Updated: Public health management of cases and contacts associated with COVID-19  

Updated December 23, 2020

Note

This page is continually under review and will be updated as this situation evolves. Please visit the provincial and territorial resources for COVID-19 page for updated guidance specific to your province or territory.

On this page

• Case management
• Contact management
  • Table 1: Contact management recommendations by exposure risk level
• Appendix 1: Recommendations for isolation of COVID-19 cases in the community
• Appendix 2: Assessment of a suitable isolation location for a case of COVID-19
• Appendix 3: Recommended infection prevention and control precautions when caring for a case in the home or co-living setting
• Acknowledgments
• References

The Public Health Agency of Canada (PHAC), in collaboration with Canadian public health experts, has developed this guidance for federal/provincial/territorial (FPT) public health authorities (PHAs) to support the management of cases and contacts of COVID-19 within their jurisdictions.

The strategy outlined in this guidance focuses on case and contact management to mitigate the health impacts of COVID-19 on Canadians ^{Reference 1}. This guidance is set in the Canadian context and is based on the available scientific evidence and expert opinion. In interpreting and applying this guidance, it is important to recognize that the health, disability, economic, social, or other circumstances faced by some individuals and households may limit their ability to follow the recommended measures. This may necessitate adapted case management and contact responses in some situations.

The COVID-19 pandemic has evolved in different ways across Canada. Provincial and territorial (PT) PHAs continue to adjust restrictive public health measures based on the epidemiology of COVID-19 in their jurisdictions, taking into consideration other important indicators, such as the capacity of their health systems. As jurisdictions experience a new wave of illness, increasing cases, hospitalizations, and deaths can challenge capacity in the public health and health care systems, and require adjustments to public health measures in the impacted areas.

This guidance is subject to change as new information on transmissibility and epidemiology becomes available. It should be read in conjunction with relevant PT and local legislation, regulations and policies. Coronavirus disease (COVID-19) outbreak updates are available.

Case management

Reporting and notification

The interim national case definition for COVID-19 provides surveillance case definitions as well as associated surveillance reporting requirements.

It is important for frontline health care providers to notify PHAs of cases of COVID-19 in accordance with jurisdictional reporting requirements. PHAs need to provide overall co-ordination with health care providers and provincial laboratories for the management and reporting of cases, and to establish communication links with all involved health care providers for the full duration of illness. PHAs should report confirmed cases of COVID-19, as well as probable cases where feasible, to PHAC within 24 hours of receipt of their own notification.

In some instances, cases or contacts of cases are identified with epidemiological linkages that span two or more jurisdictions within and/or between provinces/territories. During case investigation, it may also be identified that the case acquired their infection, or was potentially exposed, in another jurisdiction. PHAs should use established inter-jurisdictional communication channels to enable timely case and contact management. Examples where this may be required include when a case travelled between jurisdictions during their communicable period; or when contacts reside in a different jurisdiction than a case.

Laboratory testing

Laboratory testing strategies have evolved over time. Each PT has modified their approach (e.g., who is being tested) based on factors such as evolving evidence, new technology, laboratory capacity and local epidemiological circumstances. At present, a validated reverse transcription polymerase chain reaction (RT-PCR) test on a clinically appropriate sample collected by a trained health care provider is the gold standard for the diagnosis of SARS-CoV-2 infection.

Appropriate laboratory testing for COVID-19 infection should be accessible by health care providers through community-based, hospital or reference laboratory services (e.g., a provincial public health laboratory (PHL) running a validated assay), or the National Microbiology Laboratory.

Guidance for health professionals related to laboratory testing is available. In addition, the Respiratory Virus Infections Working Group of the Canadian Public Health Laboratory Network has developed laboratory testing best practices for COVID-19 and has updated its protocol on microbiological investigation of emerging respiratory pathogens, including severe acute respiratory infections ^{Reference 2}, ^{Reference 3}.

Rapid testing for COVID-19 with point-of-care test kits has the potential to increase testing capacity; however, current data suggests that these methods are less sensitive than the current RT-PCR assays ^{Reference 4}. Interim guidance is available for use of the nucleic acid- and antigen-based rapid detection tests. Use of point-of-care tests continue to be evaluated in the COVID-19 response, as well as the role of serology and genomic testing.

There is evidence that, although uncommon, individuals can become re-infected with SARS-CoV-2 ^{Reference 5}. Evidence is evolving on the frequency of occurrence of re-infection, and timing relative to prior infection. Refer to guidance for laboratory testing for individuals suspected of being re-infected for more information.

Clinical management/treatment

Clinical management of the case, whether in the home or in an acute care setting, is based on the case's condition and at the discretion of the case's health care provider. Refer to relevant guidance on clinical management of patients with COVID-19.

Health care providers involved in home care for a case should follow interim guidance developed for infection prevention and control in home care settings. Guidance for household members providing care for a case in the home, or occupants/staff in a co-living setting, are detailed in Appendix 1.

Case management in the community

Epidemiologic evidence suggests that the majority of people with COVID-19 do not require care in a hospital ^{Reference 6}.

When care in a hospital is not required, people with COVID-19 (i.e., "cases") should isolate themselves in the home or co-living setting (e.g., student residence, group home, shelter, etc.), away from other household members or occupants, as directed by their PHA. They should isolate for a minimum of 10 days from the onset of symptoms for a symptomatic case, or from the collection date of a positive specimen for an asymptomatic case.

During isolation, the case should be advised not to leave the isolation setting, whether it is their home, the co-living setting, or an alternate setting identified by their PHA or health care provider. They should:

• Where possible, avoid contact or shared spaces (e.g., same room) with others, including members of their household;
• Not go out unless required or directed to do so to seek medical care;
• Not go to school, work, or other public places; and
• Not take public transportation to seek medical care, if possible.

If the case must go out to seek medical care, they should always wear a medical mask if available (preferred), or a well-constructed and well-fitting non-medical mask. Additional information is available about non-medical masks, including when they should be used, and the proper material, structure, and fit.

Isolating in the community

When isolating in the community-at home or in a co-living setting-it is important that cases of COVID-19 reduce the risk of transmission, through direct or indirect contact, to other members of the household or occupants in the co-living setting as much as possible. They should wear a medical mask if available (preferred), or a well-constructed and well-fitting non-medical mask; remain in their dedicated room as much as possible; and follow recommended personal preventive practices.

Guidance for isolating at home or in other co-living settings, as well as recommendations when strict adherence to isolation requirements may not be possible, are available in Appendix 1.

Assessing suitability for isolation in the community

The PHA, in collaboration with the case and their health care provider, as appropriate, will determine the location where a case of COVID-19 isolates. It is important that cases who do not require hospital-level care convalesce in a suitable environment where effective isolation can be maintained and appropriate monitoring (e.g., for worsening of illness) can be provided.

Considerations for a suitable environment will depend on the individual and their living situation; and may vary depending on the sex, gender, or other socioeconomic or identity factors of the case.

Factors to consider when determining the suitability of an isolation location in the community (i.e., home, co-living setting), include the following:

• Can the case's clinical condition be managed as an outpatient?
• Is the case able to manage their own care?
• Does the case require care? Is someone available to provide the care?
• What are the characteristics of the home or co-living configuration?
• Are there others with greater risk of more severe disease or outcomes in the home or co-living setting?
• Is the home or co-living setting suitable for isolation?
• Can the case access adequate supplies and necessities?

The PHA plays an important role in assessing the suitability of the case's isolation setting, and the considerations listed above are detailed in Appendix 2.

Psychosocial considerations

PHAs should encourage individuals, families and communities to create a supportive environment for people who are isolating to take care of their mental health, and minimize stress and hardship associated with isolation as the financial, social, and psychological impact can be substantial.

Obtaining and maintaining public trust are key to successful implementation of these measures. Clear messages about isolation, including the criteria, rationale, justifications, and duration, as well as ways in which persons will be supported during the isolation period, will help to generate public trust. Messaging should also be sensitive to the needs of populations confronting social, economic, cultural or other vulnerabilities. Additional information on the psychological impacts of COVID-19 is available.

For Indigenous Peoples, mandatory isolation away from home due to COVID-19 may trigger re-traumatization based on the history of forced removals. There is also the potential for new trauma if their ability to practice cultural and/or spiritual activities is limited. To avoid relocation of persons with COVID-19 to locations outside of their community, many Indigenous communities have re-purposed facilities or set up temporary structures to use as isolation sites so that community members may safely isolate in situations where their home setting is not suitable.

Public health monitoring of cases

Ideally, PHAs should provide or facilitate active daily monitoring of cases of COVID-19, as long as feasible based on available resources.

Active daily monitoring of COVID-19 cases will vary by PHA, but generally should include providing information related to the following:

• Isolation in the home or co-living setting;
• Appropriate infection prevention and control precautions, personal preventive practices, and environmental cleaning;
• Self-monitoring for symptoms, including daily temperature checks;
• Steps to take if symptoms worsen, including instruction on self-care and how/when to access medical care; and
• When and where to access diagnostic testing for COVID-19, if appropriate based on provincial/territorial testing strategies.

Cases of COVID-19 should be monitored until they have met the criteria set by the PHA for discontinuing isolation.

Discontinuation of isolation for cases in the community

The PHA should direct the discontinuation of isolation of cases in the community (i.e., those not hospitalized or residents of long-term care facilities). Criteria may include:

• For symptomatic cases:
  • At least 10 days have passed since onset of first symptom.
  • The case is afebrile and has improved clinically; absence of cough should not be required for those known to have chronic cough or for those who are experiencing reactive airways post infection.
• For asymptomatic cases:
  • At least 10 days have passed since the date their positive specimen was collected.

In general, repeat laboratory testing (e.g., a negative test result) as the basis for discontinuing home isolation is not recommended. There may be exceptions to these criteria for which PHA and/or clinical care providers may determine a longer isolation period is warranted (e.g., immunocompromised individuals, those hospitalized due to COVID-19).

Contact management

All recommendations for contacts of COVID-19 cases apply regardless of vaccination status or vaccine rollout progress. This content will be updated as needed based on new evidence regarding vaccine effectiveness and coverage in Canada.

It is important to identify and manage the contacts of cases of COVID-19 to reduce ongoing transmission of the virus in the community. Several objectives may be achieved through contact management activities by PHAs, including:

• To facilitate rapid identification of secondary cases of COVID-19 (or source cases, in the context of backward contact tracing);
• To facilitate early implementation of public health measures as appropriate, depending on the contact's exposure risk; and
• To gain a better understanding of the epidemiology of COVID-19.

Early identification of contacts, and direction regarding diagnostic testing for COVID-19 based on existing PT testing strategies, is a key component of rapid case identification and management to reduce transmission of the coronavirus.

In an outbreak context, contact tracing and management also serves the purpose of active case finding during an investigation. Where an outbreak is suspected, the PHA may adopt a situation-specific definition for those at high risk of exposure (i.e., "close contact") to help efficiently target their contact investigation and case finding efforts. For example, all individuals at an event associated with a high risk of transmission could be evaluated as being at high risk of exposure (i.e., all guests at a wedding, or participants of an indoor fitness class). This approach may be considered when the outbreak setting results in a high risk of exposure for most participants, or where individual risk assessments are not feasible.

Outbreaks may have a greater impact on certain groups due to their social, economic, health, or other vulnerabilities, such as living in a remote and isolated community, living in poverty or crowded settings, having underlying health conditions, or advanced age. For case and contact finding in the context of an outbreak in these populations, it may be useful for the PHA to adopt a more sensitive definition for those at high risk of exposure (i.e., close contacts), to facilitate case finding.

Forward (traditional) contact tracing

The public health approach to COVID-19 case and contact management to date has been largely focused on interrupting chains of transmission through forward contact tracing, which involves identifying individuals at risk of exposure to SARS-CoV-2 from an identified case. The goal of forward tracing is to identify and quarantine (self-isolate), or facilitate self-monitoring of, potentially exposed individuals to stop future chains of transmission.

Contacts should be identified and managed as per the recommendations in this document, where feasible based on public health resources. The level and intensity of public health actions may vary among jurisdictions according to the local epidemiology of COVID-19 at a given time. Alternative contact management strategies that PHAs may consider when resources are constrained are detailed below.

An individual risk assessment conducted by the PHA can help identify each contact's exposure risk level, determine the required parameters of quarantine (self-isolation) or self-monitoring, and PHA actions for the 14-day monitoring period.

Given that transmission of SARS-CoV-2 can occur from cases who are symptomatic, pre-symptomatic, or asymptomatic, contact tracing should include:

• Identifying people who were exposed to a symptomatic case in the period starting 48 hours prior to the case developing a symptom consistent with COVID-19, and until the case was no longer considered infectious (e.g., 10 days following symptom onset for a non-hospitalized case).
• Identifying people who were exposed to a laboratory confirmed asymptomatic case in the period starting 48 hours prior to the day their positive specimen was collected, and until the case was no longer considered infectious (e.g., 10 days after specimen collection date) ^{Reference 7}.

Table 1 provides guidance for classifying contacts as either high or low risk, depending on their exposure, for the purposes of determining recommended actions. The information provided in Table 1 is not intended to replace more personalized advice provided to contacts, based on comprehensive individual risk assessments conducted by PHAs.

Table 1: Contact management recommendations by exposure risk level

Note: All potential exposures described below are considered to have occurred when the case was communicable in determining exposure risk level.
Risk Level	Description	Recommendations for the contact
High risk exposure (close contact)	HCW who provided direct physical care to a case, or a laboratory worker handling COVID-19 specimens, without consistent and appropriate use of recommended PPE and infection prevention and control practices.Footnote a Anyone who lives with a case, has direct physical contact with a case, or is exposed to their infectious body fluids, including the case's caregiver, intimate partner, child receiving care from the case, etc. Anyone who has shared an indoor space (e.g., same room) with a case for a prolonged period of time,Footnote b including closed spaces, crowded places, or settings where close interactions may occur (e.g., social gatherings, workplaces, etc.), without adhering to appropriate individual-level and setting-specific risk mitigation measures. Footnote c Anyone who has had a close-range conversation with a case or has been in settings where a case engaged in singing, shouting, or heavy breathing (e.g., exercise), without adhering to appropriate individual-level and setting-specific risk mitigation measures.Footnote c	Quarantine (self-isolation) Footnote d at home for 14 days from last exposure. Follow recommended personal preventive practices. If living with the case, avoid further exposure to the case and wear a well-constructed and well-fitting, non-medical mask when in a shared space (e.g., same room) with the case. Follow PHA directions related to testing requirements. Self-monitor for the appearance of symptoms consistent with COVID-19 for 14 days following their last exposure to the case. Take and record temperature daily and avoid the use of fever-reducing medications (e.g., acetaminophen, ibuprofen) as much as possible. These medications could mask an early symptom of COVID-19; if these medications must be taken, advise the PHA Reference 8. If symptoms occur, isolate away from others within the home or co-living setting as quickly as possible; put on a medical mask if available (preferred), or well-constructed and will-fitting non-medical mask; and contact the PHA for further direction, which will include: where to go for care, appropriate mode of transportation to use, and IPC precautions to be followed. Avoid close contact with those who are at risk for developing more severe disease or outcomes from COVID-19. Contacts who are at risk for developing more severe disease or outcomes should not provide care for the case and should stay elsewhere if feasible.
Low risk exposure	HCW who provided direct physical care to a case, or a laboratory worker handling COVID-19 specimens, with consistent and appropriate use of recommended PPE and infection prevention and control practices. Footnote a Anyone who has shared an indoor space (e.g., same room) with a case, including closed spaces, crowded places, or settings where close interactions occur (e.g., social gatherings, workplaces, etc.), with adherence to appropriate individual-level and setting-specific risk mitigation measures. Footnote c Anyone who has had a close-range conversation with a case or has been in settings where a case engaged in singing, shouting, or heavy breathing (e.g., exercise), with adherence to appropriate individual-level and setting-specific risk mitigation measures. Footnote c	Self-monitor for symptoms for 14 days following their last exposure. If symptoms occur, isolate away from others as quickly as possible, put on a medical mask if available (preferred), or well-constructed and will-fitting non-medical mask, and contact the PHA for further direction, which will include: where to go for care, appropriate mode of transportation to use, and IPC precautions to be followed. Where possible avoid interactions with individuals at higher risk for severe illness. Follow PHA directions related to testing requirements. Follow recommended personal preventive practices.
Acronyms: HCW: health care worker PPE: personal protective equipment NMM: non-medical mask IPC: infection prevention and control

Where community transmission of SARS-CoV-2 is occurring, everyone in the community should be encouraged to follow recommended personal preventive practices, as well as community specific measures. Since transient interactions with a case (e.g., walking by a case, or being briefly in the same room) may result in an unrecognized exposure that is less likely to be identified through contact tracing efforts, it is important that community members follow all recommended precautions.

The duration of contact management for a contact who develops symptoms compatible with COVID-19 within 14 days of last exposure to a case should be based on the following considerations:

• If laboratory testing is conducted and the test result is negative for SARS-CoV-2, consider continuing to manage the individual as a contact for the duration of the possible 14-day incubation period, based on an individual risk assessment. The contact may be considered for re-testing if they have a worsening or progression of symptoms, and management would depend on the results of the second test.
• If laboratory testing is not conducted, the contact who develops symptoms should be managed as a probable/suspect case as applicable, and they should complete at least 10 days of isolation. Since they are still a contact of a case and not a laboratory confirmed case themselves, depending on the timing of symptom onset and last exposure to a case, this individual may need to quarantine (self-isolate) after the isolation period, for 14 days from the last known exposure. In this situation, the PHA should complete an individual risk assessment to determine the appropriate quarantine (self-isolation) period based on the individual's level of risk (see Table 1).

If additional members of a household with a case become ill, the PHA should assess whether other asymptomatic household members need to extend their period of quarantine (self-isolation) based on their last exposure to the new case.

Alternative contact management strategies

To complement or accommodate limited local resources, PHAs may consider alternative approaches to traditional contact tracing, particularly when they are experiencing a local surge in cases ^{Reference 9}. These may include the following:

• Using well-trained non-public health staff and volunteers for certain contact tracing activities;
• Repurposing existing resources, such as call centres or hotlines;
• Reducing the intensity of follow-up of contacts based on risk assessment, for example, automated calls or text messages to low-risk contacts, or follow-up text messages instead of daily calls; and
• Leveraging available technology, such as contact tracing software, as well as web-based and mobile phone applications (e.g., COVID Alert).

During local peaks in COVID-19 cases and declared outbreaks, PHAs may also consider prioritizing contact tracing activities for specific settings where transmission may have occurred (e.g., schools, events, workplaces, remote communities, etc.), and/or specified contacts (e.g., those who are vulnerable, work in high-risk settings, provide care to someone who is vulnerable, etc.) ^{Reference 10}.

PHAs may also consider alternative approaches where cases, employers, or event coordinators notify contacts (i.e., simple referral); or notify contacts and provide additional information related to infection prevention and control, quarantine (self-isolation), and symptom monitoring (i.e., enhanced referral) ^{Reference 11}.

Backward contact tracing

In addition to traditional (forward) contact tracing, PHAs may consider 'backward' contact tracing, which focuses on trying to determine where and when the case likely acquired their infection. Backward contact tracing is routinely done as part of case or outbreak investigations for communicable diseases of public health significance, when PHAs collect information on a case's potential acquisition history. In this guidance, backward contact tracing is proposed as less intensive activity, and therefore potentially less resource intensive, compared to outbreak investigation.

While COVID-19 has been observed to spread steadily in the community, with one case infecting one or two other cases on average, clusters have been identified where some individuals disproportionately infect a larger number of secondary cases. This is a statistical concept called over-dispersion, where there is high individual-level variation in the distribution of the number of secondary transmissions. Clusters associated with these cases have been referred to as super-spreading events (SSEs).

In these circumstances, 'backward' contact tracing may help to:

• Find additional cases by focusing on the setting where a case's exposure likely took place; and
• Interrupt additional chains of transmission by then employing traditional (forward) contact tracing for the newly identified cases.

If the source case is identified through backward contact tracing, traditional (forward) contact tracing should be employed as detailed above, and contacts managed based on their risk of exposure as described in Table 1. As in the case of forward contact tracing, testing requirements and public health interventions may need to be scaled based on local epidemiology.

Backward contact tracing is considered to be most useful when localized outbreaks may be occurring in areas experiencing relatively low levels of transmission.

It is considerably more challenging when there is widespread community transmission, due to the volume of cases and uncertainty created by having multiple potential sources of transmission for any given case. Backward contact tracing may also be less useful during periods of restrictive public health measures, due to fewer events or localized settings where outbreaks or SSEs might occur ^{Reference 12}. Employing backward contact tracing approaches may have significant resource implications, depending on the specific contact tracing strategies used, approaches to testing, and local epidemiology.

There is currently limited evidence regarding the effectiveness of backward tracing in relation to COVID-19, so it is not possible to be more definitive about when it would be most useful. A limited number of countries have utilized this strategy, and beneficial impact was correlated with low incidence and limited community transmission ^{Reference 13}, ^{Reference 14}. Provinces/territories (PTs) should consider the utility of backward contact tracing based on their individual circumstances and available resources and, if implemented, consider evaluating the effectiveness in order to contribute to the evidence base for this practice.

Persons possibly exposed during travel

As of March 25, 2020, all travellers entering Canada must follow the rules set out by the emergency orders under the Quarantine Act. There are some exemptions to these border restrictions and mandatory quarantine requirements for which individuals or groups can apply.

Unless exempted, all incoming travellers/citizens are required to quarantine at home, or another designated location, for 14 days following their arrival to Canada.

• Quarantine instructions for travellers without symptoms of COVID-19 returning to Canada by air are available.
• Quarantine instructions for travellers without symptoms of COVID-19 returning to Canada by land are available.

Incoming travellers with symptoms are required to isolate for a minimum of 14 days following their arrival to Canada.

• Isolation instructions for travellers with symptoms of COVID-19 returning to Canada by air are available.
• Isolation instructions for travellers with symptoms of COVID-19 returning to Canada by land are available.

History of travel should be considered by PHAs during the individual risk assessment during contact tracing. Potential travel-related exposures on specific conveyances (e.g., flights, trains, cruise ships) may be available.

Contact tracing for airplane passengers and flight crew

Potential exposure to SARS-CoV-2 among passengers and crew during air travel is a topic of concern; however, risk mitigation measures such as mandatory use of masks, physical distancing, reduced occupancy, environmental cleaning, and hand hygiene, applied in a layered approach, can significantly reduce the likelihood of transmission ^{Reference 15}.

Decisions related to contact tracing individual airplane passengers and flight crew who may have been exposed to a confirmed case of COVID-19 on any flight should be made based on available resources and a risk assessment. Risk assessments should be conducted by the PHA to which the case is notified, considering the following:

• Type, severity, and onset date of symptoms for symptomatic cases, or specimen collection date for asymptomatic cases, in relation to the flight date;
• Current messaging to all international travellers, specifically that they must enter into a legally mandatory 14 day quarantine period starting the day they enter Canada;
• Current legislation, regulations and policies that may be imposed on domestic travellers by a PT upon arrival to that PT (e.g., that a domestic traveller must enter into a legally mandatory 14 day quarantine period starting the day they enter a PT);
• Timing of notification and likelihood of getting sufficient passenger contact information (e.g., within 14 days of flight); and
• Incremental benefit of individual communication to those seated within 2 metres (or more) of the case versus public communication of the flight number.

If the province/territory determines that notification to potential contacts is required, the PHA can follow local protocols for publicly communicating when a case has had a history of travel during their period of communicability. The information required is the flight number, flight date, departure/arrival locations, and affected rows of the flight. Additionally, flight exposure notifications received by PHAC's Inter-jurisdictional Notices (IJN) team can be posted on the Coronavirus disease (COVID-19): Locations where you may have been exposed to COVID-19 webpage.

Appendix 1: Recommendations for isolation of COVID-19 cases in the community

When care in a hospital is not required, cases of COVID-19 should isolate themselves in the home or co-living setting (e.g., shelter, group home, or student residence) as directed by their PHA. They should isolate for a minimum of 10 days from the onset of symptoms for a symptomatic case, or the collection date of a positive specimen for an asymptomatic case.

During isolation, the case should not leave the isolation setting, whether it is their home, co-living setting, or an alternate setting identified by their PHA or health care provider. They should:

• Avoid contact with others, including members of their household;
• Not go out unless required or directed to do so to seek medical care;
• Not go to school, work, or other public places;
• Not take public transportation to seek medical care, if at all possible; and

If a case must go out to seek medical care, they should wear a medical mask if available (preferred), or a well-constructed and well-fitting non-medical mask.

Isolating in the community

When isolating at home or co-living setting in the community, it is important that cases reduce the risk of transmission, through direct or indirect contact, to other members of the household or co-living setting as much as possible. Advice is available for individuals who are required to isolate at home due to COVID-19.

As much as possible, the following strategies should be used during isolation in the community:

• A case should have their own room and a dedicated washroom.
• When awake, the case should wear a medical mask if available (preferred), or a well-constructed and well-fitting non-medical mask, when they are sharing a space (e.g., the same room) with other household members or occupants in the co-living setting.
• The case and other members of the household or co-living setting should avoid any activities that put them in a shared space (e.g., in the same room) with one another. This includes avoiding shared activities like watching television, congregate dining (e.g., family meals), playing games, etc.
• When other members of the household or co-living setting are unable to avoid sharing a space (e.g., the same room) with the case, they should wear a well-constructed and well-fitting non-medical mask. If household members are at high risk of more severe disease or outcomes, a medical mask should be worn if available to them.
• If a member of the household or co-living setting needs to be within 2 metres of the case, or provide direct care, they should wear a medical mask if available (preferred), or a well-constructed and well-fitting non-medical mask.
• The case should avoid sharing personal items with others, as much as possible (e.g., toothbrushes, towels, bed linen, cigarettes, unwashed eating utensils, etc.).
• In situations where child care is shared between two homes, wherever possible consider having the child stay in one home for the duration of the isolation or quarantine period.
• If possible, shared spaces (e.g., same room) should be well ventilated (e.g., windows open, as weather permits).
• The case and all household members or occupants of the co-living setting should strictly follow the recommended personal preventive practices.
• A list of supplies to have at home while isolating is available.

Recommendations when strict isolation is not possible

Cases of COVID-19 who have been directed to isolate may not be able to strictly follow instructions for isolation in the home or co-living setting. This may be due to the isolation setting itself, for instance, there are not enough rooms in the home for the case to have a separate room or a dedicated washroom, or occupants in a shelter who must share space. It may also be difficult to isolate due to other factors; for example, if the case is a child, has child-/elder- care responsibilities, or lives in a multigenerational household.

When it is not possible to relocate the case, or members of the household or co-living setting, the following approaches may be considered:

• In overcrowded housing, or where a dedicated room and washroom are not available for isolation, consider having the case, household members, or other occupants relocate to another location where the case can be isolated.
• SARS-CoV-2 primarily spreads to others through large droplets that fall to the ground rapidly ^{Reference 16}, so it may be useful to separate the case from others with dividers such as curtains in a shared space (e.g., home with limited rooms, sharing space for sleeping).
• If other members of the home or co-living setting are sleeping in the same room as a case, it is important to maintain as much distance as possible from the case (ideally a minimum of 2 metres). This may be accomplished by separating beds and having occupants sleep head-to-toe.
• If a separate washroom is not available, open the window, turn on the exhaust fan to improve ventilation, put the lid of the toilet down before flushing and, when possible, clean and disinfect surfaces touched by the case after each use ^{Reference 17}.

Appendix 2: Assessment of a suitable isolation location for a case of COVID-19

The location where a COVID-19 case will be isolated should be determined by the public health authority (PHA), in collaboration with the case and their health care provider, as applicable. It is important that cases who do not require hospital-level care convalesce in a suitable environment where effective isolation and appropriate monitoring (e.g., for worsening of illness) can be provided.

Considerations for a suitable environment will depend on the individual and their living situations, and may vary depending on the sex, gender, or other socioeconomic or identity factors of cases.

Factors to consider when determining the suitability of an isolation location:

Can the case's clinical condition be managed as an outpatient?

For isolation in the community, including the home or a co-living setting (e.g., shelter, group home, student residence, etc.), it must be possible to manage the case as an outpatient, taking into consideration their baseline health status and the presence of risk factors for more severe disease or outcomes. If hospitalization is required (e.g., worsening condition, health emergency, direction of health care provider), home isolation will no longer be feasible.

Is the case able to manage their own care?

Symptomatic and asymptomatic cases should be able to monitor themselves for new or worsening symptoms; take appropriate action as advised by the PHA or their health care provider, including concerning self-care; properly wear a medical mask if available (preferred), or a well-constructed and well-fitting non-medical mask; maintain appropriate personal preventive practices (e.g., maintain proper hygiene practices, clean and disinfect high-touch surfaces, etc.), and isolate away from others.

A case's ability to manage their own care may be impacted by various factors, including:

• Social and economic circumstances, such as poverty (e.g., unable to purchase necessary supplies, housing instability, etc.), unstable employment, inflexible working conditions, food insecurity, and domestic violence or abuse;
• Individual skills, abilities and vulnerabilities, such as difficulty reading, speaking, understanding or communicating; physical or psychological difficulty undertaking personal preventive practices; need for assistance with personal or medical care activities or supplies; or need for ongoing supervision. COVID-19 guidance on considerations for people with disabilities in Canada is available.
• Social or geographic isolation such as lacking family, friends, or community resources for support ^{Reference 18}, or residing in an area with reduced access to services or supports; including mental health and addiction support.
• The ability for the case to access plain-language instructions in the appropriate languages related to proper personal hygiene practices, isolating away from others, self-monitoring for symptoms, and when to seek help. Note that male gender cases are more likely to live alone and may be less likely to seek help ^{Reference 19}, ^{Reference 20}.

Does the case require care? Is someone available to provide the care?

Some circumstances may require a household member to provide direct care to the case; for example, when the case is a child, an elderly relative who requires support, or a case who is very ill. When this occurs, the following should be considered:

• The caregiver should be willing and able to provide the necessary care and monitoring for the case.
• The caregiver should reduce their risk of COVID-19 infection by wearing a medical mask if available (preferred), or a well-constructed and well-fitting non-medical mask, when providing direct care, or within 2 metres of the case. They should also use appropriate eye protection and disposable gloves while providing care to the case (see Appendix 3).
• Advice is available to support those caring for someone with COVID-19 at home:
  • How to care for a child with COVID-19 at home: Advice for caregivers
  • How to care for someone with COVID-19 at home
  • How to care for a person with COVID-19 at home: Advice for caregivers

What are the characteristics of the home or co-living configuration?

Cases may be in various household configurations that may hinder their ability to isolate themselves. For instance, the case may be a single-parent who must provide care to a child, or they may live in a multi-generational home with shared child- and elder-care responsibilities. If the case provides care to a child where childcare is shared between parents in two separate homes, consideration should be given to the most appropriate location for the child while the case is isolating.

Special consideration is needed to support cases who live in co-living settings, such as student residence, shelters, and overcrowded housing, when isolating. The preferred option is to provide the case in these settings with a single room and a private washroom, which may require relocating the case, their roommates, or other household members to another location.

If it is not possible to provide the case with a single room and a private washroom in the co-living setting, or to relocate the case, efforts should be made to cohort confirmed cases together. For example, if two cases reside in a co-living setting and single rooms are not available, they could share a double room. Specific guidance has been developed on the considerations for people experiencing homelessness and for post-secondary institutions.

Are there others with greater risk of more severe disease or outcomes in the home or co-living setting?

Household members, or other occupants in co-living settings, who are at risk for more severe disease or outcomes from COVID-19 should not provide care to the case and alternative arrangements may be necessary. This could include temporarily relocating these individuals or the case outside of the home to a location determined by public health, such as a designated hotel.

Is the home or co-living setting suitable for isolation?

The PHA should determine if the home or co-living setting is suitable for isolation of the case. Cases may live in conditions where they lack available space to provide a dedicated room and private washroom for the case, such as an overcrowded house, student residence where the case has a roommate, or a homeless shelter. Housing conditions should also be assessed, including access to potable, running water, and the state of repair of the home. Safety of the setting should also be assessed in terms of the potential occurrence of gender-based or family violence or other abuse.

Can the case access adequate supplies and necessities?

Consider whether or not the case has access to supplies and necessities for the duration of isolation, such as food, running water, drinking water, supplies for infection control (e.g., masks), and cleaning supplies. A list of supplies to have at home while isolating is available. Those residing in remote and isolated communities may wish to consider stockpiling the needed supplies, as well as food and medications usually taken, if it is likely that the supply chain may be interrupted or unreliable.

A case who does not have access to adequate food or necessary supplies could contact local leadership, public health or organizations that provide direct support. Guidance is available for hand washing in the absence of running or clean water.

If the home or co-living setting is inadequate for home isolation based on the assessment, PHAs should collaborate with the case and their health care provider, to determine a more suitable location. This may involve relocating the case to a more suitable community setting, hospitalizing the case, or accessing additional community supports and resources where available.

Appendix 3: Recommended infection prevention and control precautions when caring for a case in the home or co-living setting

Anyone who provides direct care to a case of COVID-19 should wear a medical mask if available (preferred), or a well-constructed and well-fitting non-medical mask, as well as eye protection whenever providing direct care or within 2 metres of the case. Caregivers should wear disposable gloves, if available, when in direct contact with the ill person or their environment, including soiled materials and surfaces. Hand hygiene should be performed before putting gloves on and after removing them.

Advice is available to support those caring for someone with COVID-19 at home:

• How to care for a child with COVID-19 at home: Advice for caregivers
• How to care for someone with COVID-19 at home
• How to care for a person with COVID-19 at home: Advice for caregivers

Additional information may be provided to caregivers in the home related to how to appropriately put on (don) and take off (doff) eye protection and gloves.

Eye protection

Eye protection is recommended to protect the mucous membranes of the caregiver's eyes while providing direct care to a case of COVID-19, or during any activities likely to generate splashes or sprays of bodily fluids, including respiratory secretions.

• Eye protection should be worn over prescription eyeglasses. Prescription eyeglasses alone are not adequate protection against respiratory droplets.
• Protective eye wear should be put on after putting on a mask.
• If using gloves, they should be donned (see below) after applying eye protection.
• To remove eye protection, first remove gloves and perform hand hygiene. Then remove the eye protection by handling the arms of goggles or sides or back of face shield. The front of the goggles or face shield is considered contaminated.
• Discard the eye protection into a plastic lined waste container. If the eye protection is not intended for single use, clean it with soap and water and then disinfect it with approved hard-surface disinfectants or, if not available, a diluted bleach solution, being mindful not to contaminate the environment with the eye protection. Refer to Clean and disinfect all high-touch surfaces for instructions on diluting bleach.
• Perform hand hygiene.

Gloves

Disposable single use gloves, if available, should be worn when in direct contact with the ill person, cleaning contaminated surfaces, and handling items soiled with bodily fluids, including dishes, cutlery, clothing, laundry, and waste for disposal.

Gloves are not a substitute for hand hygiene; caregivers must perform hand hygiene before and after putting on and taking off gloves.

• Gloves should be removed, hand hygiene performed, and new gloves applied when they become soiled or torn during care.
• To remove gloves safely, with one of your gloved hands pull off your glove for the opposite hand from the fingertips, as you are pulling, form your glove into a ball within the palm of your gloved hand. To remove your other glove, slide your ungloved hand in under the glove at the wrist and gently roll inside out, and away from your body. Avoid touching the outside of the gloves with your bare hands.
• Discard the gloves in a plastic-lined waste container.
• Perform hand hygiene.
• Double-gloving is not necessary.

Reusable utility gloves may be used; however, they must be cleaned with soap and water then disinfected after each use with approved hard-surface disinfectants or, if not available, a diluted bleach solution. Instructions are available for diluting bleach.

Acknowledgments

The Public Health Measures (PHM) technical guidance is developed and approved in collaboration with federal, provincial and territorial partners, via the Technical Advisory Committee (TAC) and/or the Special Advisory Committee (SAC). In its guidance development process, PHM also works closely with: multilateral partners; other government departments; First Nations, Inuit and Métis stakeholders (through the Public Health Working Group on Remote and Isolated Communities); Sex and Gender-based Analysis (SGBA) experts at Public Health Agency of Canada; and other external stakeholders with a vested interest or a stake in the guidance.

This current iteration was prepared by: Jill Williams, Jill Sciberras, Lynn Cochrane, Corey Green, Sharon E. Smith, Angela Sinilaite, Alexandra Nunn, Fanie Lalonde and Lisa Paddle

Previous iterations prepared by: Sharon E. Smith, Angela Sinilaite, Alexandra Nunn, Fanie Lalonde and Lisa Paddle

and supported by: Canadian Pandemic Influenza Preparedness (CPIP) Task Group Members, an external expert group: Bonnie Henry, Susy Hota, Brian Schwartz, Carolina Alfieri, Ian Gemmill, Kim Daly (ISC), Todd Hatchette, Erin Henry, Nadine Sicard, Michelle Murti and Eleni Galanis