Interim advice for preparedness and response to cases of COVID-19 at points of entry in the European Union (EU)/EEA Member States (MS)
The interim advice documents listed below were prepared after a request from the European Commission's Directorate-General for Health and Food Safety (DG SANTE). An ad-hoc working group was established with members from the EU HEALTHY GATEWAYS joint action consortium.
The scope of the advice provided in the documents listed below is to assist public health authorities in developing their short-term and long-term national and local preparedness plans. It further contains useful advice for the air, maritime and ground transport sectors.
POINTS OF ENTRY
Public health measures at points of entry (VERSION 3 - 20/02/2020)
and general advice at points of entry for public health measures and screening:
and general advice at points of entry for public health measures and screening:
- Buses and bus stations
and general advice at points of entry for public health measures and screening:
- Trains and rail stations
and general advice at points of entry for public health measures and screening:
Training resources for COVID-19
Online training resources for COVID-19
- EU HEALTHY GATEWAYS JOINT ACTION
- Training of the trainers’ course “Preparedness and response to public health events at airports” (EU HEALTHY GATEWAYS 2019);
- Training of the trainers’ course “Preparedness and response to public health events at ports” (EU HEALTHY GATEWAYS 2019);
- Evidence-based best practices on entry/exit screening for infectious diseases in humans (DG SANTE 2019).
The training materials of the training course are available to the EU MS and access can be given by the EU HEALTHY GATEWAYS joint action (contact email: email@example.com).
All past webinars are listed here https://www.healthygateways.eu/Core-work-packages/Training
To access the available for play-back viewing webinars please apply on the link below by completing the webinar(s) you are interested in: https://www.healthygateways.eu/Contact-Us
Q & A
Τhe following questions were made by participants during the webinars conducted by the EU HEALTHY GATEWAYS joint action in response to the COVID-19 outbreak. Answers are based on guidelines from ECDC and WHO considering the current knowledge about SARS-CoV-2 as of 5 March 2020. For any further information or comment please contact firstname.lastname@example.org
The survival time of SARS-CoV-2 in the environment is currently unknown. The survival of SARS-CoV is estimated to be several days and MERS-CoV >48 hours at an average room temperature (20°C) on different surfaces [1, 2]. SARS-CoV-2 has been isolated from respiratory specimens, stool, urine, and gastrointestinal mucosa [3-5]. SARS-CoV-2 has been detected by PCR in rooms where COVID-19 patients were hospitalised from surfaces of the toilet bowl and sink, and the air exhaust outlets . Interim guidance for environmental cleaning in non-healthcare facilities exposed to SARS-CoV-2 can be found at: https://www.ecdc.europa.eu/en/publications-data/interim-guidance-environmental-cleaning-non-healthcare-facilities-exposed-2019 
Technical recommendations for cleaning and disinfection on ships
While case management is in progress on board a cruise ship, a high level of cleaning and disinfection measures should be maintained on board as per the outbreak management plan available on the ship.
Medical facilities, cabins and quarters occupied by patients and contacts of COVID-19 should be cleaned and disinfected in accordance with the WHO guidance for infection prevention and control during health care when COVID-19 infection is suspected. All other areas should be cleaned and disinfected according to the procedures applied in response to Norovirus gastroenteritis outbreak .
Laundry, food service utensils and waste from cabins of suspect cases and contacts should be handled as infectious, in accordance with the outbreak management plan provided on board for other infectious diseases (Norovirus gastroenteritis) . Staff who will perform cleaning and disinfection should be trained in the adequate selection and use of personal protective equipment (PPE).
Cleaning environmental surfaces with water and detergent and applying commonly used hospital disinfectants (such as sodium hypochlorite) is an effective and sufficient procedure . Antimicrobial agents effective against different coronaviruses can be found in the following table, which has been extracted from the ECDC guidance for environmental cleaning in non-healthcare facilities exposed to SARS-CoV-2 .
Source: ECDC Technical Report. Interim guidance for environmental cleaning in non-healthcare facilities exposed to SARS-CoV-2
All frequently touched areas, such as all accessible surfaces of walls and windows, the toilet bowl and bathroom surfaces, should be also carefully cleaned .
The use of 0.1% sodium hypochlorite (dilution 1:50 if household bleach at an initial concentration of 5% is used) after cleaning with a neutral detergent is suggested for decontamination purposes, although no data on the effectiveness against the SARS-CoV-2 are available. For surfaces that could be damaged by sodium hypochlorite, 70% concentration of ethanol is needed for decontamination after cleaning with a neutral detergent .
Chairs and sofas, as well as wall coverings and window treatments, should be thoroughly disinfected with suitable virucidal disinfectant after all visible contaminants have been removed. Allowing them to air dry in the sun is beneficial, if possible .
Soiled mattresses should be steam cleaned or discarded .
Chlorine bleach can damage textiles . Other disinfectant agents that are less damaging to furnishings could be used.
Carpets and furnishings that cannot be laundered can be cleaned with detergent and warm water and then with steam . Vacuuming of carpets should not take place in cabins occupied by infected people unless the carpet has been previously disinfected . Contaminated carpets should be steam cleaned and then disinfected .
Steam cleaning is claimed to be an effective method of cleaning soft surfaces such as carpets and curtains during Norovirus outbreaks. However, steam cleaning is questionable as a disinfection method alone as it is difficult to reach high enough temperatures within soft furnishings. It may be that it has a role combined with other measures. If detergents are used, application must be done with a clean disposable cloth .
All textiles (e.g. bed linens, curtains, etc.) should be washed using a hot-water cycle (90°C) and adding laundry detergent . If a hot-water cycle cannot be used due to the characteristics of the tissues, specific chemicals should be added when washing the textiles (e.g. bleach or laundry products containing sodium hypochlorite, or decontamination products specifically developed for use on textiles) .
Technical recommendations for cleaning and disinfection on aircrafts
Following an event of an Acute Respiratory Illness (ARI) case on board, the airline should ensure that cleaning and disinfection procedures are followed consistently and correctly using the licenced products suitable for the aircraft at the highest acceptable concentrations . Special attention should be given to the zone of risk in the cabin area (e.g. seats, headrests, table-tops, handsets, and other materials coming in contact with the suspect case) where the case was seated, as well as all shared facilities and high-touched surfaces [9, 13]. The service staff who will clean and disinfect the aircraft should be specially trained and apply the standard procedures for cleaning and disinfecting contaminated surfaces with infectious agents using the appropriate PPE.
WHO advises the following procedures for cleaning and disinfection in case a public health event has occurred on board :
- Ensure any disinfection is conducted using products licensed for use in the country occupied. The disinfectants must be tested by a certified laboratory according to the specifications of the aircraft manufacturers for material compatibility tests.
- Any contaminated items must be handled appropriately to mitigate the risk of transmission:
- Disposable items (hand towels, gloves, tissues) should be double bagged and sent to incineration or similar final disposal, according to the States Parties guidelines for infectious waste management.
- Reusable items that can be washed and treated/disinfected (gowns or linens) must be tagged and sent to a facility for washing and treatment, as recommended according to infection control procedures, depending on the type of contamination/infectious agent, if known.
Based on recommended disinfectants for aircrafts during the previous 2003 SARS outbreak and for MERS CoV, the recommended disinfectants are products containing ethanol in concentration of 70% or 0.1% sodium hypochlorite, provided that these products have been tested by a certified laboratory according to the specifications of the aircraft manufacturers for material compatibility tests. For other products, the label of the manufacturer should mention that the disinfectant is effective against emerging viruses or against coronaviruses or that have sporicidal effect.
Affected areas are defined by WHO in the website https://www.who.int/
In the latest travel advice published by WHO on 29 February 2020, the following are defined as affected areas:
“Affected areas” are considered those countries, provinces, territories or cities experiencing ongoing transmission of COVID-19, in contrast to areas reporting only imported cases. As of 27 February 2020, although China, particularly the Province of Hubei, has experienced sustained local transmission and has reported by far the largest number of confirmed cases since the beginning of the outbreak, lately the situation in China showed a significant decrease in cases. At the same time, an increasing number of countries, other than China, have reported cases, including through local transmission of COVID-19. As the epidemic evolves, it will be expected that many areas may detect imported cases and local transmission of COVID-19. WHO is publishing daily situation reports on the evolution of the outbreak (available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/). The outbreaks reported so far have occurred primarily within clusters of cases exposed through close-contacts, within families or special gathering events. COVID-19 is primarily transmitted through droplets from, and close contact with, infected individuals. Control measures that focus on prevention, particularly through regular hand washing and cough hygiene, and on active surveillance for the early detection and isolation of cases, the rapid identification and close monitoring of persons in contact with cases, and the rapid access to clinical care, particularly for severe cases, are effective to contain most outbreaks of COVID-19 .
Specimen collection and laboratory testing will be conducted at the health care facility where the suspect case has been transferred.
Please see answer to question 1 above.
Although currently there is no evidence of airborne transmission, a precautionary approach is recommended due to uncertainties surrounding the potential for aerosol-mediated transmission of the virus. Transmission through inhalation of aerosols during aerosol-generating procedures, may have occurred in some cases  .
Whenever possible, ships isolation rooms with mechanical ventilation should have negative pressure with minimum of 12 air changes per hour, while isolation rooms with natural ventilation, should provide a ventilation rate of at least 160 litres/second . All air handling units on board the ship should be adjusted to supply 100% outside air and no air recirculation should take place.
This will depend on the policy of each country and authority. Exchange of questions, opinion, and experiences could be done between points of entry or through the central level.
This will be judged by the physician and occupational health specialist for the specific persons and workplace.
This could be applied as a precautionary measure.
Scenario 1: A suspect case is detected on board while a ship is in port and as many travellers are on tours, others walking in the city and others are on board.
Since according to the scenario the symptomatic person is currently on board, the procedures for managing the symptomatic suspect traveller will start immediately on board. The procedures for identifying the close contacts will start immediately with the persons who are currently on board. The procedures for identifying the close contacts who are currently ashore will start once they are back to the ship. If it is feasible, their return back could be arranged earlier than scheduled. All other steps will be followed according to the EU HEALTHY GATEWAYS advice for ship operators: https://www.healthygateways.eu/Novel-coronavirus.
Scenario 2: A suspect case is detected in one of the buses that are transferring passengers to the organized tours (there could be other buses doing the same stops and visiting the same places at the same time of the bus where a suspect case was detected).
The suspect case on board the bus should be transferred with an ambulance to the hospital immediately, if this is feasible. Further advice about management of a suspect case on the bus can be found in the EU HEALTHY GATEWAYS advice for bus operators: https://www.healthygateways.eu/Novel-coronavirus
The identification and management of close contacts on board the ship will take place according to the procedures described in the EU HEALTHY GATEWAYS advice for ship operators: https://www.healthygateways.eu/Novel-coronavirus.
Scenario 3: One of the drivers or guides becomes a suspect case and has performed tours for cruise lines in the past 14 days or is at that moment working with cruise line passengers.
The advice for bus operators should be followed in regard to the suspect driver or guide while on the bus. All persons who had been in close contact with the suspect driver or guide the previous 14 days should be informed about their exposure. Close contacts who are still on board should be managed according to the EU HEALTHY GATEWAYS advice. All other persons who participated in previous cruises and have disembarked should be managed according to the ECDC advice for management of close contacts: https://www.ecdc.europa.eu/en/publications-data/public-health-management-persons-including-health-care-workers-having-had-contact
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2. van Doremalen, N., T. Bushmaker, and V.J. Munster, Stability of Middle East respiratory syndrome coronavirus (MERS-CoV) under different environmental conditions. Euro Surveill, 2013. 18(38).
3. Ling, Y., et al., Persistence and clearance of viral RNA in 2019 novel coronavirus disease rehabilitation patients. Chin Med J (Engl), 2020.
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6. Ong, S.W.X., et al., Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. JAMA, 2020.
7. European Centre for Disease Prevention and Control, ECDC TECHNICAL REPORT - Guidelines for the use of non-pharmaceutical measures to delay and mitigate the impact of 2019-nCoV February 2020 2020: Stockholm.
8. EU SHIPSAN ACT JOINT ACTION (20122103) - European Commission Directorate General for Health and Food Safety, European Manual for Hygiene Standards and Communicable Diseases Surveillance on Passenger Ships. Second ed. 2016: EU SHIPSAN ACT JOINT ACTION (20122103).
9. World Health Organization, Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. Interim guidance. 25 January 2020. 2020.
10. European Centre for Disease Prevention and Control, Interim guidance for environmental cleaning in non-healthcare facilities exposed to SARS-CoV-2. 2020, ECDC: Stockholm.
11. European Centre for Disease Prevention and Control, ECDC TECHNICAL REPORT. Infection prevention and control for the care of patients with 2019-nCoV in healthcare settings. 2020, ECDC: Stockholm
12. Klaus, J., et al., Disinfection of aircraft : Appropriate disinfectants and standard operating procedures for highly infectious diseases. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz, 2016. 59(12): p. 1544-1548.
13. World Health Organization. Summary of SARS and air travel. 2003 23 May 2003 21/1/2020]; Available from: https://www.who.int/csr/sars/travel/airtravel/en/.
14. World Health Organization, Handbook for the Management of Public Health Events in Air Transport. Updated with information on Ebola virus disease and Middle East respiratory syndrome coronavirus. 2015: World Health Organization.
15. World Health Organization. International travel and health Updated WHO recommendations for international traffic in relation to COVID-19 outbreak 29 February 2020. 2020; Available from: https://www.who.int/ith/2019-nCoV_advice_for_international_traffic-rev/en/
16. EU HEALTHY GATEWAYS JOINT ACTION PREPAREDNESS AND ACTION AT POINTS OF ENTRY (PORTS, A., GROUND CROSSINGS),. Interim advice for preparedness and response to cases of the 2019-nCoV acute respiratory disease at points of entry in the European Union (EU)/EEA Member States (MS). 2020 03/02/2020 12/2/2020]; 2nd:[Available from: https://www.healthygateways.eu/Novel-coronavirus.
17. Rothe, C., et al., Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. The New England journal of medicine, 2020: p. 10.1056/NEJMc2001468.
18. World Health Organization. Clinical management of severe acute respiratory infectionwhen novelcoronavirus (nCoV)infection is suspected. Interim guidance. 2020 28 January 2020; Available from: https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf?sfvrsn=bc7da517_2.
Disclaimer: This document arises from the EU HEALTHY GATEWAYS Joint Action that was funded by the European Union’s Health Programme (2014-2020).The content of this document represents the views of the authors only and is their sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA) or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains.
Guidance for COVID-19 from WHO, EC, ECDC, US CDC, EASA, ICAO, IATA, UIC, IMO, ICS
World Health Organization
- Interim Guidance - Management of ill travellers at Points of Entry – international airports, seaports and ground crossings – in the context of COVID -19 outbreak 19 March 2020 https://apps.who.int/iris/bitstream/handle/10665/331512/WHO-2019-nCoV-POEmgmt-2020.2-eng.pdf
- Interim guidance- Global Surveillance for human infection with coronavirus disease (COVID-19). 20 March 2020 https://apps.who.int/iris/bitstream/handle/10665/331506/WHO-2019-nCoV-SurveillanceGuidance-2020.6-eng.pdf
- Interim Guidance - Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19) 19 March 2020 https://www.who.int/publications-detail/considerations-for-quarantine-of-individuals-in-the-context-of-containment-for-coronavirus-disease-(covid-19)
- Interim guidance - Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts. 17 March 2020 https://www.who.int/publications-detail/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts
- Coronavirus disease (COVID-19) outbreak: rights,roles and responsibilities of health workers, including key considerations for occupational safety and health 18 March 2020 https://www.who.int/publications-detail/coronavirus-disease-(covid-19)-outbreak-rights-roles-and-responsibilities-of-health-workers-including-key-considerations-for-occupational-safety-and-health
- Interim Guidance - Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19) 19 March 2020 https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf
- Interim guidance - Water, sanitation, hygiene, and waste management for the COVID-19 virus. 19 March 2020 https://www.who.int/publications-detail/water-sanitation-hygiene-and-waste-management-for-covid-19
- Interim guidance - Operational considerations for managing COVID-19 cases or outbreak in aviation. 18 March 2020 - https://apps.who.int/iris/bitstream/handle/10665/331488/WHO-2019-nCoV-Aviation-2020.1-eng.pdf
- Interim guidance - Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. 19 March 2020 https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125
- Interim guidance - Critical preparedness, readiness and response actions for COVID-19. 19 March 2020 https://www.who.int/publications-detail/critical-preparedness-readiness-and-response-actions-for-covid-19
- Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (COVID-19) outbreak. 19 March 2020 https://www.who.int/publications-detail/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak
- Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response. 16 March 2020. https://www.who.int/publications-detail/risk-communication-and-community-engagement-(rcce)-action-plan-guidance
- Interim guidance - Considerations in the investigation of cases and clusters of COVID-19. 13 March 2020. https://www.who.int/internal-publications-detail/considerations-in-the-investigation-of-cases-and-clusters-of-covid-19
- Q&A on Mass Gatherings and COVID-19. 11 March 2020 https://www.who.int/news-room/q-a-detail/q-a-on-mass-gatherings-and-covid-19
- Interim guidance - Responding to community spread of COVID-19. 7 March 2020 https://www.who.int/docs/default-source/coronaviruse/20200307-responding-to-covid-19-communitytransmission-final.pdf?sfvrsn=ec5fa30a_5
- The COVID-19 risk communication package for healthcare facilities. 2 March 2020 https://iris.wpro.who.int/handle/10665.1/14482
- Q&A on infection prevention and control for health care workers caring for patients with suspected or confirmed 2019-nCoV. 1 March 2020 | Q&A https://www.who.int/news-room/q-a-detail/q-a-on-infection-prevention-and-control-for-health-care-workers-caring-for-patients-with-suspected-or-confirmed-2019-ncov
- Updated WHO recommendations for international traffic in relation to COVID-19 outbreak. 29 February 2020. https://www.who.int/ith/2019-nCoV_advice_for_international_traffic-rev/en/
- Interim Guidance - Operational considerations for managing COVID-19 cases/outbreak on board ships
- Interim Guidance - Key planning recommendations for Mass Gatherings in the context of the current COVID-19 outbreak
- Operational Readiness Checklist for COVID-19. 12 February 2020
- Key considerations for repatriation and quarantine of travellers in relation to the outbreak of novel coronavirus 2019-nCoV. 11 February 2020
- Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). 30 January 2020.
- Risk communication and community engagement (RCCE) readiness and response to the 2019 novel coronavirus (2019-nCoV). 29 January 2020
- Updated WHO advice for international travel and trade in relation to the outbreak of pneumonia caused by a new coronavirus in China. 27 January 2020
- Global Surveillance for human infection with novel coronavirus (2019-nCoV). Interim guidance v3
- Surveillance case definitions for human infection with novel coronavirus (nCoV). 21 January 2020
- Laboratory testing for 2019 novel coronavirus (2019-nCoV) in suspected human cases (17 January 2020 ed.).
- Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected Interim guidance. 12 January 2020.
- National capacities review tool for a novel coronavirus (nCoV) 9 January 2020
- WHO Statement Regarding Cluster of Pneumonia Cases in Wuhan, China. 09 January 2020
- Emergencies preparedness, response - Pneumonia of unknown cause – China. 5 January 2020
- Strengthening health security by implementing the International Health Regulations (2005). Public health passenger locator card.
- Emergencies preparedness, response - Procedures for prevention and management of probable cases of SARS on international cargo vessels. 23 May 2003.
- Emergencies preparedness, response - Recommended procedures for prevention and management of probable cases of SARS on International Cruise Vessels. 4 June 2003.
- Summary of SARS and air travel. May 2003.
European Centre for Disease Prevention and Control
US Centers for Disease Control and Prevention
Last update: 27/03/2020