Individual and community-based measures to mitigate the spread of COVID-19 in Canada

As COVID-19 continues to circulate in Canada and a significant proportion of the population is now vaccinated, different public health measures may be required. This is based on the level of transmission in a community and other key indicators. Access guidance for adjusting public health measures in the context of COVID-19 vaccination.

Last updated: August 11, 2021

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Preamble

The Public Health Agency of Canada (PHAC), in collaboration with Canadian public health experts, has updated this guidance on the use of non-pharmaceutical public health measures (PHM) to mitigate community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). The primary audiences for the guidance are federal/provincial/territorial (FPT) and regional/local public health authorities (PHA). In the operationalization of this guidance, it is recognized that each PHA may have unique approaches to implement individual and community-based measures, based on jurisdiction-specific considerations.

Principles and concepts outlined in The Canadian pandemic influenza preparedness: Planning guidance for the health sector were used as a foundation in the development of this guidance.

This guidance identifies non-pharmaceutical PHM, which include individual and community-based measures to mitigate the transmission of SARS-CoV-2. It uses a risk-based approach to identify risks and mitigation strategies that would be applicable for various community settings, including congregate living settings, workplaces/businesses, child and youth settings, outdoor recreational spaces and activities, and gatherings and events. This guidance does not apply to any health care settings, for which specific infection prevention and control guidance is available.

This guidance considers the Canadian context, is based upon the best available scientific evidence and expert opinion, and is subject to change as new information becomes available on effectiveness of PHM, vaccine effectiveness and coverage, or transmission of SARS-CoV-2 variants of concern (VOC).

In interpreting and applying this guidance, it is important to recognize that the health, age, economic, social or other circumstances (e.g., caregiving responsibilities) faced by some individuals and households may limit their ability to follow the recommended measures. PHA may need to tailor PHM recommendations for these circumstances.

The timing and intensity of SARS-CoV-2 activity has differed in jurisdictions across the country. It is recommended that this guidance be read in conjunction with relevant PT and local legislation, regulations and policies. For up-to-date and evolving information regarding COVID-19, visit Canada.ca/coronavirus.

Introduction

The goal of Canada's COVID-19 pandemic response and recovery is to minimize serious illness and overall deathsFootnote a, while minimizing societal disruption as a result of the COVID-19 pandemic.

PHM are non-pharmaceutical interventions used to reduce community transmission of SARS-CoV-2, thereby reducing the number of persons who are infected and reducing the demand for health care services to a manageable level, while continuing to provide services for urgent non-COVID-19 health care needs. PHM are usually implemented in combination, known as layering, as combinations of PHM are more effective than single measures on their own.

The PHM outlined in this guidance include personal preventive practices recommended for individuals, management of cases of COVID-19 and their high-risk contacts, and community-based measures to protect groups and the community at large. While PHM are effective in reducing COVID-19 transmission, they can have important consequences beyond the scope of COVID-19 management. These consequences include extensive social, psychological, and economic impacts, particularly on Indigenous Peoples and populations whose circumstances increase their vulnerability, including people at risk for more severe disease or outcomes from COVID-19, persons with disabilities, persons who are racialized, among others at increased riskReference 1 Reference 2 Reference 3 Reference 4.

Adherence to PHM and sustainability over time may be influenced by a variety of factors, such as contextual (e.g., living, working, community conditions), financial and social circumstances, and cultural and spiritual factorsReference 5. This is particularly relevant for persons who are racialized who can be disproportionately impacted by the implementation of PHM. The length of the pandemic and the resulting pandemic fatigue may also impact adherence to PHMReference 6. To promote adherence to measures, messaging should be adapted depending on the age, sex, gender, ability status, parental and caregiving responsibilities, and other socioeconomic or identity factors of individualsReference 7 Reference 8 Reference 9. For example, men are more likely than women to report low levels of concern about the COVID-19 pandemic, including men in the highest risk age groupsReference 10. Women are more likely than men to report high levels of stress in their lives, in part because the pandemic may have exacerbated the gender division of unpaid family work, and women are more likely to have caregiving responsibilities (e.g., for children or elderly family members)Reference 11 Reference 12. Public education and communication strategies that consider these factors, and are tailored to other relevant factors, are critical in promoting adherence to PHM. See further details on these strategies in Appendix A.

Transmission of SARS-CoV-2

The understanding of SARS-CoV-2 transmission has evolved since the beginning of the pandemic and underpins PHA recommendations on the use of PHM. Infected individuals generate respiratory droplets and aerosols, which can be transmitted to others. Activities that are more likely to generate respiratory droplets and aerosols include: heavy breathing (e.g., during exercise), talking, singing, shouting, coughing, and sneezing. The droplets vary in size from large droplets that may fall to the ground relatively quickly near the person who is infected, to small droplets called aerosols which may remain suspended in the air and travel on ambient air currentsReference 13 Reference 14. The risk of transmission via respiratory aerosols is greater in poorly ventilated indoor environments where there is a high density of people and extended duration of contactReference 14. The relative infectiousness of droplets of different sizes, and the amount of virus in respiratory droplets needed to cause infection (i.e., infectious dose), is not clear.

Infectious droplets or aerosols may come into direct contact with the mucous membranes of another person's nose, mouth, or eyes, or they may be inhaled into the nose, mouth, and airways, with smaller aerosols penetrating deeper into the lungs. The virus may also spread when a person touches another person (e.g., a handshake) or an object (referred to as fomites) that has the virus on it, and then touches their mouth, nose, or eyes with unwashed handsReference 14.

Transmission of SARS-CoV-2 may vary depending on factors such as age, infectiousness, presence of symptoms, illness severity, and characteristics of the virus itself (e.g., VOC), as well as adherence to personal preventive practices, such as physical distancing, proper use of well-constructed and well-fitting masks, hand hygiene, and respiratory etiquetteReference 14. There is no evidence to date to suggest differences in mode of transmission of circulating VOC.

Environmental factorsReference 14, settings, and specific activities can contribute to the risk of viral transmission, including enclosed spaces, especially those with poor ventilation, crowded settings, and close interactions. Settings where these factors overlap or involve activities such as singing, shouting or heavy breathing (e.g., aerobic exercise) are considered higher risk. Examples of these settings include family gatherings and other social gatherings, religious services, funerals, and choir practices, as well as in occupational settings including health care facilities and meat processing plantsReference 15 Reference 16 Reference 17 Reference 18. The duration of exposure in such settings is also likely to increase the risk of transmission. It is exceedingly important that PHM be applied in a "layered" manner in these settings to reduce the risk of transmission.

Long-standing social and economic inequities put certain subpopulation groups at increased risk of exposure to SARS-CoV-2 and complications related to COVID-19. Social determinants, such as housing that is below standards, overcrowding, adverse working conditions, and poor nutrition put groups such as persons who are racialized, people living in poverty, Indigenous Peoples, and persons with disabilities, among others, at increased risk.

It is likely that multiple modes of transmission occur; however, on a population level, close-range and direct interactions are higher risk than distant interactions. Interactions that take place in indoor settings, particularly if poorly ventilated, are higher risk than those that take place in outdoor settings. In addition, interacting with individuals from outside of one's immediate householdFootnote b in crowded settings is higher risk than having limited interactions with few individuals. Transmission can occur during interactions of any duration; however, the longer the duration the higher the risk.

Adjusting public health measures over time

In response to the COVID-19 pandemic, FPT governments and First Nations, Inuit and Métis leadership have implemented a wide variety of PHM in their respective jurisdictions to prevent and to control SARS-CoV-2 transmission, including implementing restrictive measures such as stay at home orders, closures of public gathering places such as schools, day cares, non-essential businesses, and restrictions on gatherings and travel. The implementation of these measures has varied across the country owing to differences in the timing and intensity of COVID-19 activity and other jurisdiction-specific considerations.

Using a risk management approach helps to weigh the potential advantages of particular interventions against their disadvantages and other consequences. FPT governments and First Nations, Inuit and Métis leadership have used risk assessments in decision-making on PHM. These risk assessments take into account a variety of factors such as local virus activity including VOC, the risk profile of their population, and health system capacity, which are balanced against broader societal and economic consequences of the PHM. Jurisdictions have adjusted (lifting and reinstating) restrictive PHM as required to manage resurgences of COVID-19 cases. Criteria and indicators to support PT decision-making on adjusting PHM are set out in Guidance for a strategic approach to lifting restrictive public health measures. PT governments have developed their own plans for adjusting PHM within their jurisdictions.

Modelling studies suggest that PHM will need to continue as long as required to control the spread of SARS-CoV-2 pending sufficient population coverage with the COVID-19 vaccineReference 19 Reference 20 Reference 21. Vaccine-related factors that will influence adjustments to PHM include population vaccine coverage, as well as data on their effectiveness to prevent infection and to reduce transmission, and duration of protection from illness.

Ongoing community transmission of COVID-19 and the emergence of VOC internationally and in Canada is concerning; however, transmission of the virus can be controlled with the strict use of and adherence to PHM. In the United Kingdom, where VOC B.1.1.7 is now the dominant strain, application of more stringent PHM was able to control the pandemic. Modelling suggests that even with limited relief of restrictive PHM there will be a significant resurgence in casesReference 22. It will be important for FPT governments to use a risk-based approach when considering adjustments to PHM, weighing the social and economic benefits of lifting restrictive PHM against the consequences of a resurgence of cases from a more transmissible variant. The context of VOC may require more stringent PHM, along with the capacity to test, trace and isolate all cases, and strict adherence to PHM by the public.

Personal preventive practices

It is recommended that PHA continue to reinforce and consider approaches that support adherence to personal preventive practices to help protect individuals from becoming infected and prevent virus transmission from those who are infected. Appendix A provides recommendations for communicating and educating the public on PHM.

Self-monitoring, isolation and quarantine

All individuals should self-monitor for symptoms compatible with COVID-19 and if symptoms develop, they and/or their caregiver should be provided with instructions on how to isolate themselves at home, when to seek medical attention, and when to be tested.

Rapidly detecting and isolating all cases, and tracing and quarantine of all high-risk contacts in a timely manner is even more important in light of SARS-COV-2 VOC. Public health follow-up should encourage, and when necessary enforce, appropriate isolation of cases and quarantine of contacts according to the guidance on Public health management of cases and contacts associated with COVID-19Reference 23. It is recommended that individuals in the community be encouraged to plan ahead by maintaining a supply of essential medications, home supplies, and extra non-perishable food for themselves and all members of the household under their care in the event that they need to isolate or quarantine. As it may not be possible for some individuals to acquire these supplies, it is recommended that PHA provide guidance on available resources and supports in their jurisdictions.

Physical distancing

Given evidence of transmission via respiratory droplets and aerosols, physical distancing continues to be important, especially in light of more transmissible VOCReference 14 Reference 24 Reference 25 Reference 26 Reference 27. Interactions that are in closer proximity may have a greater risk of transmission than interactions at a distanceReference 25.

It is recommended that PHA provide clear communications to the public on the rationale for physical distancing measures, and reinforce the importance of avoiding close proximity and direct contact between individuals who are not from the same immediate household. Physical distancing includes:

Use of masks

SARS-CoV-2 can spread from individuals who are symptomatic, as well as those who are asymptomatic and pre-symptomatic. Although there is no specific evidence related to masking and SARS-CoV-2 VOC, the increased transmission potential of VOC highlights the importance of mask-wearing and adhering to other public health measures.

The use of non-medical masks that are well-constructed, well-fitting and worn properly play an important role in reducing the transmission of SARS-CoV-2 Reference 28 Reference 29 Reference 30 Reference 31. Non-medical masks have been found to be effective for source control by preventing the infectious respiratory particles of a person who has COVID-19 from coming into contact with others. In addition, there is evidence that non-medical masks can provide some protection to the wearer from the infectious respiratory particles of others. It is recognized that there is a synergistic protective effect when both the infected and exposed individuals wear non-medical masks Reference 31 Reference 32.

The efficacy of a non-medical mask depends on breathability, filtration efficiency, and of critical importance, fit. Masks (non-medical or medical) that are loose fitting or gaping away from the face have been found to have lower filtration efficacy compared to tight-fitting masks with no gapsReference 33. Masks should completely cover the nose, mouth and chin without any gaps and should be held in place securely with ties or ear loops. It may be difficult to achieve proper fit if the mask wearer has certain types of facial hair. The fit of a reusable non-medical mask can be improved by adding a nose wire (if it does not already have one) or by adjusting the head ties or ear loops so that the mask sits closer to the face.

Disposable masks (medical or non-medical) tend to have poorer fit, leaving gaps between the mask and face of the wearer. Some options to improve fit of disposable masks include modifying ear loops and tucking in the sides of the mask, layering a cloth mask over top of the disposable one, or using a mask fitter or braceReference 34 Reference 35. A medical mask should not be layered on top of another medical mask.

Well-fitting, two-layered masks comprised of different material types (e.g., combined cotton and polyester), or masks made from one type of material but with greater than two layers have been shown to reduce the risk of spreading or being exposed to SARS-CoV-2, and have exhibited similar outward blocking efficiencies as medical masks, while still maintaining comparable breathabilityReference 36.

Studies have found that filtration efficiency is dependent on fabric quality (e.g., tightness of the weave, fibre or thread diameter) and inherent characteristics of the fabric (e.g., electrostatic charge and hydrophobicity)Reference 36. The addition of a middle layer of filter-type fabric, such as non-woven polypropylene, is recommended to reduce transmission potentialReference 37.

It is important to balance the filtration efficiency of a mask with its breathability, as materials that have poor breathability can cause discomfort and will redirect air to flow from the edges of the mask (i.e., gaps between the mask and face). Non-medical masks constructed of more than three layers or made with non-porous materials (e.g., plastic) have been found to have very poor breathability Reference 32 Reference 36.

Recommendations regarding the use of masks vary between jurisdictions. PHAC recommends that non-medical masks be worn when individuals are in a shared space (indoors and outdoors) with others from outside their immediate household, or as advised by the local PHA. Masks alone will not prevent transmission of the virus, therefore it is recommended that masks be considered as an added layer of protection along with other mitigation measures (e.g., physical distancing, hand hygiene) Reference 32 Reference 38.

Medical masks make medical claims or representations of reducing or preventing COVID-19 infection for the user, in addition to providing source control to protect others from potential infectious particles of the wearerReference 39. In the community setting, there are specific circumstances when the use of a medical mask is recommended instead of a non-medical mask. This includes for anyone diagnosed with or suspected to have COVID-19 while in shared indoor and outdoor space with others, if receiving care, or if going out to seek medical care. Medical masks are also recommended for anyone who needs to provide care to someone diagnosed or has symptoms of COVID-19. Individuals who are at risk of more severe disease or outcomes from COVID-19 or are at higher risk of exposure because of their work or living situation should consider using a medical mask.

It is recommended that the use of respirators (e.g., N95) be limited to health care and other settings where they are required, and where informed by a point of care risk assessment of the mask wearer. All individuals required to use respirators should be fit tested and trained in their use.

It is recommended that PHA provide information, in age-appropriate language, on safe mask use, including refraining from touching the mask while wearing, and not placing a mask on anyone who has trouble breathing or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.

A child's ability to properly use and care for their mask is impacted by factors such as age, maturity, and physical or cognitive ability. Masks should not be placed on children under two years of age. Between the ages of two and five years, children may be able to wear a mask if supervised. This will depend on their ability to tolerate it, as well as put it on and take it off. Children older than five years of age should wear a mask in situations or settings where they are recommended. In addition to the overall quality of the fabric, breathability, filtration, and comfort, consideration can be given to making masks child-friendly, such as being appropriately sized, having colours and designs that children enjoy, and having extras on hand in case the child's mask become lost or soiled.

Non-medical masks with a clear or transparent window are available for individuals who require them. Groups that may benefit from clear masks include persons who are Deaf or hard of hearing and persons providing support, persons with communication disabilities, children, seniors, people with dementia, people who have difficulty with face recognition, or anyone experiencing confusion, stress or anxiety. People who wear masks with a clear or transparent window should be reminded that their mask should not impede their breathing, to not let excess moisture collect on the inside of the mask, and to remove the mask before sleeping as the plastic part could form a seal around the mouth and nose and make it hard to breathe.

Mask regulation in Canada

Masks that make medical claims or representations (e.g., claims of anti-viral or anti-microbial action) are considered medical devices and are regulated as Class I medical devices by Health Canada. Examples of medical claims or representations include: to protect the user from contracting COVID-19; for anti-viral or anti-bacterial protection (e.g., contains a drug or biologic); for use as a medical mask.

All medical masks, regulated as medical devices, must meet particle or bacterial filtration standards, such as American Society for Testing and Materials (ASTM) F2100. These standards may include requirements for pressure differentials, flammability, and possible fluid resistance. Non-medical masks making medical claims would be required to meet the same standard. Labelling for medical masks must contain clear statements on their intended use (e.g., the purpose for which the device is manufactured, sold or represented), specific performance specifications for their proper use (e.g., filtration efficiency and fluid resistance), and bilingual labelling, either on the packaging or with the device itself.

Non-medical masks that do not make medical claims or indicate that they will reduce or prevent the user from contracting a disease are not regulated as medical devices. Some disposable, single use non-medical masks may look like medical masks, making it important to review the package labelling.

Health Canada has not set out or endorsed any standards for non-medical masks at this time. There are some international standards for non-medical masks, including:

Information on regulatory considerations for non-medical masks is available.

To support adherence to recommendations on the use of masks, it is important for PHAs to provide clear communications to the public on the rationale of community mask use and the appropriate and safe use of masks, such as when, how, and why they should be used, the type of mask to choose, and any contraindications to mask use. Information for the public on the appropriate use, care, fit, and composition of non-medical masks, including how to make one at home, is available.

Hand hygiene and respiratory etiquette

Hand hygiene refers to washing hands with soap and water for 20 seconds or using an alcohol-based hand sanitizer containing at least 60% alcohol. Frequent handwashing has been shown to reduce viral transmission across a variety of settings by up to 44%, and a systematic review in office settings found that hand hygiene was effective in reducing respiratory and gastrointestinal illness in office employeesReference 40. Health Canada has published a list of hand sanitizers that are authorized for sale in Canada.

Respiratory etiquette, a long-standing standard public health recommendation, describes a combination of measures intended to minimize the dispersion of infectious respiratory droplets when an infected or ill person is coughing, sneezing, laughing or talking, to reduce virus transmission. The best way to do so is through the consistent use of a non-medical or medical mask, as appropriate. When not wearing a mask (e.g., in settings such as one's immediate household), recommendations including coughing or sneezing into a tissue or the bend of the arm, not the hand, are still applicable. When tissues are used they should be disposed of as soon as possible in a plastic lined waste container and hand hygiene performed immediately afterwards.

Cleaning and disinfection

Cleaning and disinfection refers to the routine cleaning and disinfecting of frequently used surfaces and objects to help prevent the transmission of SARS-CoV-2 through self-inoculation. The virus has the potential to survive in the environment for several hours to days Reference 14 Reference 41 Reference 42, depending on the surface type, relative temperature or humidity of the environment, and can remain viable longer on smooth surfaces such as plastic or steel, compared to cardboard or cottonReference 43,Reference 44. Additionally, increases in temperature and humidity reduce SARS-CoV-2's ability to survive on surfacesReference 45. Cleaning and disinfecting of surfaces and objects can inactivate the virus, making it no longer infectious Reference 14 Reference 41 Reference 43 Reference 46.

High-touch surfaces and objects such as toilets, bedside tables, light switches, door handles, and children's toys should be first cleaned (to physically remove dirt) and then disinfected frequently, and is recommend twice daily if someone in the household is symptomatic or has tested positive for COVID-19Reference 41.

Only approved hard-surface disinfectants that have a Drug Identification Number (DIN) should be used. A DIN is an 8-digit number assigned by Health Canada that confirms that the disinfectant product is approved and safe for use in Canada. When approved hard surface disinfectants are not available for household disinfecting, a diluted bleach solution can be prepared in accordance with the instructions on the label, or in a ratio of 5 millilitres (mL) of bleach per 250 mL of water OR 20 mL of bleach per litre of water. This ratio is based on bleach containing 5% sodium hypochlorite to give a 0.1% sodium hypochlorite solution. Follow instructions for proper handling of household (chlorine) bleach.

If they can withstand the use of liquids for disinfecting, high-touch electronic devices such as keyboards, tablets, television remotes, and smartphones may be disinfected with alcohol (e.g., alcohol prep wipes) often. All used disposable contaminated items should be placed in a plastic lined waste container before disposing of them with other household waste.

Ventilation

Proper ventilation has an important role in reducing the transmission of COVID-19 indoorsReference 47. Ventilating a room or indoor space replaces the indoor air with outdoor air. This will dilute and replace air that is potentially contaminated with SARS-CoV-2 virus. It is important to note that proper indoor ventilation alone is not likely to reduce transmission of SARS-CoV-2, particularly during close unprotected contact, or in the absence of other protective measures.

COVID-19: Guidance on indoor ventilation during the pandemic provides information regarding indoor ventilation, including practical tips for individuals on how to improve indoor air ventilation and filtration in their homes to help reduce the spread of COVID-19.

Other personal preventive practices

It is recommended that PHA continue to educate people about the importance of adherence to personal preventive practices and their appropriate use. Fact sheets containing detailed instructions for the public are available.

Community-based measures

Overview

Community-based measures are PHM that apply to settings where the public gathers, such as businesses and workplaces, child and youth settings, community gatherings and events, outdoor recreational spaces, congregate living settings, and public transportation. Community-based measures are implemented by governments, First Nations, Inuit and Métis leadership, employers, owners, organizers, planners, and administrators (collectively referred to as operators throughout the rest of this document) to protect their employees and individuals who are accessing community settings.

Settings such as First Nations, Inuit and Métis communities and remote and isolated communities have additional considerations and require tailored approaches based on geography, culture, and social determinants of health impacted by the historical and ongoing legacy of colonialization. Guidance for those living in First Nations, Inuit and Métis communities and remote and isolated communities is provided in Appendix B.

Risk assessments should be integrated into PHA decisions about the use of community-based PHM, including whether to impose or lift restrictive measures and how to mitigate risks for community settings that are open. When conducting a risk assessment, it is important to identify the risks (potential) and hazards (actual) associated with the setting and the population accessing it, and the corresponding mitigation strategies to help to minimize risk or to reduce consequences of the hazard. To maximize mitigation efforts, a "layered" approach should be used by applying multiple measures together aimed at reducing the risk of COVID-19 spread. The risk assessment and mitigation considerations used in this document incorporate and build upon the following:

Core public health measures for all community settings

The core PHM that apply to all community settings, regardless of the current level of COVID-19 activity, consist of physical distancing measures including limits on gathering sizes, promotion of personal preventive practices, screening in order to prevent people with COVID-19 from entering community settings, and proper ventilation and enhanced cleaning and disinfection of the community setting.

Physical distancing measures

Physical distancing can reduce the risk of transmitting COVID-19 in community settingsReference 14 Reference 25 Reference 26 Reference 27. Close interactions have a greater risk of transmission than interactions at a distanceReference 25. However, physical distancing may be impractical or unpredictable in some settings, and in others it may not be sustainable over time. Consequently, layering with other mitigation measures is very important.

Key physical distancing strategies are outlined in the following sections of this guidance. Operators should be encouraged to develop additional innovative approaches to physical distancing in their own setting. There may be circumstances when people cannot physically distance appropriately, such as persons with guide dogs that have not been trained to the new rules, seniors who require assistance with personal care, or people living in crowded or congregate settings. In addition to physical distancing strategies, operators will need to follow PHA directives on the size of gatherings.

Promotion of personal preventive practices

It is essential for operators of community settings to promote and facilitate adherence to personal preventive practices, as outlined previously in this document, to reduce the spread of COVID-19 by:

Preventing people with COVID-19 infection from entering community settings

Screening for COVID-19 symptoms and exposure risks is a way to reduce the chance of virus transmission in community settings. There are various ways to screen individuals before entering a workplace or public setting. Operators should consider the local level of virus activity along with the risks for their setting in deciding what type of screening would be most appropriate. Jurisdictions may mandate active screening for some settings, and may use rapid testing in screening for pre-symptomatic and asymptomatic individuals in community settings as a strategy to reduce the virus transmission.

Passive screening measures, where individuals are expected to self-monitor and self-report possible illness or exposure to someone with COVID-19, should be put into place in all settings. This usually consists of signage at points of entry to remind people not to enter if they are ill or have possibly been exposed (e.g., contact with a household member who was diagnosed with COVID-19 or recent travel history outside of Canada). Similar messaging can be communicated on voicemails and websites.

Active screening measures, where individuals are asked questions about possible signs or symptoms of infection and possible exposure to someone with COVID-19 or have had recent travel history outside of Canada, should be considered in some circumstances, for example:

Active screening protocols may involve a self-assessment (e.g., using a web-based tool or completing a questionnaire upon arrival). If active screening is conducted in person (e.g., posing direct questions), it should take place in a well ventilated area and the screener should be at the greatest physical distance possible from others, wearing a non-medical mask, using a physical barrier if available, and following Occupation Health and Safety (OHS) directives. Customers or clients could be asked about illness and exposure risks when they are booking their appointments, and again at reception when arriving at the premises. Settings that have put active screening measures into place also need to have a procedure for handling persons who screen positive.

Ventilation in non-residential settings

Improving ventilation, air flow, and access to fresh air are principles that can reduce the risk of SARS-CoV-2 transmission in any indoor setting, including non-residential settings such as schools, workplaces, commercial spaces, retail settings, and any other setting accessed by the public. General principles detailed in the indoor ventilation guidance mentioned previously in this document would also apply in these settings.

In these non-residential settings, ventilation should be considered as an additional layer of protection, along with other PHM. Efforts should also be made to move activities outdoors whenever possible, and to reduce the number of occupants in a space to avoid accumulation of potentially infectious droplets and aerosols in the air (e.g., occupancy limits, curbside pickup, etc.). It is recommended that experienced HVAC professionals be consulted to ensure that HVAC systems supplying the setting are functioning optimally.

For schools that are open during the pandemic with on-site instruction, it is recommended that activities be conducted outside whenever possible, class sizes be minimized to reduce crowding, and physical distancing maintained where feasible. Guidance is available for Planning for the 2021-2022 school year in the context of COVID-19 vaccination, as well as a risk assessment and mitigation tool: Reducing COVID-19 risk in community settings: A tool for operators.

Opening windows and doors, even for a short duration (e.g., recess, lunch break), may be appropriate to improve fresh air and airflow; however, a proper functioning HVAC system, if available in the school, may provide better ventilation and filtration. It is recommended that schools consult with appropriate decision-makers, an experienced HVAC professional, and other personnel as appropriate (e.g., engineer, environmental public health officer, etc.) to ensure that these systems are functioning optimally and with adequate air exchanges where applicableReference 48.

Enhanced cleaning and disinfecting of community settings

In all settings, surfaces and objects that are frequently touched with hands are most likely to be contaminated. These surfaces include money/cash, doorknobs, handrails, elevator buttons, light switches, cabinet handles, faucet handles, tables, countertops, and electronics. In child and youth settings, such surfaces may also include toys and play/sports equipment.

In addition to routine cleaning and disinfecting, high-touch surfaces and shared spaces such as kitchens and bathrooms should be cleaned and disinfected more often, as well as when visibly dirty. Items that cannot be easily cleaned (e.g., newspapers, magazines, stuffed toys) should be removed.

Operators must provide education and training on the safe use of products used for cleaning and disinfecting and any personal protective equipment (PPE) that will be used during the process, and must ensure that these measures meet the requirements of the applicable federal, provincial or territorial OHS legislation.

Procedures for cleaning and disinfecting public spaces is availableReference 49. A list of Health Canada approved hard surface disinfectants is available as well.

Non-medical masks in community settings

When establishing policies for use of non-medical masks in workplaces and other community settings, operators should follow masking directives from PHA, as well as consider the occupational requirements of individuals and the specific configuration of the setting. They must ensure they mitigate against any possible physical injuries (e.g., interfering with the ability to see or speak clearly, or becoming accidentally lodged in equipment the wearer is operating) and psychological injuries (e.g., stigmatization or bullying if individuals are/are not wearing a mask) that might inadvertently be caused by wearing a non-medical mask. Masks may not be suitable for all types of occupations. Recommendations for use of masks in a workplace setting should be based on risk assessments of specific environments and risk of exposure, in accordance with directives of OHS authorities and/or PHA.

It is recommended that operators consult with their OHS department and local PHA before introducing mask-wearing policies to the workplace.

Risk assessment and mitigation considerations for community settings

An important consideration when assessing risk of SARS-CoV-2 transmission is the level of local community virus activity, including SARS-CoV-2 VOC, as this influences the likelihood of COVID-19 introduction into a setting. If there are known COVID-19 cases in the community, the likelihood that it could be introduced into a setting is higher. The proportion of individuals who visit a setting from outside of the community can also influence the risk of COVID-19 introduction and spread. In accordance with public health ethics, measures put in place to mitigate risk should be proportionate with the risk in the community.

Assessing risk and identifying risk mitigation measures are integral to safe operations within community settings during the COVID-19 pandemic. Understanding the risk factors associated with COVID-19 (e.g., transmission, those who are at risk of more severe disease or outcomes) provides the foundation for conducting risk assessments and identifying mitigation strategies that can be used when determining if, and how, a community setting can operate safely during the pandemic. Table 1 provides high-level considerations, based on identified risk factors, to support conducting risk assessments in community settings, as well as potential risk mitigation considerations. Setting-specific risk assessments and mitigation strategies should take into account the unique circumstances of each setting and be considered in the context of legal responsibilities under the applicable FPT OHS legislation.

Table 1: Risk assessment and mitigation considerations by risk factor
Risk assessment considerations Risk mitigation considerations
Risk factor: Transmitted through respiratory droplets and aerosolsFootnote 1
People who have COVID-19 may be asymptomatic, pre-symptomatic, or symptoms may be mild
  • Discourage ill individuals from entering the setting
    • Have signage and/or communiques or policies regarding symptoms and potential or actual risk exposures, and stay home/no entry when ill or have had an exposure
    • Develop plans to manage illness in the setting until the ill person or person who has had a potential or actual exposure can leave
  • Implement symptom and exposure screening measures
  • Reinforce the PHA directives on mask-wearing, physical distancing, minimizing interactions, etc.

Risk of transmission varies with the type of interaction, i.e., having:

  • close interaction (e.g., close conversations, direct contact) is considered higher risk than more distant interaction
  • prolonged interaction (e.g., prolonged time in close proximity versus short time in close proximity) is considered higher risk than brief interaction
  • interacting with multiple people from outside of one's immediate household is considered higher risk than having limited interactions with fewer people
  • Promote physical distancing and reduce interactions among individuals – examples:
    • Reduce number of individuals in setting
    • Encourage work from home opportunities
    • Rearrange physical layout to promote distancing
    • Visual cues and directional markings to support recommended distancing
    • Install physical barriers between individuals (e.g., grocery store cashiers and shoppers)
  • Establish alternate practices that reduce length and number of interactions between individuals
  • Reinforce the PHA directives on non-medical mask use by individuals in shared indoor and outdoor spaces
Risk factor: Transmitted through touching an infected person or contaminated surface or objectFootnote 2
Some cultural practices involve physical contact between individuals (e.g., handshakes, hugs) and thus increase risk of transmission
  • Promote alternate (non-contact) ways of greeting or congratulating one another (e.g., waving)
High touch surfaces and objects can become contaminated with SARS-CoV-2 and increase risk of transmission
  • Remove unnecessary shared items in the setting
  • Reduce the use of shared items where possible
  • Restrict access to non-essential common areas
  • Increase the frequency of cleaning and disinfection, particularly of shared areas (e.g., washrooms, lunchrooms), high touch surfaces (e.g., faucet handles, doorknobs) and equipment (e.g., recreational equipment, electronic equipment)
Risk factor: Activity and setting characteristicsFootnote 3
Enclosed spaces are presumed to have greater risk of transmission
  • Ensure proper ventilation in indoor spaces (optimize HVAC systems, open windows/doors)
  • Recommend or require the wearing of non-medical masks
Crowded spaces are presumed to have greater risk of transmission
  • Reduce occupancy to recommended minimal levels
  • Establish policies to support interactions from the greatest distance possible
  • Recommend or require the wearing of non-medical masks
Noisy settings that require individuals to speak loudly or have close contact in order to communicate may present increased risk of transmission
  • Reduce noise level to prevent individuals from needing to speak loudly or have close interaction in order to be heard
Activities that are more likely to generate respiratory droplets and aerosols are presumed to increase risk of transmission in indoor settings or outdoors when physical distancing cannot be maintained
  • Prohibit activities indoors that are more likely to generate respiratory droplets and aerosols (e.g., singing, shouting, cheering) unless measures are in place to reduce transmission, e.g., establishing policies to support interactions from the greatest distance possible, optimizing indoor air quality in shared spaces through proper ventilation, reducing occupancy
  • Reinforce the PHA directives on the use of non-medical masks
Risk of transmission may be greater if individuals travel from an area of higher virus transmission to an area of lower transmission
  • Have signage to remind individuals from outside of the community or region to not access the setting
Risk factor: Personal preventive practices not consistently followedFootnote 4
Inconsistent implementation or non-adherence to personal preventive practices increases the risk of transmission
  • Promote and facilitate personal preventive practices among individuals in the setting
    • Provide signs and communiques that remind people to follow personal preventive practices (e.g., stay home when ill, minimize non-essential in-person interactions, maintain the greatest physical distance possible from others, wear a non-medical mask as recommended, hand hygiene, etc.)
    • Provide adequate access to hand hygiene stations/supplies
Risk factor: More severe disease or outcomes in certain populationsFootnote 5
Some individuals are at higher risk for more severe disease or outcomes from COVID-19 should they become infected
  • Provide accommodations to help reduce risk of illness in these individuals (e.g., dedicated shopping hours, delivery services, work or study from home options, etc.)

Footnotes

Footnote 1

COVID-19 spreads from a person who has contracted COVID-19 to others through respiratory droplets and aerosols created when a person who has contracted COVID-19 talks, sings, shouts, coughs or sneezes.

Return to footnote 1 referrer

Footnote 2

Transmitted through touching another person (e.g., a handshake) or a surface or object that is contaminated with SARS-CoV-2, then touching one's mouth, nose, or eyes.

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Footnote 3

Environmental factors, setting characteristics, and specific activities can contribute to the risk of viral transmission.

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Footnote 4

COVID-19 can be transmitted when personal preventive practices are not consistently followed.

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Footnote 5

COVID-19 can cause more severe disease or outcomes in certain populations.

Return to footnote 5 referrer

Setting specific considerations

To support prevention and mitigation of COVID-19 in the community further, a risk assessment and mitigation tool has been developed for operators of a wide range of non-health care community settings. Reducing COVID-19 risk in community settings: A tool for operators is a resource intended to be used alongside and in support of occupational health and safety requirements as well as guidance, legislation, and regulations from PHAs, relevant PT governments and Indigenous leadership. The tool is intended to assist operators in considering risks during the COVID-19 pandemic and to provide examples of strategies that may be implemented to mitigate potential risks.

Other web published public health advice that may serve as useful references for PHA include the following:

Other setting specific considerations can be found in the following:

Appendix A: Communications and public education

Communication of information and advice in a public health emergency is a critical public health intervention that helps to protect public health, to save lives, and to minimize the overall social and economic impacts. It is recommended that FPT PHA use a risk communications approach to provide health care providers, members of the public, and key stakeholders with the timely, trusted, accessible, evidence-informed and complete information they require to protect themselves, their families, their communities, and businesses.

Maintaining public trust is vital so that members of the general public will continue to support and follow public health advice. The guiding principles for maintaining trust include a commitment to use the least restrictive means to achieve the desired result, along with empathy and caring, competence and expertise, honesty and transparency, and commitment and dedication. Trust will be facilitated by continuing to:

Maintaining good relationships with stakeholders and media is vital for:

Messages should include ways to reduce risk as well as rationales for decision-making to encourage trust and adherence to advice. Additional considerations include the need for:

Address stigma at every opportunity. Stigma can undermine social cohesion and prompt possible social isolation of groups, which might contribute to a situation where the virus is more, not less, likely to spread. Guidance on how to address social stigma, including communication tips and messages, is availableReference 50 Reference 51.

Rumours and misinformation can circulate rapidly and widely via social media. It is important that these rumours be quickly identified and countered by PHA.

Community engagement with community leaders and stakeholders is important for:

Messaging that should be avoided by governments, First Nations, Inuit and Métis leadership, and organizations when addressing the public includes:

Appendix B: First Nations, Inuit and Métis communities and remote and isolated communities

This guidance is intended to support First Nations, Inuit and Métis leadership, local public health departments, regional health authorities and FPT governments as they implement PHM for the COVID-19 response in First Nations, Inuit and Métis communities and remote and isolated communities. The considerations included in this appendix are based on principles outlined in the Canadian pandemic influenza preparedness: Planning guidance for the health sectorReference 52. Coronavirus (COVID-19) and Indigenous communities provides information to the public about what the Government of Canada is doing to support First Nations and Inuit Communities in preparing for, monitoring, and responding to COVID-19.

A multitude of factors can influence the health status of an individual or a population. For many First Nations, Inuit and Métis communities, culture and tradition are integral components of a holistic approach to health and well-being. It is critical to recognize their unique strengths which contribute to their resiliency such as teachings from Elders, nurtured relationships of family and community, revitalization of language and culture, connections to the land, traditional healing, and cultural ceremoniesReference 53 Reference 54.

The overall health of those living in First Nations, Inuit and Métis communities and remote and isolated communities can be affected by social, environmental, and economic factors rooted in colonialism, including housing, water quality or access, food security, pre-existing health conditions, limited access to health care, education, and income. These factors are important to consider in the context of mitigating the spread and impact of COVID-19.

Many First Nations, Inuit and Métis communities, including those that are in remote and isolated communities are at particular risk to infectious disease outbreaks due to these social, environmental, and economic factors. First Nations, Inuit and Métis communities experience more overcrowded or poor housing conditions, lack of access to clean water and sanitation, higher rates of pre-existing health conditions and co-morbidities, and limited access to health careReference 55. Being isolated may be protective against exposure to COVID-19; however, the introduction of the virus into communities can lead to outbreaks with disproportionate consequences.

PT and community-specific variations with respect to infrastructure, human resource capacity, and planning principles should be taken into account when reading this document. It is recommended that this guidance be considered in conjunction with relevant FPT guidance and planning documents, which should take into consideration existing treaties, agreements, relationships, and capacities within the First Nations, Inuit and Métis communities. Planning for adjustment of PHM in First Nations, Inuit and Métis communities and remote and isolated communities should be coordinated with First Nations, Inuit and Métis leadership, local, regional and FPT partners.

Public health measures and mitigation strategies

Many First Nations, Inuit and Métis communities and remote and isolated communities have adopted strategies to prevent introduction of COVID-19, (e.g., by restricting all non-essential travel in and out of the community), and these strategies have been maintained, adjusted, and removed as determined necessary by community leadership. Once introduced, COVID-19 can spread rapidly in these settings. It is recommended that timely case and contact investigation and management occur in collaboration with the local PHA and the community public health professionals.

As in other communities, the personal preventive practices and community-based measures are also extremely important for First Nations, Inuit and Métis communities and remote and isolated communities. However, there may be challenges in their implementation due to the additional conditions and predisposing factors for infectious disease outbreaks present in these communities, as described below. Potential strategies for implementing personal preventive practices and community-based PHM in First Nations, Inuit and Métis communities and remote and isolated communities are listed below.

Availability of non-medical supplies

Delivery and transportation of non-medical supplies (e.g., soap, food, household items) in First Nations, Inuit and Métis communities and remote and isolated communities can be challenging due to limited or disrupted transportation in and out of the community, and other factors such as inclement weather and/or illness precluding individuals from being able to access supplies. Government and public health authorities are working with First Nations, Inuit and Métis leadership to mitigate shortages and increase availability of non-medical supplies wherever possible.

Strategies to consider:

Crowded or poor housing conditions

First Nations, Inuit and Métis communities and remote and isolated communities typically experience higher rates of overcrowding and housing standards that are often below adequacy and suitability standards. This is of concern because overcrowding and inadequate housing conditions contribute to increased likelihood of transmission of communicable diseases. They also pose challenges for people who need to be isolated or quarantined.

Strategies to consider:

Essential travel

Even with restricted travel, some essential activities require travel in and out of the community, such as medical appointments, food and supply delivery, and rotations in and out of health care personnel and other essential service workers.

Strategies to consider:

Limited access to running water

Some First Nations, Inuit and Métis communities and remote and isolated communities have limited access to running water or clean running water for hand hygiene.

Strategies to consider:

Transmission of virus in public gatherings

The potential for spread of infection during public gatherings may put additional strain on already limited health care resources in First Nations, Inuit and Métis communities and remote and isolated communities.

Strategies to consider:

Need for tailored messaging

First Nations, Inuit and Métis communities and remote and isolated communities may not be exposed to public health awareness campaigns to the same degree as urban communities with unlimited access to internet and public information campaigns. The messaging that First Nations, Inuit and Métis communities and remote and isolated communities receive is often not suited or tailored to their circumstances (e.g., limited access to water, health care, and supplies) and considerations to culture, health literacy, disabilities, and language can present barriers to adoption of public health advice.

Strategies to consider:

Additional guidance for Indigenous communities can be found here.

Additional resources

National Collaborating Centre for Indigenous Health. Core principles for good health living messages in First Nations, Inuit and Métis remote and isolated northern communities. 2020. Available from: https://www.nccih.ca/634/Core_Principles_for_Good_Healthy_Living_Messages_in_First_Nations,_Inuit_and_M%C3%A9tis_Remote_and_Isolated_Northern_Communities.nccih?id=7 [accessed February 4, 2020]

Public Health Agency of Canada. Help reduce the spread of COVID-19: Information for Indigenous communities. 2020-04-21. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/indigenous-peoples-help-reduce-spread-covid-19.html

Appendix C: Congregate living settings, including settings with vulnerable populations

A congregate living setting is a location where a number of unrelated people reside in close proximity for either a limited or an extended period of time. In most cases, residents share common rooms such as a dining room, kitchen, or washroom, and they may or may not have private sleeping quarters.

Community-based congregate living settings can include, but are not limited to, shelters for persons experiencing homelessness, student dormitories, overnight camps for children and teens, agricultural worker dormitories, industrial camps, construction trailers, group homes for persons with disabilities, and independent seniors' residences. Separate guidance has been developed for congregate living settings where health care services are delivered. This includes long-term care homes for individuals who require continuous supervised care, including professional health services, personal care, and other services such as meals, laundry, and housekeeping. Separate guidance has also been developed for persons with disabilities, as well as an OHS tip sheet for correctional facilities.

It is recommended that congregate living setting operators take steps to identify possible COVID-19 exposure risks in their setting and consider the feasibility of steps to mitigate these risks when operating during the COVID-19 pandemic. This risk assessment involves evaluating the setting for areas where people have frequent contact with each other and share spaces, surfaces, and objects. Additional measures are needed when physical distancing cannot be consistently maintained in the setting.

In interpreting and applying risk assessment and mitigation considerations, it is important to recognize that the health, age, ability status, or other socio-economic and demographic circumstances faced by some individuals and groups may limit their ability to follow the recommended measures. This may necessitate tailored responses and recommendations in some situations, while still aiming to reduce transmission of SARS-CoV-2.

COVID-19 risks in congregate living settings

The risk of acquiring and/or transmitting COVID-19 infection may be elevated in congregate living settings for a number of reasons, such as:

Risk mitigation considerations for congregate living settings

Mitigation strategies are essential to prevent the introduction of COVID-19 into these settings, and to reduce the chance of further transmission, which could lead to outbreaks. The operators of congregate living spaces should be encouraged to maximize risk mitigation potential. A "layered" approach should be used by applying multiple measures together aimed at reducing the risk of COVID-19 spread. It is recommended that PHM guidance also be considered within the context of applicable FPT directives and OHS legislation.

To prevent the entry of COVID-19 into congregate living settings, it is recommended that all individuals entering the setting, including residents, staff, volunteers, etc., be screened for symptoms of COVID-19 and risk exposures prior to entry into the setting. Consideration may also be given to the use of COVID-19 testing in congregate living settings to screen for asymptomatic cases.

For workplaces with congregate living settings such as farms, mining and industrial camps, it is recommended that employers implement temporary measures for all new worker's entering the setting for 14 days to minimize the frequency and intensity of their exposure to other workers and staff (e.g., single quarters or reduced number of roommates, private washroom, physical distancing during meals). In addition, it is recommended that employers consider limiting the movement of workers and other staff from one congregate living work setting to another.

In addition to personal preventive practices and mitigation strategies that are described above, some potential strategies that could be applicable to congregate living settings are suggested below; however, measures must be tailored to each setting.

All travellers entering Canada must follow the rules set out by the emergency orders under the Quarantine Act. This includes mandatory quarantine requirements following their arrival to Canada. The quarantine of travellers entering Canada reduces the likelihood of introduction of COVID-19 from areas outside of Canada. Temporary foreign workers, who are often housed in congregate living settings, are included among those who are required to complete a mandatory quarantine.

Mitigation strategies for preventing illness in congregate living settings can also be found in the following guidance documents:

Additional resources

Alberta Health Services. Guidelines for COVID-19 Outbreak Prevention, Control and Management in Congregate Living Sites. March 2020. Available from: https://alignab.ca/wp-content/uploads/2020/03/if-ppih-outbreak-management-congregate-guidelines.pdf [accessed January 19, 2021]

Ontario Ministry of Health. COVID-19 Guidance: Congregate Living for Vulnerable Populations. May 28, 2020. Available at: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_congregate_living_guidance.pdf [accessed January 19, 2021] Ontario Ministry of Health. COVID-19 Guidance: On-farm outbreak management. Version 1. September 21, 2020. Available at: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/COVID-19_Farm_Outbreak_guidance.pdf [accessed February 2, 2020]

Canadian Centre for Occupational Health and Safety. Work Camps. June 1, 2020. Available from: https://www.ccohs.ca//images/products/pandemiccovid19/pdf/work_camps.pdf [accessed January 19, 2021]

BCCDC. BC Ministry of Health. Protecting Industrial Camp Workers, Contractors, and Employers Working in the Agricultural, Forestry, and Natural Resource Sectors During the COVID-19 Pandemic. July 28, 2020. Available from http://www.bccdc.ca/Health-Info-Site/Documents/COVID_public_guidance/All-sector-work-camps-guidance.pdf [accessed January 19, 2021]

Government of Alberta. Guidance for managers and operators of Industrial work camps. June 5, 2020. Available from: https://www.alberta.ca/assets/documents/covid-19-work-camps-fact-sheet.pdf [accessed January 19, 2021]

Government of Canada. Workplace guidance for sector employers and employees. October 16, 2020. Available from: https://www.agr.gc.ca/eng/covid-19-information-for-the-agriculture-and-agri-food-industry/workplace-guidance/?id=1588862952557 [accessed January 21, 2020]

Appendix D: Transportation

Public transportation (e.g., taxis, rideshares, buses, subways, rail, and ferries) is an essential service that helps to keep communities functioning. There are COVID-19 related transmission risks associated with public transportation for passengers and workers due to the nature of the setting where there is crowding and time spent in an enclosed space with individuals from outside one's immediate householdReference 56.

Limiting the availability of public transit disproportionately affects segments of the population that rely on it to get to school or work, or to access essential goods or services. Some persons with disabilities rely on specialized services such as modified buses to serve their needs, whereas others use public transportation but may need help getting in and out of the vehicle.

Certain populations are more likely to rely on public transportation and therefore may have increased risk of exposure, including young people and those with lower incomes. These factors make it extremely important to adopt measures in these contexts to mitigate these risks and maintain public transit services.

Transportation of groups of workers to remote work camps or agricultural settings also carry risks to passengers and drivers, and should consider using mitigation strategies that are similar to the examples described below for public transportation.

Potential mitigation considerations for transportation

Mitigation strategies are essential to prevent the introduction of COVID-19 into these settings, and to reduce the chance of further transmission, which could lead to outbreaks. The operators of these settings should be encouraged to maximize risk mitigation potential. A "layered" approach should be used by applying multiple measures together aimed at reducing the risk of COVID-19 spread. It is recommended that PHM guidance also be considered within the context of applicable FPT directives and OHS legislation.

In addition to personal preventive practices and mitigation strategies that are described above, some examples of strategies that could be applicable to public transportation are suggested below; however, measures must be tailored to each setting.

Additional resources

Acronyms

ASTM
American Society for Testing and Materials
CBM
community-based measures
FPT
federal, provincial and territorial
OHS
occupational health and safety
PHA
public health authority(ies)
PHAC
Public Health Agency of Canada
PHM
public health measures
PPE
personal protective equipment
PT
provinces and territories
VOC
variants of concern

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: Jennifer Lowe, Sharon E. Smith, Lynn Cochrane and Lisa Paddle.

Previous iterations prepared by: Lisa Paddle, Fanie Lalonde, Corey Green, Katie Rutledge-Taylor, Sharon E. Smith, Christina Jensen, Lynn Cochrane, Alexandra Nunn, Jill Williams, Daniel Myran and Susan Tamblyn.

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, Pamela Wolfe-Roberge (ISC), Todd Hatchette, Erin Henry, Nadine Sicard, Michelle Murti, Eleni Galanis and Rob Stirling

Footnotes

Footnote a

The goal of minimizing deaths due to all causes includes deaths from/with COVID-19, and deaths otherwise related to the COVID-19 pandemic (e.g., due to decreased availability of emergency/acute care services or operating rooms for treatment of non-COVID illnesses/conditions, or delays in routine monitoring of chronic conditions).

Return to footnote a referrer

Footnote b

Immediate household is defined as anyone who currently lives and shares common spaces in a housing unit (e.g., house, apartment). This can include family members, as well as roommates or people who are unrelated.

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Footnote c

For operational purposes, an appropriate physical distance is at least 2 metres. In general, if in-person interactions must take place, individuals should be encouraged to interact with those outside of their immediate household from the greatest distance possible, and with other personal preventive practices in place for a "layered" approach.

Return to footnote c referrer

References

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Timiskaming Health Unit, "Mitigating unintended harms of covid-19 public health measures among low income populations rapid review," 12 June 2020. [Online]. Available: https://www.timiskaminghu.com/websites/timiskaminghu.com/files/COVID-19/Mitigating%20Unintended%20Harms%20Rapid%20Review-Final.pdf. [Accessed March 4 2021].

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Statistics Canada., "Study: Impact of economic consequences of covid-19 on Canadian's social concerns," [Online]. Available: https://www150.statcan.gc.ca/n1/daily-quotidien/200528/dq200528e-eng.htm]. [Accessed March 4 2021].

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Alberta Health Services, "COVID-19 Scientific Advisory Group Rapid Evidence Report: Attitudes and Adherence to COVID-19 Guidelines," September 2020. [Online]. Available: https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-sag-rapid-evidence-report-attitudes-and-adherence-to-covid-19-guidelines.pdf. [Accessed March 4 2021].

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Charoenwong, B., Kwan, A. & Pursiainen, V., "Social connections with COVID-19–affected areas increase compliance with mobility restrictions," Science Advances, vol. 6, no. 47, 18 Nov 2020.

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Abacus data, "COVID-19 and Canadians' State of Mind: Worried, lonely, and expecting disruption for at least 2 to 3 months," 25 March 2020. [Online]. Available: https://abacusdata.ca/?s=Covid-19+and+canadians%27+state+of+mind. [Accessed March 4 2021].

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Reference 11

Alon, T., Doepke, M., Olmstead-Rumsey, J. et al., "The Impact of COVID-19 on Gender Equality," National Bureau of Economic Research, April 2020.

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Reference 12

Statistics Canada, "Gender differences in mental health during the COVID-19 pandemic," 9 July 2020. [Online]. Available: https://www150.statcan.gc.ca/n1/pub/45-28-0001/2020001/article/00047-eng.htm. [Accessed March 4 2021].

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Public Health Agency of Canada (PHAC), "COVID-19: Guidance on indoor ventilation during the pandemic," 2020. [Online]. Available: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/guidance-documents/guide-indoor-ventilation-covid-19-pandemic.html. [Accessed March 4 2021].

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Reference 14

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Reference 15

Yong, S.E.F., Angerson, D.E., Wei, W.E. et al., "Connecting clusters of COVID-19: an epidemiological and serological investigation," The Lancet Infectious Diseases, vol. 20, no. 7, pp. 809-815, 21 April 2020.

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Reference 16

Dyal, J.W., Grant, M.P., Broadwater, K. et al., "COVID-19 Among Workers in Meat and Poultry Processing Facilities ― 19 States, April 2020," MMWR Morb Mortal Wkly Rep, vol. 69, no. 18, pp. 557-561, 2020.

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Leclerc, Q.J., Fuller, N.M., Knight, L.E. et al., "What settings have been linked to SARS-CoV-2 transmission clusters?," Wellcome Open Research, vol. 5, no. 83, 2020.

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Hamer, L., Dubbel, P., Capron, I. et al., "High SARS-CoV-2 Attack Rate Following Exposure at a Choir Practice — Skagit County, Washington, March 2020," MMWR Morb Mortal Wkly Rep, vol. 69, pp. 606-610, March 2020.

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Reference 19

Tuite, A.R., Fisman, D.N. & Greer A.L., "Mathematical modelling of COVID-19 transmission and mitigation strategies in the population of Ontario, Canada," Canadian Medical Association Journal (CMAJ), vol. 192, no. 19, pp. E497-E505, 11 May 2020.

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Gumel, A.B., Iboi, E.A., Ngonghala, C.N. et al., "Mathematical assessment of the roles of vaccination and non-pharmaceutical interventions on COVID-19 dynamics: a multigroup modeling approach," medRxiv: The Preprint Server for Health Sciences, 2020.

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Reference 21

Viches, T.N., Zhang, K., Van Exan, R. et al., "Projecting the impact of a two-dose COVID-19 vaccination campaign in Ontario, Canada," medRxiv: The Preprint Server for Health Sciences, 2020.

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Reference 22

Public Health Agency of Canada, "Update on COVID-19 in Canada: Epidemiology and modelling," 19 02 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-20210219-en.pdf. [Accessed March 4 2021].

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Reference 23

Public Health Agency of Canada (PHAC), "Updated: Public health management of cases and contacts associated with COVID-19," 2020. [Online]. Available: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-cases-contacts.html. [Accessed March 4 2021].

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Reference 24

Chu, D.K., Akl, E.A., Duda, S. et al., "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," The Lancet, vol. 395, no. 10242, pp. 1973-1987, 2020.

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Reference 25

Jones, N.R., Qureshi, Z.U., Temple, R.J. et al., "Two metres or one: what is the evidence for physical distancing in covid-19?," BMJ, vol. 370, no. m3223, 2020.

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Reference 26

Zhang, S. & Duchaine, C., "SARS-CoV-2 and Health Care Worker Protection in Low-Risk Settings: a Review of Modes of Transmission and a Novel Airborne Model Involving Inhalable Particles," Clinical Microbiology Reviews, vol. 34, no. 1, pp. e00184-20, 2020.

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Reference 27

National Collaborating Centre for Methods and Tools, "Rapid Review: What is known about the risk of COVID-19 transmission across different indoor settings in the community such as restaurants and gyms?," 4 November 2020. [Online]. Available: https://www.nccmt.ca/covid-19/covid-19-rapid-evidence-service/30. [Accessed 04 03 2021].

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Reference 28

Karaivanov A., Lu S.E., Shigeoka H. et al., "Face Masks, Public Policies and Slowing the Spread of COVID-19: Evidence from Canada," medRxiv: The Preprint Server for Health Sciences, 2020.

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Reference 29

Kwon, S., Joshi, A.D., Lo, C. et al., "Association of social distancing and masking with risk of COVID-19," medRxiv: The Preprint Server for Health Sciences, 2020.

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Reference 30

Scott, N. Saul, A. et al., "The Introduction of a Mandatory Mask Policy Was Associated with Significantly Reduced COVID-19 Cases in a Major Metropolitan City," The Lancet (preprint), 2020.

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Reference 31

Howard, J., Huang, A., Li, Z. et al., "An evidence review of face masks against COVID-19," Proceedings of the National Academy of Sciences of the United States of America (PNAS), vol. 118, no. 4, p. e2014564118, January 2021.

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Reference 32

Pan, J., Hard, C., Leng, W. et al., "Inward and outward effectiveness of cloth masks, a surgical mask, and a face shield," medRxiv: The Preprint Server for Health Sciences, 20 November 2020.

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Reference 33

Mueller, A.V., Eden, M.J., Oakes, J.M. et al., "Quantitative method for comparative assessment of particle removal effieciency of fabric masks as alternatives to standard surgical masks for PPE," Cell Press, vol. 3, no. 3, pp. 950-962, 2 September 2020.

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Reference 34

Centers for Disease Control and Prevention, "Scientific brief: Community use of cloth masks to control the spread of SARS-CoV-2," 20 November 2020. [Online]. Available: https://www.cdc.gov/coronavirus/2019-ncov/more/masking-science-sars-cov2.html. [Accessed March 4 2021].

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Reference 35

Clapp, P.W., Sickbert-Bennett, E.E., Samet, J.M. et al. , "Evaluation of cloth masks and modified procedure masks as personal protective equipment for the public during the COVID-19 pandemic," JAMA Internal Medicine [PREPRINT}, 10 December 2020.

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Reference 36

Emerging Sciences Group Public Health Agency of Canada, "Emerging evidence on COVID-19: Rapid review on the characteristics of effective non-medical face masks in reducing the risk of SARS-CoV-2 transmission," 2021. [Online]. Available: phac.evidence-donnees.probantes.aspc@canada.ca.

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Reference 37

World Health Organization, "Mask use in the context of COVID-19: Interim guidance," 1 December 2020. [Online]. Available: https://apps.who.int/iris/handle/10665/337199. [Accessed February 26 2021].

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Reference 38

Haug, N., Geyrhofer, L., Londei, A. et al., "Ranking the effectiveness of worldwide COVID-19 government interventions," Nature Human Behaviour, vol. 4, pp. 1303-1312, 2020.

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Reference 39

European Centre for Disease Prevention and Control, "Using face masks in the community: First update," European Centre for Disease Prevention and Control, Stockholm, 2021.

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Reference 40

Zivich P.N., Gancz A.S., Aiello A.E., "Effect of hand hygiene on infectious diseases in the office workplace: A systematic review," Am J Infect Control, vol. 46, no. 4, pp. 448-455, 2018.

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Reference 41

National Collaborating Centre for Environmental Health, "Reducing COVID-19 Transmission Through Cleaning and Disinfecting Household Surfaces," 2020. [Online]. Available: https://ncceh.ca/documents/guide/reducing-covid-19-transmission-through-cleaning-and-disinfecting-household-surfaces. [Accessed March 4 2021].

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Reference 42

Marquès, M. & Domingo, J.L., "Contamination of inert surfaces by SARS-CoV-2: Persistence, stability and infectivity. A review.," vol. 193, no. 110559, 2020.

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Reference 43

Gerlach, M., Wolff, S., Ludwig, S. et al., "Rapid SARS-CoV-2 inactivation by commonly available chemicals on inanimate surfaces," Journal of Hospital Infection, vol. 106, no. 3, pp. 633-634, 2020.

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Reference 44

Van Doremalen N., Bushmaker T., Morris D.H., et al., "Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1," The New England Journal of Medicine (NEJM), vol. 382, pp. 1564-1567, 2020.

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Reference 45

National Collaborating Centre for Environmental Health, "High-humidity Environments and the Risk of COVID-19 Transmission," 16 October 2020. [Online]. Available: https://ncceh.ca/documents/field-inquiry/high-humidity-environments-and-risk-covid-19-transmission. [Accessed March 4 2021].

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Reference 46

Riddell, S., Goldie, S., Hill, A. et al., "The effect of temperature on persistence of SARS-CoV-2 on common surfaces," Virology Journal, vol. 17, no. 145, 2020.

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Reference 47

Scientific Advisory Group for Emergencies, Environmental and Modelling Group, "Role of Ventilation in Controlling SARS-CoV-2 Transmission," [Online]. Available: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/928720/S0789_EMG_Role_of_Ventilation_in_Controlling_SARS-CoV-2_Transmission.pdf. [Accessed March 4 2021].

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Reference 48

The Heating, Refrigeration and Air Conditioning Institute of Canada, "Reducing the Risk of Virus Transmission via HVAC Systems in Schools," January 2021. [Online]. Available: https://www.hrai.ca/uploads/userfiles/files/2021%2001%20--%20Guidance%20for%20Schools.pdf. [Accessed March 4 2021].

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Reference 49

Public Health Agency of Canada (PHAC), "COVID-19: Cleaning and disinfecting," 2020. [Online]. Available: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/cleaning-disinfecting.html. [Accessed March 4 2021].

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Reference 50

CIFRC, Unicef, WHO, "Social Stigma associated with COVID-19," 20 February 2020. [Online]. Available: https://www.who.int/docs/default-source/coronaviruse/covid19-stigma-guide.pdf. [Accessed March 4 2021].

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Reference 51

Centers for Disease Control and Prevention (CDC), "Reducing Stigma," 2020. [Online]. Available: https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/reducing-stigma.html. [Accessed March 4 2021].

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Reference 52

Pan-Canadian Public Health Network Council, "Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector," August 2018. [Online]. Available: https://www.canada.ca/en/public-health/services/flu-influenza/canadian-pandemic-influenza-preparedness-planning-guidance-health-sector.html. [Accessed March 4 2021].

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Reference 53

National Collaborating Centre for Aboriginal Health, "Culture and language as a social determinants of First Nations, Inuit and Métis health," June 2016. [Online]. Available: https://www.nccih.ca/495/Culture_and_language_as_social_determinants_of_First_Nations,_Inuit,_and_M%C3%A9tis_health.nccih?id=15. [Accessed March 4 2021].

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Reference 54

National Collaborating Centre for Aboriginal Health, "Family is the focus," 2015. [Online]. Available: https://www.nccih.ca/docs/health/RPT-FamilyFocus-EN.pdf. [Accessed March 4 2021].

Return to footnote 54 referrer

Reference 55

National Collaborating Centre for Aboriginal Health, "Determinants of the prevalence and severity of influenza infection in Indigenous populations in Canada," 2016. [Online]. Available: http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/175/NCCAH-FS-InfluenzaDeterminants-Part02-Halseth-EN-Web.pdf. [Accessed March 4 2021].

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Reference 56

European Centre for Disease Prevention and Control, "Considerations for infection prevention and control measures on public transport in the context of COVID-19," 29 April 2020. [Online]. Available: https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-public-transport-29-April-2020.pdf. [Accessed March 4 2021].

Return to footnote 56 referrer

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