Adjusting public health measures in the context of COVID-19 vaccination

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Introduction

As COVID-19 continues to circulate in Canada and more people are getting vaccinated, different public health measures (PHMs) may be required, based on the level of transmission and other key indicators outlined below.

This interim guidance provides considerations for adjusting PHMs in the context of COVID-19 vaccination in Canada. Governments and public health authorities (PHAs) across the country need to plan for these adjustments, as vaccination coverage increases in the population, the number of new and active cases decreases, and as pressures on the healthcare system and public health ease.

This interim guidance considers the Canadian context, is based on the best available scientific evidence and expert opinion, and is informed by the pandemic guidance for individuals and communities: Individual and community-based measures to reduce the spread of COVID-19 in Canada. It also reflects the goals of Canada's COVID-19 pandemic response and recovery to minimize serious illness and overall deaths, while minimizing societal disruption. For more information, refer to the federal/provincial/territorial public health response plan for ongoing management of COVID-19.

The primary audience for the guidance are federal/provincial/territorial (FPT) and regional/local PHAs. Operators of non-health care community-based settings that have public access (e.g. workplaces, businesses, schools) may also find aspects of this guidance useful. In the application of this guidance, it is recognized that each PHA may have unique approaches to implementing individual and community-based measures, based on jurisdiction-specific considerations.

This guidance is not prescriptive in nature; rather, it aims to provide recommendations that can support individual and community-based measures considered by Provincial/Territorial (PT) authorities going forward. It should be read alongside, and in support of relevant PT and local legislation, regulations, and policies.

A risk-based approach to COVID-19

Transmission of SARS-CoV-2

Understanding how SARS-CoV-2, the virus that causes COVID-19, is transmitted helps to determine the approach to a risk assessment and implementation of corresponding risk mitigation measures to help to reduce the spread of COVID-19. For more information refer to the Public Health Agency of Canada's (PHAC) modes of transmission webpage and guidance on individual and community-based measures to mitigate the spread of COVID-19 in Canada.

Risk assessment and mitigation for COVID-19

The risk associated with COVID-19 is based on a variety of factors, such as epidemiology, the type of the setting, the people accessing the setting, as well as vaccine coverage; and the risk should be assessed in advance of programs/ operations. COVID-19 vaccines lower the risk of severe outcomes even if some transmission occurs, and assessing overall risk should also take this into account.

In some situations, PTs, municipalities, regional/local PHAs and Indigenous community leadership may need to implement community-based measures to mitigate risks of SARS-CoV-2 transmission, as well as advise and promote adoption of individual-level measures (i.e., personal preventive practices) that individuals can take to protect themselves and others. Regional/local PHAs will provide advice on what individual and community-based PHMs are advised, based on local circumstances.

When PHAs determine that PHMs need to be maintained or re-instated in the community, operators of community settings can use PHAC's COVID-19 risk mitigation tool: Reducing COVID-19 risk in community settings: A tool for operators.

As more people in Canada become vaccinated against COVID-19, individuals should continue to follow regional/local PHA advice on visiting or gathering with others. The web-based tool My COVID-19 Visit Risk Calculator can be helpful in determining their individual-level risk.

Lastly, employers have health and safety obligations toward employees. Moreover, they have an interest in mitigating COVID-19 impacts, avoiding workplace outbreaks and fostering consumer confidence. The risk assessment for each workplace will vary based on community and workplace factors. Employers may refer to the Canadian Centre for Occupational Health and Safety website for further advice.

Impact of COVID-19 vaccination

As noted in the Canadian Immunization Guide, vaccines are a cornerstone of public health and their use has significantly contributed to the prevention and control of infectious diseases in Canada and internationally. COVID-19 vaccines are effective at preventing serious outcomes, such as severe illness, hospitalization and death due to COVID-19, as well as reducing the risk of infection and transmission among those vaccinated Footnote a.

The single-most important step that PTs, municipalities, regional/local PHAs and Indigenous community leadership can take to manage the COVID-19 epidemic in Canada, is promote, encourage, and facilitate the uptake of approved COVID-19 vaccines across the country. In the absence of an immune escape variant of concern (VOC) Footnote b, this will help minimize incidence of cases, hospitalizations and deaths due to COVID-19.

The National Advisory Committee on Immunization (NACI) continues to assess the potential for emerging VOCs to escape immunity induced by currently available vaccines. NACI's recommendations on the use of COVID-19 vaccines provides up-to-date evidence on COVID-19 vaccines, including vaccine effectiveness, epidemiology and evidence pertaining to VOCs and vaccine effectiveness.

Although some individuals may refuse or are not able to be vaccinated against COVID-19, it is important that adjustments to PHMs do not introduce stigmatization based on vaccination status. However, in certain circumstances, PHAs and/or operators of some settings may provide different advice to individuals who are partially vaccinated, unvaccinated or ineligible for vaccination (e.g., in the context of case and contact management activities, or COVID-19 screening and testing for individuals who are not vaccinated).

For individual-level advice on following PHMs in the context of Canada's vaccine rollout, refer to PHAC's What being vaccinated against COVID-19 means for me awareness resource.

Adjusting public health measures

The COVID-19 pandemic has caused significant societal and economic disruption in Canada due to illnesses and deaths, burden on healthcare resources, and widespread implementation of individual and community-based PHMs, Footnote 1, Footnote 2, Footnote 3, Footnote 4. At the time of publication, the response to the pandemic has been strengthened by the widespread availability and uptake of COVID-19 vaccines, but some individual and community-level caution should be exercised. Specifically, it will be important to remain diligent around adjusting PHMs, as there are still uncertainties due to:

As more people in Canada are vaccinated against COVID-19, this interim guidance distinguishes between core and additional PHMs as follows:

Core PHMs are at the foundation of good public health practice to control the spread of COVID-19, influenza and other respiratory viruses (e.g., staying at home if ill, practicing hand hygiene and respiratory etiquette). They should be everyday practices.

Additional PHMs could be considered when more rigorous COVID-19 infection prevention and control measures are warranted and/or when recommended by the regional/local PHA. These additional PHMs may include recommendations related to physical distancing, wearing masks, and avoiding non-essential travel. Some individuals may choose to continue using additional PHMs, based on a personal risk assessment and/or personal preference.

As more people become vaccinated against COVID-19, core PHMs may be consistently applied in both pandemic and non-pandemic times. Many of the core PHMs that may become part of the everyday practices for prevention of COVID-19 can also help to promote good public health practice for other respiratory infections such as influenza and respiratory syncytial virus (RSV). However, periods of additional individual and community-based PHMs may be needed in response to increased rates of SARS-CoV-2 transmission and other indicators described below. The additional measures that are put in place should be proportionate with the risk in the local community, balanced against the risk of unintended consequences of the intervention, and responsive to the local circumstance (e.g., enhancing measures during an outbreak and relaxing them when the outbreak is controlled).

Whenever possible, regional/local PHAs should proactively communicate in an accessible manner when changes in recommendations or advice related to individual or community-based measures are expected to occur based on a risk assessment, and explain the reasons for changes when they are implemented. This transparency can help to promote adherence because people will understand the rationale behind the decisions and the effectiveness of the measures required, and can prepare for these changes Footnote 5, Footnote 6, Footnote 7.

Individuals/settings may also choose to adopt certain PHMs (e.g., mask wearing, physical distancing, screening and testing programs), even during low-risk periods for COVID-19. These decisions may be based on a personal or setting-specific risk assessment (e.g., during periods of high respiratory illness activity, settings that are closed or crowded, if an individual is at risk of more severe disease or outcomes or interacting with these individuals). To prevent discrimination and stigmatization towards these individuals/settings, it will be important to clearly communicate that these behaviours are acceptable. One strategy to do this could be encouraging people to consider and act in ways that help or benefit other people, and do their part to keep each other safe. When people feel like they are a part of a group or community response, they may be more likely to follow PHMs, which is particularly true if they see other people following them Footnote 8.

Key indicators and other important factors

PHAs may benefit from having plans available for instating, maintaining, easing, or re-instating PHMs, based on several key indicators and other factors described below.

Vaccination coverage is an important factor in determining when pandemic restrictions may be gradually lifted. Modelling estimates from PHAC (PDF) indicate the risk of easing PHMs is minimized when at least 75% of the eligible population is fully vaccinated and measures are gradually lifted, but that a higher level of coverage will be required to reduce potential resurgence of the B.1.617.2 (Delta) VOC. However, models have also indicated that, with sufficient first dose coverage, some restrictions can be gradually lifted without overwhelming the health care system. Recommendations may change in the context of evolving evidence or new, more transmissible, variants.

The regional/local PHA will determine whether and when it is necessary to instate, maintain, ease, or re-instate measures, by considering the following indicators:

It will also be important to consider other factors, such as:

Specifically, PHAs may choose to implement certain PHMs (see Table 2 below for examples) in settings where there is low vaccine coverage. For example, schools or child/youth settings with individuals who do not meet age-based requirements for vaccination. When determining whether these measures are required, it will be important to consider both the risk of COVID-19 in the setting and the unintended consequences of these measures. Further information for schools is available in the Planning for the 2021-2022 school year in the context of COVID-19 vaccination guidance. Similarly, testing, screening and wastewater surveillance in settings with low vaccine coverage can play key roles in preventing or addressing upswings in community prevalence.

As more people in Canada are vaccinated against COVID-19, it will be important to optimize testing, screening and surveillance activities that can manage localized outbreaks, while maintaining surge capacity in the event of increased incidence or an immune escape VOC Footnote b. Testing technologies and strategies will need to take into account the epidemiology of COVID-19 and vaccine coverage in the population.

Table 1 and Table 2 below outline considerations for how PHAs may adjust individual and community-based PHMs, respectively, in the context of COVID-19 vaccination. These recommendations are based on the assumption that at least 75 percent of the eligible population in Canada has been fully vaccinated, and that the indicators/factors described above have been considered by the PHA. Please note, that for the purposes of this interim guidance, being fully vaccinated means that at least 14 days have been passed since the completion of the recommended number of doses of a Health Canada approved COVID-19 vaccine.

For individuals

In the operationalization of the recommendations in Table 1, it is recognized that each PHA may have unique approaches to adjusting PHMs recommendations, based on jurisdiction-specific considerations, including for those who are ineligible for vaccination. Recommendations described below should be applied under the direction from regional/local PHA and FPT governments, and should also be based on a personal risk assessment.

Individuals are at lower risk of getting COVID-19 when:

Individuals (especially individuals who are partially vaccinated or unvaccinated) are at higher risk of getting COVID-19 Footnote c when any of the following apply:

For Table 1 below, the assumption is: at least 75% of the eligible population in Canada (PDF) is fully vaccinated Footnote 9 and the PHA has taken into consideration the indicators/factors listed above.

Table 1: Considerations for adjusting individual public health measures in the context of COVID-19 vaccination
PHA's advice for individuals When individuals are at lower risk of getting COVID-19 When individuals are at higher risk of getting COVID-19
Core public health measures

Stay at home when ill

Individuals should stay at home when ill (e.g., with COVID-19 or another respiratory illness). Follow the advice of the regional/local PHA.

Recommended Recommended

Follow the advice of the regional/local PHA regarding the need to quarantine, isolate or undergo testing, as required

PCR tests, rapid tests and self-tests may all have a role in a recommended testing strategy. This advice may depend on a variety of factors, including vaccination status.

For additional information, refer to PHAC's guidance on Public health management of cases and contacts associated with COVID-19

Recommended, based on advice from the regional/local PHA

Fully vaccinated individuals without symptoms are not typically required to quarantine after exposure to someone with COVID-19

Recommended, based on advice from the regional/local PHA

Improve indoor ventilation

To improve indoor ventilation, individuals could participate in activities outdoors when possible; open exterior windows and doors when it is safe to do so and as weather permits. In consultation with a professional, ensure the heating, ventilation and air conditioning (HVAC) system is properly functioning, adjusted appropriately for the setting, and that it is cleaned as per manufacturer's instructions.

For more information, refer to PHAC's At home: Using ventilation and filtration to reduce the risk of aerosol transmission of COVID-19 and PHAC's Guidance on indoor ventilation during the pandemic.

Recommended Recommended

Practice hand hygiene and respiratory etiquette

Hand hygiene and respiratory etiquette are important personal preventive practices that were recommended before the pandemic and continue to be effective against COVID-19 and other illnesses.

Recommended Recommended

Clean and disinfect surfaces and objects Footnote d

Individuals should clean and disinfect their environment as per their regular routines. If an individual is going into a workplace setting, they should continue to follow their workplace policies on cleaning and disinfecting.

Recommended

Recommended

Other measures individuals may consider include more frequent cleaning and disinfecting of:

  • Washrooms
  • High-touch surfaces or objects (e.g., door knobs, faucet handles, table surfaces, water fountains, toys)
  • Areas accessed by an individual who is ill or exposed

For more information, refer to COVID-19: cleaning and disinfecting.

Additional public health measures

Avoid closed spaces and crowded places

Closed spaces with poor ventilation and crowded places may be higher risk for getting COVID-19 (or other respiratory illnesses) Footnote 10, Footnote 11, Footnote 12, Footnote 13. Individuals are at higher risk in settings where these factors overlap or involve activities such as:

  • singing
  • shouting
  • close-range conversations
  • heavy breathing (like exercise)
Not required, unless recommended by the regional/local PHA

May be recommended, follow advice from the regional/local PHA regarding restrictions in public spaces

Recommended for individuals who are partially vaccinated or unvaccinated, or those who are at risk of more severe disease or outcomes, or according to regional/local PHA advice

Individuals are also encouraged to conduct a personal risk assessment to determine if they should consider these measures

Minimize in-person interactions and practice physical distancing

Physical distancing is one of the most effective ways to limit the spread of COVID-19 (and other respiratory illnesses) Footnote 14, Footnote 15, Footnote 16.

When PHAs are determining whether to recommend distancing measures, it will be important to consider both the risk of COVID-19 and the unintended consequences of the measures.

Not required, unless recommended by the regional/local PHA

May be recommended, follow advice of the regional/local PHA on physical distancing and interacting or gathering with those who are not from the same immediate household

Recommended for individuals who are partially vaccinated or unvaccinated, or those who are at risk of more severe disease or outcomes, or according to regional/local PHA advice

Individuals are also encouraged to conduct a personal risk assessment to determine if they should consider these measures

Wear a mask

A well-constructed, well fitting and properly worn non-medical mask can help protect the wearer and those around them Footnote 17, Footnote 18, Footnote 19, Footnote 20, Footnote 21, Footnote 22.

Not required, unless recommended by the regional/local PHA

Recommended if an individual experiencing respiratory symptoms needs to leave their home for essential reasons, especially if in close contact with others (and preferably, a medical mask)

May be recommended, follow advice of the regional/local PHA

Recommended if an individual experiencing respiratory symptoms needs to leave their home for essential reasons, especially if in close contact with others (and preferably, a medical mask)

Recommended for individuals who are partially vaccinated or unvaccinated, or those who are at risk of more severe disease or outcomes, or according to regional/local PHA advice

Individuals are also encouraged to conduct a personal risk assessment to determine if they should consider this measure

Avoid non-essential travel outside of Canada

For more information on travel outside of Canada

Follow federal PHA advice

Individuals who are fully vaccinated without symptoms should not typically be required to quarantine following travel

There may be limits on international travel for individuals who are fully vaccinated with a vaccine not recognized by the country of destination, or individuals who are partially vaccinated or unvaccinated

Follow federal PHA advice on border restrictions

For communities

In the operationalization of the recommendations in Table 2, it is recognized that each PHA may have unique approaches to adjusting PHMs recommendations, based on jurisdiction-specific considerations, including for those who are ineligible for vaccination. Recommendations described below should be applied under the direction of regional/local PHA and FPT governments, and should also be based on a setting-specific risk assessment.

The community is at lower risk of COVID-19 spread when:

The community is at higher risk of COVID-19 spread Footnote c when any of the following apply:

For Table 2 below, the assumption is: at least 75% of the eligible population in Canada (PDF) is fully vaccinated Footnote 9 and the PHA has taken into consideration the indicators/factors listed above.

Table 2: Considerations for adjusting community-based public health measures in the context of COVID-19 vaccination
PHA's advice for community-based settings When communities are at lower risk of COVID-19 spread When communities are at higher risk of COVID-19 spread
Core public health measures

Prevent individuals who are ill from entering public spaces

Ensure public spaces have strict policies so individuals who are ill do not enter.

Testing, screening and surveillance provide critical data and may serve as an early warning that community prevalence is on the rise.

Establish testing and/or screening strategies for public spaces, as recommended by the regional/local PHA, including procedures and notification protocols for those who test/screen positive.

PHAs may also consider surveillance activities at the community/municipal level, such as wastewater surveillance, to minimize potential for community outbreaks.

Refer to Reducing COVID-19 risk in community settings: A tool for operators for additional information.

Passive symptom screening (e.g., signage at entry points) and exclusion policies are recommended, based on regional/local PHA advice

Active symptom screening (e.g., questionnaires) and exclusion policies are recommended, based on regional/local PHA advice

Testing strategies (e.g., workplace rapid antigen testing) may be used for screening activities, though its greatest role may be in the context of case finding during outbreaks; follow the regional/local PHA advice

Develop plans and procedures for managing individuals in the setting who develop symptoms compatible with or have an exposure to COVID-19

Refer to the Reducing COVID-19 risk in community settings: A tool for operators for additional information

Recommended Recommended

Follow advice of the regional/local PHA for case and contact management activities

Regional/local PHAs will manage outbreaks as they occur, and make risk-based decisions for case and contact management activities.

Operators of community settings should follow the advice of regional/local PHAs related to testing, isolation of cases, and quarantine of contacts.

For additional information, refer to PHAC's guidance on public health management of cases and contacts associated with COVID-19.

Recommended

Case and contact management activities may be modified by regional/local PHAs based on the local epidemiology, and focused on outbreak management in a low-risk scenario

Recommended

Regional/local PHAs may scale up case and contact management activities in communities where populations are vulnerable, may be at risk of more severe disease or outcomes, and/or have lower vaccine coverage rates. When appropriate, they may also implement other enhanced public health activities, such as backward contact tracing

Improve indoor ventilation

To improve indoor ventilation, operators of public settings could offer activities outdoors when possible, open exterior windows and doors when it is safe to do so and as weather permits. In consultation with a professional, they should ensure the heating, ventilation and air conditioning (HVAC) system is properly functioning, adjusted appropriately for the setting, and that it is cleaned as per manufacturer's instructions.

For additional information refer to PHAC's guidance on indoor ventilation during the pandemic.

Recommended Recommended

Promote and facilitate hand hygiene and respiratory etiquette

Hand hygiene and respiratory etiquette were recommended before the pandemic and continue to be effective personal preventive practice for COVID-19 and other illnesses.

Recommended Recommended

Ensure proper cleaning and disinfecting of surfaces and objects Footnote d

Ensure routine environmental cleaning and disinfecting for public spaces, according to operational cleaning and disinfecting policies (e.g., pre-pandemic policies).

Recommended

Recommended

Other measures may include more frequent cleaning and disinfecting of:

  • Washrooms, cafeterias and food service areas
  • High-touch surfaces or objects (e.g., door knobs, faucet handles, table surfaces, water fountains, toys)
  • Areas accessed by an individual who is ill or exposed

For more information, refer to COVID-19: cleaning and disinfecting.

Additional public health measures

Implement policies and procedures that minimize in-person interactions and support physical distancing

Physical distancing is one of the most effective ways to limit the spread of COVID-19 (and other respiratory illnesses) Footnote 14, Footnote 15, Footnote 16. For operational purposes, an appropriate physical distance is at least 2 metres.

When PHAs are determining whether to recommend distancing measures, it will be important to consider both the risk of COVID-19 and the unintended consequences of the measures.

Not required, unless recommended by the regional/local PHA

May be recommended, follow regional/local PHA advice on physical distancing and interacting or gathering with those who are not from the same immediate household

Operators/ administrators may also conduct a setting-specific risk assessment to determine if these measures should be implemented (e.g., if the settings involve people who are at risk of more severe disease or outcomes; or if the setting is a congregate living, such as a long-term care facility or shelter)

Implement face mask policies

A well-constructed, well fitting and properly worn non-medical mask can help protect the wearer and those around them Footnote 17, Footnote 18, Footnote 19, Footnote 20, Footnote 21, Footnote 22.

Not required, unless recommended by the regional/local PHA

Recommend for individuals who may be experiencing respiratory symptoms but need to enter the setting for essential reasons, especially if in close contact with others (and preferably, a medical mask)

May be recommended, based on regional/local PHA advice

Recommended for individuals who may be experiencing respiratory symptoms but need to enter the setting for essential reasons, especially if in close contact with others (and preferably, a medical mask)

Operators / administrators may also conduct a setting-specific risk assessment to determine if these measures should be implemented (e.g., if the settings involve people who are at risk of more severe disease or outcomes; or if the setting is a congregate living, such as a long-term care facility or shelter)

Provide accommodations and/or enhanced measures to protect those at risk of more severe disease or outcomes Follow usual policies May be recommended, based on regional/local PHA advice. For example, virtual/remote activities, alternative service hours

Implement policies that address PHA advice on travel restrictions / border measures

Refer here for More information on travel outside of Canada

Recommended Recommended

Considerations for remote, isolated and Indigenous communities

The overall health of people living in remote and isolated communities in Canada is differentially affected by social, environmental and economic factors, including housing, water quality or access, food security, pre-existing health conditions, precarious employment, education and income. These factors, in addition to limited access to health care, are important to consider when adjusting PHMs. For example, practicing proper hand hygiene may be challenging in settings that are lacking access to running or clean water. Avoiding closed spaces or crowded places, or adequately separating a sick individual from others may also be difficult in settings with overcrowding or housing shortages. In these situations, a conservative approach to mask wearing (e.g., the use of medical masks in overcrowded housing) may be recommended. It will also be important for visitors/workers entering remote, isolated and Indigenous communities to comply with PHA and/or workplace advice regarding the need to undergo testing.

Additionally, there are a variety of barriers that must be considered when increasing vaccination coverage for Indigenous peoples and those living in remote and isolated communities. These barriers must be addressed appropriately, as these efforts will be important aspects of minimizing incidence of cases, hospitalization and deaths due to COVID-19. More information is available at Indigenous Services Canada.

Guidance for remote and isolated and First Nations, Inuit and Metis communities, is also available.

Additional resources

Acknowledgments

This technical guidance was developed in consultation with the Canadian Pandemic Influenza Preparedness (CPIP) Task Group and with federal, provincial and territorial partners via the Technical Advisory Committee (TAC) and/or the Special Advisory Committee (SAC). This guidance was also developed in consultation with other government departments, various multilateral partners, Indigenous stakeholders, and other external stakeholders with an interest in this subject matter.

Footnotes

Footnote a

For more information, refer to Health Canada and the National Advisory Committee on Immunization.

Return to footnote a referrer

Footnote b

An immune escape VOC may be resistant to available vaccines or natural immunity from prior infection.

Return to footnote b referrer

Footnote c

Although all individuals (regardless of their vaccination status) may be at higher risk of being infected with SARS-CoV-2 in the high-risk scenarios described in Table 1 and 2, those who are fully vaccinated will be at much lower risk of serious illness.

Return to footnote c referrer

Footnote d

It is unclear exactly how long SARS-CoV-2 remains on different surfaces and objects. Evidence suggests it can remain on surfaces and objects from a few hours to days, depending on the type of surface and environmental conditions. It is uncertain to what extent contaminated surfaces or objects play a role in the spread of COVID-19, so a precautious approach is recommended when there is an ill person in the setting.

Return to footnote d referrer

References

Footnote 1

Public Health Ontario, "Rapid Review: Negative impacts of community-based public health measures on children, adolescents and families during the COVID-19 pandemic: Update," 11 January 2021. [Online]. Available: https://www.publichealthontario.ca/-/media/documents/ncov/he/2021/01/rapid-review-neg-impacts-children-youth-families.pdf?la=en. [Accessed 24 June 2021].

Return to footnote 1 referrer

Footnote 2

Statistics Canada, "Study: Impact of economic consequences of COVID-19 on Canadians' social concerns," 28 May 2020. [Online]. Available: https://www150.statcan.gc.ca/n1/daily-quotidien/200528/dq200528e-eng.htm. [Accessed 24 June 2021].

Return to footnote 2 referrer

Footnote 3

Public Health Ontario, "Economic Impacts Related to Public Health Measures in Response and Recovery during the COVID-19 Pandemic," 11 March 2021. [Online]. Available: https://www.publichealthontario.ca/-/media/documents/ncov/phm/2021/03/eb-covid-19-economic-impacts.pdf?la=en.. [Accessed July 2021].

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Footnote 4

European Centre for Disease Prevention and Control, "COVID-19 in children and the role of school settings in transmission - second update," 8 July 2021. [Online]. Available: https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-in-children-and-the-role-of-school-settings-in-transmission-second-update.pdf. [Accessed July 2021].

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Footnote 5

A. Braunack-Mayer, R. Tooher, J. E. Collins, J. M. Street and H. Marshall, "Understanding the school community's response to school closures during the H1N1 2009 influenza pandemic," BMC Public Health, vol. 13, no. 1 doi: 10.1186/1471-2458-13-344, pp. 1-15, 2013.

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Footnote 6

A. Bish and S. Michie, "Demographic and attitudinal determinants of protective behaviours during a pandemic: A review," British journal of health psychology, vol. 15, no. 4 DOI: 10.1348/135910710X485826, pp. 797-824, 2010.

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Footnote 7

H. Seale, C. E. Dyer, I. Abdi, K. M. Rahman, Y. Sun, M. O. Qureshi and M. S. Islam, " Improving the impact of non-pharmaceutical interventions during COVID-19: examining the factors that influence engagement and the impact on individuals," BMC Infectious Diseases, vol. 20, no. 1, pp. 1-13, 2020.

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Footnote 8

P. Lunn, C. Belton, C. Lavin, F. McGowan, S. Timmons and D. Robertson, "Using Behavioral Science to help fight the Coronavirus," Journal of Behavioral Public Administration,, vol. 3, no. 1, pp. 1-15, 2020.

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Footnote 9

Public Health Agency of Canada, "Update on COVID-19 in Canada: Epidemiology and Modelling," 28 May 2021. [Online]. Available: https://www.canada.ca/content/dam/phac-aspc/documents/services/diseases-maladies/coronavirus-disease-covid-19/epidemiological-economic-research-data/update-covid-19-canada-epidemiology-modelling-20210528-en.pdf. [Accessed 23 June 2021].

Return to footnote 9 referrer

Footnote 10

National Collaborating Centre for Environmental Health, "The Basics of SARS-CoV-2 Transmission," 21 March 2021. [Online]. Available: https://ncceh.ca/documents/evidence-review/basics-sars-cov-2-transmission. [Accessed 24 June 2021].

Return to footnote 10 referrer

Footnote 11

Office of the Chief Science Advisor of Canada, "The Role of Bioaerosols and Indoor Ventilation in COVID-19 Transmission," 28 September 2020. [Online]. Available: https://science.gc.ca/eic/site/063.nsf/eng/h_98176.html. [Accessed 24 June 2021].

Return to footnote 11 referrer

Footnote 12

European Centre for Disease Prevention and Control, "Heating, ventilation and air-conditioning systems in the context of COVID-19: first update," 11 November 2020. [Online]. Available: https://www.ecdc.europa.eu/en/publications-data/heating-ventilation-air-conditioning-systems-covid-19. [Accessed 24 June 2021].

Return to footnote 12 referrer

Footnote 13

Scientific Advisory Group for Emergencies, Enviornmental and Modelling Group, "Role of ventilation in controlling SARS-CoV-2 transmission," 30 September 2020. [Online]. Available: https://www.gov.uk/government/publications/emg-role-of-ventilation-in-controlling-sars-cov-2-transmission-30-september-2020. [Accessed 24 June 2021].

Return to footnote 13 referrer

Footnote 14

D. Chu, E. Akl, S. Duda, K. Solo, s. Yaacoub and H. Schunemann, "Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis," Lancet, vol. 395, no. 10242, pp. 1973-1987, 27 June 2020.

Return to footnote 14 referrer

Footnote 15

N. Jones, Z. Qureshi, R. Temple, J. Larwood, T. Greenhalgh and L. Bourouiba, "Two metres or one: what is the evidence for physical distancing in COVID-19?," BMJ, vol. 370, August 2020.

Return to footnote 15 referrer

Footnote 16

Public Health Agency of Canada Emerging Science Group, "Evidence Brief on SARS-CoV-2 Virus Dispersion Distance," June 2020. [Online]. Available: https://www.nccmt.ca/covid-19/covid-19-evidence-reviews/171. [Accessed 24 June 2021].

Return to footnote 16 referrer

Footnote 17

Public Health Agency of Canada Emerging Sciences Group, "Rapid Review on the Characteristics of Effective Non-Medical Masks in reducing the Risk of SARS-CoV-2," January 2021. [Online]. Available: https://www.nccmt.ca/covid-19/covid-19-evidence-reviews/261. [Accessed 24 June 2021].

Return to footnote 17 referrer

Footnote 18

M. Wilson, F. Gauvin, K. Waddel, K. Moat and J. Lavis, "COVID-19 Rapid Evidence Profile #1: What is known about approaches to and safety of conserving, reusing, and repurposing different kinds of masks?," McMaster Health Forum, 14 April 2020. [Online]. Available: https://www.mcmasterforum.org/docs/default-source/covidend/rapid-evidence-profiles/covid-19-rep-1_ppe.pdf?sfvrsn=52a657d5_4. [Accessed 24 June 2021].

Return to footnote 18 referrer

Footnote 19

J. O'Keefe, "Masking during the COVID-19 pandemic - an update of the evidence," National Collaborating Centre for Environmental Health, May 2021. [Online]. Available: https://ncceh.ca/documents/guide/masking-during-covid-19-pandemic-update-evidence. [Accessed 24 June 2021].

Return to footnote 19 referrer

Footnote 20

L. Asadi and e. al., "COVID-19 Scientific Advisory Group Rapid Evidence Report - Double Masking and Improved Mask Fit," Alberta Health Services, 19 March 2021. [Online]. Available: https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-sag-double-masking-improved-fit-rapid-review.pdf. [Accessed 24 June 2021].

Return to footnote 20 referrer

Footnote 21

K. Shakya, A. Noyes, R. Kallin and R. Peltier, "Evaluating the efficacy of cloth facemasks in reducing particulate matter exposure," Exposure Science & Environmental epidemiology, vol. 27, pp. 352-357, August 2016.

Return to footnote 21 referrer

Footnote 22

A. Mueller, M. Eden, J. Oakes, C. Bellini and L. Fernandez, "Quantitative method for comparative assessment of particle removal efficiency of fabric masks as alternatives to standard surgical masks for PPE," Matter, vol. 3, no. 3, pp. 950-962, September 2020.

Return to footnote 22 referrer

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