Lifting of restrictive public health measures - Recommendations from the F/P/T Special Advisory Committee on COVID-19

Recommendations from the Federal/Provincial/Territorial (F/P/T) Special Advisory Committee on COVID-19

Foundations for Living with COVID-19 in Canada: Lifting of Restrictive Public Health Measures

April 30, 2020

On this page

• Objectives
• Principles
• Criteria and indicators
• Ongoing collaboration across jurisdictions

The status of the COVID-19 epidemic varies across Canada. Nationally, we have started to see the impact of public health measures on the flattening of the epidemic curve and slowdown in the growth of new cases. The nature and phase of the COVID-19 epidemic is different across and within provinces and territories. The F/P/T Special Advisory Committee (SAC) on COVID-19 provides advice to support a pan-Canadian coordinated approach to support governments’ decisions in transition to living with COVID-19 in Canada. This document provides recommendations and guidance for re-opening approaches that can be tailored to jurisdictions across the country. It draws on and supports the First Ministers Statement on a shared public health approach to support restarting the economy, and elaborates further advice on indicators that governments can use and a proposed gradual approach to lifting of public health measures.

SAC members have agreed to the following objectives, principles, criteria, indicators and initial approach to inform decisions of governments in re-opening and key conditions for easing restrictions to guide transition planning across Canada. 

Objectives

The objectives of the Canada’s COVID-19 pandemic response and our joint recovery are:

• To minimize all serious illness and death, and
• To minimize societal disruption, including reducing the burden on health care.

It is acknowledged that as some public health measures are lifted, some degree of COVID-19 transmission will be unavoidable. Until targeted therapies or vaccine is available, the aim will be to carefully balance the risks associated with spread of COVID-19 with the unintended social and health consequences of restrictive public health measures. As governments develop plans to gradually lift restrictions, areas of focus include:

• protecting the health of Canadians;
• easing restrictions gradually;
• protecting high-risk groups (e.g., those vulnerable due to age, underlying health conditions, remote location, close living spaces and temporary or unstable living spaces);
• ensuring our public health capacity remains strong to prepare for and respond to any future waves of the pandemic, including through enhanced testing and contact tracing; and,
• supporting a broad range of economic sectors.

Principles

• Science and evidence-based decision-making – Decisions to ease and/or reinstate measures should be based on current public health situations as advised by public health officials.
• Coordination and collaboration – Strong collaboration to date has served Canadians well and continued collaboration is key to ongoing success. Governments agree to support the continuation of supply chains across borders to maintain economic activity, access to protective equipment and food security for all Canadians. Governments will continue to share information about challenges and opportunities. Since provinces, territories and the Government of Canada may need to move forward at different times and in potentially different ways it will be important to maintain the coordination and collaboration that has taken place throughout the pandemic (e.g., consistent guidance on occupational health and safety requirements).
• Accountability and transparency – Each government will continue to be accountable to its residents, and will monitor the impacts of measures to restart the economy and provide
  updates on progress. Data sharing is critical to understanding the situation across Canada and is essential to informing efforts to reopen segments of the economy.
• Flexibility and proportionality – Public health measures should be relaxed based on the level of threat and in a controlled and phased manner based on information that may change over time. This includes information on risks around the disease and health of Canadians, as well as social and economic benefits to them. It also includes local and sectoral contexts (e.g., different workplaces, educational institutions, and social activities). It is recognized that there will be differences within jurisdictions on approaches taken and that measures may need to be re-imposed if the understanding of the information changes.

Criteria and indicators

To determine whether jurisdictions are ready to lift or loosen various restrictive public health measures, the SAC has agreed on a set of criteria and indicators that will help inform government decisions on readiness for transition of any measures. These seven criteria and thirteen indicators may also be used by each government to assess the need for re-introduction of specific measures as the pandemic progresses.

1. COVID-19 transmission is controlled

• Indicator 1.1: Number of cases (linked and non-linked), hospitalizations, intensive care unit (ICU) admissions and deaths per day
• Indicator 1.2: Reproduction number, absolute and relative changes in cases, hospitalizations and deaths

2. Sufficient public health capacity is in place to test, trace and isolate all cases.

• Indicator 2.1: Testing capacity
• Indicator 2.2: Resources to trace contacts
• Indicator 2.3: Ability to isolate all cases
• Indicator 2.4: Ability to quarantine all contacts

3. Expanded health care capacity exists: the incidence of new cases should be maintained at a level that the health system can manage including substantial clinical care capacity to respond to surges. 

• Indicator 3.1: Critical care capacity
• Indicator 3.2: Availability of personal protective equipment (PPE)

4. Supports are in place for vulnerable groups/communities and key populations to minimize outbreak risks

• Indicator 4.1: Availability of guidance for staff and residents to prevent transmission among vulnerable groups/settings
• Indicator 4.2: Number, size, and status of outbreaks in high vulnerability settings

5. Workplace preventive measures are established to reduce risk

• Indicator 5.1: Availability of guidance for workers and employers to prevent transmission of COVID-19 in the workplace
• Indicator 5.2: Number of workplace outbreaks

6. Avoiding risk of importation of cases

• Indicator 6.1: Number of international travel-related cases

7. Engage and support communities to adjust to the new normal

• Indicator 7.1: Communications strategies in place

This set of criteria and indicators provide a data and evidence-driven basis for decisions to lift or adjust some public health measures. Together these indicators could determine, objectively, each government’s readiness for the gradual, lifting (or re-instating) of measures that will ultimately allow the safe restarting of our economy and societal activities.

Public health advice: initial phase to gradually lift public health measures

This section highlights SAC’s advice on core personal public health practices that governments can consider for the duration of the COVID-19 pandemic, outlines the initial measures that can be adjusted, and provides general recommendations regarding how to approach operationalization and implementation of mitigation strategies.

This is a pan-Canadian approach that can be implemented regionally/provincially based on local circumstances. Transition should be slow, gradual, and tailored to jurisdictional contexts including remote and isolated communities, with sufficient time between each phase of transition to detect changes (e.g., 2 incubation periods, or 28 days). Given the additional risks and considerations for remote, isolated and Indigenous communities, these communities will require special focus, including culturally appropriate measures, and protections to prevent introduction of new cases from other regions where measures may be lifted earlier.

Jurisdictions will also be monitoring the effectiveness (harms and benefits) of specific measures, including their unintended consequences, as new information becomes available with a view to adjusting less effective measures as appropriate.

Core personal public health practices

With no targeted therapies or vaccine available, core personal public health practices will need to become the “new normal” in order to maximize our ability as a society to control the rapid spread of the virus. Everyone has a role to play and the following core personal public health practices are fundamental, and should underlie all phases of the COVID-19 response:

• Staying informed, being prepared and following public health advice
• Continuing to practice good hygiene (hand hygiene, avoid touching face, respiratory etiquette, disinfect frequently touched surfaces)
• Maintaining physical distancing as much as possible when outside of the home (i.e. from non-household members)
• Continuing to increase environmental cleaning and ventilation of public spaces and worksites
• Staying at home and away from others if symptomatic/feeling ill – do not go to school/work and follow jurisdictional/local public health advice
• Staying at home if at high risk of severe illness
• Continuing to wear a medical mask, or if not available a non-medical mask or face covering if you experience symptoms, and, will be in close contacts with others or go out to access medical care
• Consider the use of non-medical masks in situations where physical distancing cannot be maintained
• Reducing personal non-essential travel 

Frequent and transparent communications to the public by governments will be important to help engage Canadians on their role to reduce the risk of COVID-19 by adopting these practices. These communications should be incorporated into governments’ on-going community and engagement strategies with the public and should emphasize the continued importance of these core personal practices as restrictive public health measures are loosened. Engagement strategies should also consider and address challenges, barriers and opportunities to maintain these measures at the population level and in specific populations.

Initial phase: lifting a set of public health measures

Based on the seven criteria to help support governments in lifting restrictive public health measures, certain measures of the current COVID-19 response may be lifted, under specific conditions, which include allowing:

1. Some non-essential businesses able to open
2. Daycare and education settings/camps to operate/open
3. Additional outdoor activities/ recreation to resume
4. Non-urgent health care services to resume
5. Small critical cultural ceremonies (such as funerals)

The above five measures have been included for consideration by governments in the first phase for the following reasons: their interconnectedness with other measures (e.g., work and childcare), feasibility of physical distancing and required conditions, seasonality, need to reduce unintended consequences of restrictive measures and ability to decrease societal disruption and stimulate economic activity.

Specific conditions for lifting public health measures

The specific conditions for the lifting of the restrictive measures recommended as a first phase should be met in order to reduce contact intensity and number of contacts and therefore the risk of transmission. Meeting the following conditions will increase the ability to mitigate the risk associated with loosening of measures. The proposed first phase could include allowing:

1. Some non-essential businesses able to open

• Core personal practices supported to the extent possible (e.g. hand hygiene stations, tissues/wastebaskets)
• Maintain physical distancing whenever possible (e.g., telework when possible, signage, floor markings, appropriate spacing of restaurant tables)
• Efforts are made to prevent the entry of sick individuals (e.g. signage about not entering if symptomatic at entrance to business or when booking appointment)
• Employ physical barriers (e.g., Plexiglass at checkout) and other engineering controls (e.g., increasing ventilation)
• Increase environmental cleaning (e.g., increase the frequency of cleaning/disinfecting high-touch surfaces)
• Offer special options for persons at high-risk of severe illness (e.g., online/phone ordering, curbside pick up, special hours)

2. Daycare and education settings/camps to operate/open

• Maintain the provision of online learning as an option for students vulnerable to the impacts of COVID-19 (e.g. immune-compromised)
• Core personal practices supported (e.g. provide education, supervised hand hygiene)
• Screening for all staff and students/campers
• Maintain physical distancing as much as possible (e.g., separation of desks, no assemblies, no high-contact sports, limit extracurricular activities)
• Staff and students/campers at higher risk of severe illness remain at home
• Environmental cleaning (e.g., increase the frequency of cleaning/disinfecting high-touch surfaces)
• Non-medical masks may be considered; however, they are not recommended for children < 2 years of age

3. Additional outdoor activities/ recreation to resume

• Core personal practices supported to the extent possible
• Maintain physical distancing between members of different households when participating in outdoor recreation (e.g. picnics, camping)
• No large gatherings, even outdoors and when appropriately physically distanced
• Sports – allow only those that can main physical distancing (e.g., low/no contact, separation on sidelines)
• Equipment – no sharing, cleaning common sporting equipment in between use

4. Non-urgent health care services to resume

• Core personal practices supported (e.g. hand hygiene supplies, tissues)
• Physical distancing measures in place (e.g. tele-medicine, no waiting in waiting room, call in from car)
• Scheduling to protect patients at higher risk of severe illness (e.g., certain days, beginning of day)
• Environmental cleaning (e.g., increase frequency of cleaning/disinfecting high-touch surfaces, between patients)

5. Small critical cultural ceremonies (such as funerals) to take place

• Core personal practices supported (e.g. hand hygiene supplies, tissues)
• Screening of personnel and mourners prior to entering the gathering
• Persons at higher risk of severe illness should not attend
• Physical distancing maintained
• Limit size of gathering (e.g., number of participants)
• No receptions or buffet meals; single-serving refreshments only
• Ceremonies are held outdoors when possible

Additional information on lifting measures including risk assessment and mitigation advice, as well as supporting evidence will be available in a more comprehensive technical document.

Ongoing collaboration across jurisdictions

The F/P/T Special Advisory Committee (SAC) on COVID-19 will continue to meet regularly to develop further recommendations to inform governments in their decisions for Canada’s transition to living with COVID-19. This could include development and updates to national guidance and support tools, as well as provision of data and evidence-informed advice to support jurisdictions in gradually lifting public health measures. SAC members will work together to propose tools that governments could use in their communications strategies and share information on their respective approaches to monitor impacts and changes in order to protect the health of Canadians as we restart the economy and learn to live with COVID-19.