus. WaSH practitioners should work to enable more frequent and regular hand hygiene by improving access to hand hygiene facilities and using proven behavior change techniques. It is critical to perform hand hygiene at the right time, using the right technique with either alcohol-based hand rub or soap and water. 

Additional COVID-19 Infection Prevention and Control Resources

(Source 11)

  • If surfaces are dirty, clean them: Use detergent or soap and water prior to disinfection. 
  • Clean AND disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks. 

For Individuals 

Best Practices 

Cleaning 

Materials 

PPE 

For Local and Community Institutions 

Best Practices 

Materials 

For WasH and Environmental Health Implementers 

For Healthcare Facilities 

Best Practices 

Cleaning 

Waste Management  

Additional COVID-19 Systems Response Resources 

Preparedness and Response 

  • Global WaSH Cluster– COVID-19 Response Guidance Note #01 Establishes goals and responsibilities for the WaSH sector’s COVID-19 response. It does not include technical guidance but does include links to existing technical guidance for reaching each goal. 7 pages. 
  • Global WaSH Cluster– COVID-19 Response Guidance Note #02 Includes technical recommendations on COVID-19 risk mitigation measures at the institutional, community, and household level. 6 pages. 
  • Interagency Standing Committee (International forum of humanitarian partners including WHO, UNICEF, OCHA, and UNHCR)– COVID-19 Resources Relating to Accountability and Inclusion Collection of resources on improving the accountability and inclusivity of the humanitarian response to the COVID-19 outbreak. Website. 
  • Interagency Standing Committee (International forum of humanitarian partners including WHO, UNICEF, OCHA, and UNHCR)– Scaling-Up COVID-19 Outbreak Readiness and Response Operations in Humanitarian Situations Interim guidance assessing specific needs and considerations of humanitarian situations, including camps and camp-like settings as well as surrounding host communities, in scaling-up multi-sectoral preparedness and response operations for COVID-19. 8 pages.
  • UN Refugee Agency (UNHCR)– Technical WaSH Guidance for COVID-19 Preparedness and Response (UNHCR, 2020) A breakdown of key WaSH guidance for COVID-19 preparedness and response suitable for country and regional planning and for communities. Includes advice specific to refugee settings. 2 pages. 
  • UN Refugee Agency (UNHCR)– COVID-19 WaSH Preparedness and Response – RAPID CHECKLIST Rapid checklist of key WaSH preparedness and response activities for COVID-19 to support regional and country operations in planning and resource mobilization. 1 page. 
  • UN Refugee Agency (UNHCR)– WaSH Webinar #2 on COVID-19 Summarizes UNHCR operational messages on WaSH preparedness and response to COVID-19. Special emphasis on rural water supplies, communal WaSH infrastructure, and camp settings. 1.5 hours. 
  • WHO– Critical Preparedness, Readiness, and Response Actions for COVID-19 Summarizes WHO recommendations for multi-sectoral national and sub-national response to each potential transmission scenario for COVID-19 as well as a full list of available technical guidance from the organization on the novel coronavirus.  

Risk Communication 


Additional COVID-19 Water and Sanitation Resources

(Source 12)

  • WHO guidance on the safe management of drinking-water and sanitation services applies to the COVID-19 outbreak. Extra measures are not needed. Disinfection will facilitate more rapid die-off of the COVID-19 virus. Sanitation workers should have proper training and access to specific combinations of PPE elements recommended for the context in which they are working.
  • Many co-benefits will be realized by safely managing water and sanitation services and applying good hygiene practices. Such efforts will prevent many other infectious diseases, which cause millions of deaths each year.

For Individuals  

  • CDC– Water and COVID-19 FAQs Brief FAQ with information about drinking water, recreational water, and wastewater. 1 page.  

For WaSH and Environmental Health Implementers  

  • Water Research Australia– Novel Coronavirus (SARS-CoV-2) Water and Sanitation factsheet This information sheet synthesizes knowledge currently available on COVID-19, including what is known about the virus and disease, spread via and disinfection of wastewater, as well as water quality monitoring and risks to water supply chains. 3 pages. 

Resources for Monitoring Scientific Updates on the Novel Coronavirus

Web Pages

Websites

Forums

 

References:
  1. Coronavirus- World Health Organization 
  2. UNICEF Technical Note on WaSH Programme Contribution to COVID-19 Prevention and Response 
  3. WHO Scientific Brief: Transmission of SARS-CoV-2: Implications for Infection Prevention Precautions 
  4. WHO Interim Guidance: Water, sanitation, hygiene, and waste management for the COVID-19 virus 
  5. CDC: How to Protect Yourself and Others 
  6. WHO: Coronavirus disease (COVID-19) advice for the public  
  7. WHO: 14 April 2020 COVID-19 Strategy Update  
  8. Howard et al. COVID-19: urgent actions, critical reflections and future relevance of ‘WaSH’: lessons for the current and future pandemics. Journal of Water, Sanitation and Hygiene for Development washdev2020218. doi: https://doi.org/10.2166/washdev.2020.218 (Water Institute Faculty Jamie Bartram and Clarissa Brocklehurst are coauthors of this review).

COVID-19: urgent actions, critical reflections and future relevance of ‘WaSH’: lessons for the current and future pandemics

The COVID-19 pandemic placed hygiene at the centre of disease prevention. Yet, access to the levels of water supply that support good hand hygiene and institutional cleaning, our understanding of hygiene behaviours, and access to soap are deficient in low-, middle- and high-income countries. This paper reviews the role of water, sanitation and hygiene (WaSH) in disease emergence, previous outbreaks, combatting COVID-19 and in preparing for future pandemics. We consider settings where these factors are particularly important and identify key preventive contributions to disease control and gaps in the evidence base. Urgent substantial action is required to remedy deficiencies in WaSH, particularly the provision of reliable, continuous piped water on-premises for all households and settings. Hygiene promotion programmes, underpinned by behavioural science, must be adapted to high-risk populations (such as the elderly and marginalised) and settings (such as healthcare facilities, transport hubs and workplaces). WaSH must be better integrated into preparation plans and with other sectors in prevention efforts. More finance and better use of financing instruments would extend and improve WaSH services. The lessons outlined justify no-regrets investment by government in response to and recovery from the current pandemic; to improve day-to-day lives and as preparedness for future pandemics.

COVID-19: urgent actions, critical reflections and future relevance of ‘WaSH’: lessons for the current and future pandemics. G. Howard, J. Bartram, C. Brocklehurst, J. M. Colford, F. Costa, D. Cunliffe, R. Dreibelbis, J. N. S. Eisenberg, B. Evans, R. Girones, S. Hrudey, J. Willetts, & C. Y. Wright. 2020.  Journal of Water, Sanitation and Hygiene for Development 10:3, pp. 379–396. https://doi.org/10.2166/washdev.2020.218