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

Last updated: August 11, 2021

On this page

• Preamble
• Introduction
  • Transmission of SARS-CoV-2
  • Adjusting public health measures over time
• Personal preventive practices
• Community-based measures
  • Overview
  • Core public health measures for all community settings
  • Risk assessment and mitigation considerations for community settings
  • Setting specific considerations
• Appendix A: Communications and public education
• Appendix B: First Nations, Inuit and Métis communities and remote and isolated communities
• Appendix C: Congregate living settings, including settings with vulnerable populations
• Appendix D: Transportation
• Acronyms
• Acknowledgments
• Footnotes
• References

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 deaths^{Footnote 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 risk^{Reference 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 factors^{Reference 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 PHM^{Reference 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 individuals^{Reference 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 groups^{Reference 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 currents^{Reference 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 contact^{Reference 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 hands^{Reference 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 etiquette^{Reference 14}. There is no evidence to date to suggest differences in mode of transmission of circulating VOC.

Environmental factors^{Reference 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 plants^{Reference 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 household^{Footnote 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 vaccine^{Reference 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 cases^{Reference 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-19^{Reference 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 VOC^{Reference 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 distance^{Reference 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:

• Minimizing non-essential in-person interactions with people from outside of one's immediate household. If individuals must interact with people who are not part of their immediate household, the interactions should be:
  • as few and as brief as possible
  • from the greatest physical distance possible^{Footnote c}
• Avoiding common greetings, such as handshakes, hugging, and kissing
• Avoiding crowded settings, and adhering to PHA restrictions on the number of people that can gather in one place (indoors or outdoors)

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 gaps^{Reference 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 brace^{Reference 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 breathability^{Reference 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 potential^{Reference 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 wearer^{Reference 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:

• AFNOR Spec – Barrier masks V1.0 by the French Standardization Association
• Community face coverings – Guide to minimum requirements, methods of testing and use (CWA 17553:2020) by the European Committee for Standardization
• ASTM standard specifications for "Barrier Face Coverings" (i.e., non-medical masks) under the designation ASTM F3502, to address products that are neither a medical mask (per ASTM specification F2100), nor a respirator for providing inhalation protection. The specifications are intended to establish a national standard specifying minimum design, performance (i.e., filtration efficiency and air flow (breathing) resistance), and testing requirements.

Information on regulatory considerations for non-medical masks is available. Information about the types of masks and respirators available for use in the community is also 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 construction of masks, 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 employees^{Reference 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 cotton^{Reference 43},^{Reference 44}. Additionally, increases in temperature and humidity reduce SARS-CoV-2's ability to survive on surfaces^{Reference 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-19^{Reference 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 indoors^{Reference 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

• Staying informed, being prepared, and following public health advice on:
  • gathering size limits for both indoor and outdoor settings
  • non-essential trips out of one's home or community
• Avoiding closed spaces (with poor ventilation) and crowded spaces when with people from outside of one's immediate household
• Staying home and away from others as much as possible if:
  • at risk of more severe disease or outcomes from COVID-19
  • when required to do so according to the PHA
• Avoiding all non-essential travel outside of Canada

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:

• Local context: this refers to the likelihood of individuals entering the setting who are infected with the virus based on current transmission patterns in the community.
• Characteristics of individuals in the setting: this refers to the vulnerability of people in a setting to experience more severe COVID-19 disease or outcomes; whether individuals are essential workers, who if isolated or quarantined might impact the essential service they are providing; and, whether individuals in the setting have travelled from communities that have higher transmission.
• Setting characteristics: this includes the intensity of interaction between individuals, including the type of interaction (distant or close), duration of interaction (brief or prolonged), and number of interactions (few or many). The frequency of interactions with potentially infectious high-touch surfaces and objects, and the environmental characteristics of the setting (e.g., ability to ventilate an indoor setting) are also important considerations.

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 settings^{Reference 14 Reference 25 Reference 26 Reference 27}. Close interactions have a greater risk of transmission than interactions at a distance^{Reference 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:

• Supporting directives of PHA on the use of masks and other PHM;
• Providing accessible communication to increase awareness about COVID-19;
• Promoting hand hygiene and respiratory etiquette by having accessible signage, providing access to hand washing facilities, and placing hand sanitizing dispensers, tissues, and plastic lined waste containers in prominent locations throughout the workplace or public setting;
• Having policies that:
  • require individuals to stay home if they have symptoms related to COVID-19 (even if mild), have tested positive for COVID-19, are awaiting test results, or have been exposed to COVID-19, and preventing their entry into the workplace
  • enable ill workers to stay home
  • support the rapid isolation and management of individuals who develop symptoms while in the setting
  • promote reducing the risk of infection for persons at risk of more severe disease or outcomes from COVID-19, whether they be employees, customers, or participants in public activities. Examples include maintaining telework arrangements, arranging pre-opening shopping hours and expedited curbside pickup or home delivery.

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:

• where physical distancing will not be feasible between the provider and client (e.g., hair salon, massage therapy)
• where there have been cases of COVID-19 reported in the setting
• in congregate living settings
• before or on arrival at school or child care settings
• before transportation to, upon arrival at, and before departure from remote work sites or camps.

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 applicable^{Reference 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 available^{Reference 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. Return to footnote 2 referrer Footnote 3 Environmental factors, setting characteristics, and specific activities can contribute to the risk of viral transmission. Return to footnote 3 referrer Footnote 4 COVID-19 can be transmitted when personal preventive practices are not consistently followed. Return to footnote 4 referrer 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:

• Guidance for providers of services for people experiencing homelessness (in the context of COVID-19)
• Planning for the 2021-2022 school year in the context of COVID-19 vaccination

Other setting specific considerations can be found in the following:

• Appendix B: First Nations, Inuit and Métis communities and remote and isolated communities
• Appendix C: Congregate living settings, including settings with vulnerable populations
• Appendix D: Transportation

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:

• Provide clear and consistent information about COVID-19 and its prevention through trusted and authoritative sources;
• Communicate with transparency and emphasize that decisions will be made with the best scientific evidence available at the time;
• Convey the basis for and value of PHM, and the need to continue these measures over the course of the pandemic;
• Communicate the rationale and considerations for adjusting PHM as required to ensure safe operations of businesses and community-based settings; and
• Adapt communication and messaging to promote equitable responses to the diverse needs of people of all gender identities and ages, with careful consideration on cultural, socioeconomic, contextual, ability status, and all other relevant identity factors.

Maintaining good relationships with stakeholders and media is vital for:

• Facilitating consistent communication of key messages, including with PT governments where possible;
• Building scientific and public consensus about behaviours to adopt (e.g., physical distancing);
• Helping to provide clear and consistent messages, and address misinformation before it spreads.

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:

• Developing communications tools/products to inform people and reinforce PHM (e.g., staying home when sick, physical distancing, mask-wearing, hand hygiene, respiratory etiquette) and how to care for the ill. Information products and tools should use plain language and be tailored to the specific needs and capacities of target audiences so that materials are culturally and contextually relevant, and are easily understood;
• Developing tailored approaches for specific audiences (e.g., those at higher-risk, First Nations, Inuit and Métis communities and remote and isolated communities, persons who are racialized, people experiencing homelessness, new immigrants, people who do not speak English or French, persons with disabilities, youth), keeping in mind those who may not be able to use or access standard resources;
• Having messages translated into official languages, languages of Indigenous communities, and other languages as appropriate;
• Adopting a variety of methods to deliver messaging (e.g., social media, radio, website) to ensure communication reaches many segments of society
• Using narrative information to explain statistical information as it is retained far better. Bringing facts and statistics to life by leveraging real stories may be a more effective way to convey the risks of disease, the importance of following public health advice, and benefits of vaccination; and
• Leading by example by modelling desirable behaviours (e.g., physical distancing) to make it the social norm.

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 available^{Reference 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:

• Sharing information and obtaining feedback on the relevance and value of communications products and tools;
• Engaging trusted leaders and non-public health groups (e.g., Elders, spiritual leaders, educators, and community leaders/organizations) in disseminating accurate and culturally sensitive messages; and
• Identifying practical and acceptable mitigation measures, identifying and addressing concerns, and identifying for which populations and how messages need to be adapted to enhance health equity.

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

• Overstatements - Exaggerations or misleading statements, even if well intentioned, undermine trust in the individual or institution making the statement;
• Appeals to authority - Some people tend to have low trust in institutions and authority figures. Every effort should be made to explain how we know that a PHM, vaccine, or treatment is safe and effective, or why and how a position has evolved;
• Appeals to fear - People sharing their stories of experiences with others (peer-to-peer) can be effective in positioning the disease as a risk. However, when governments, First Nations, Inuit and Métis leaders, or influential individuals or institutions use flagrant appeals to fear, these appeals often backfire and tend to be read as coercive and manipulative;
• Stating the myth and fact - Even when stating a myth to dispel it, stating the myth and a fact together reinforces the myth. It is generally more effective to consistently emphasize and lead with the facts;
• Fighting narrative with facts - It is ineffective to provide statistical information to counter a narrative. Descriptive storytelling and visual means can make health information more understandable and compelling.

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 sector^{Reference 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 ceremonies^{Reference 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 care^{Reference 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:

• Encouraging and increasing awareness of individuals, families and communities (where feasible considering economic resources and storage space) to have a backup of supplies to maintain their needs (e.g., soap, household cleaning and disinfecting products, non-perishable food and fluids, tissues);
• Contacting local stores and service centres to establish protocols and timelines to ensure maintenance of supply chains;
• Providing PT collaboration and support in transportation and delivery of supplies directly to communities where possible, or to local hubs;
• Ensuring access to traditional food harvesting areas and support for traditional food systems; and
• Establishing safe food sharing programs.

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:

• Identifying culturally appropriate strategies to house people who need to isolate or quarantine if their housing does not allow adequate physical separation (e.g., use of temporarily repurposed sites such as hotels, schools, recreation centres);
• Using advice, as appropriate, from How to care for someone with COVID-19 at home, which includes considerations that may be applicable for remote and isolated communities^{Reference 23};
• Increasing ventilation in homes where possible, by opening windows and doors and ensuring mechanical ventilation systems are operating properly; and
• Encouraging access to on-the-land activities and living as a physical distancing measure.

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:

• Considering the level of risk related to where essential workers/community members are traveling from and their behaviours/activities while outside of the community when developing options for screening and potential quarantine on arrival.

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:

• Increasing the awareness of individuals and families in First Nations, Inuit and Métis communities and remote and isolated communities of alternative means for effective hand hygiene if they lack clean running water;
• If the community is on a boil water advisory or do not consume advisory, continuing to use the water for handwashing and personal hygiene. Infants and toddlers should be sponge bathed to avoid accidentally swallowing the water;
• If the community is on a do not use advisory, meaning that the water is not safe for any use, using bottled water and soap for handwashing;
• If there is no access to running water, having individuals wash their hands in a large bowl and then throwing out the water from the handwashing bowl after each individual use;
• Using alcohol-based hand sanitizer containing at least 60% alcohol for hand hygiene if soap and water are not available. If hands are visibly soiled, hand wipes should be used first to remove any soil or organic material, followed by the use of hand sanitizer;
• Establishing a reliable supply of hand hygiene products for the community;
• Establishing additional handwashing or hand sanitizing stations within the community, e.g., at community buildings; and
• Increasing education and awareness about effective hand hygiene methods.

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:

• Considering the presence of illness in the community, as well as the capacity of health care services, availability of health care providers, access to basic medical supplies, medications, and areas to isolate suspected cases when deciding whether or not to cancel or postpone public gatherings, even if they fall within allowable numbers in size; and
• Finding ways to adjust cultural ceremonies and traditional activities so they can occur safely. This includes considering the number of participants, altering activities that are more likely to generate respiratory droplets and aerosols, such as singing and heavy breathing, ability to physical distance (e.g., wider drum circles), ability for effective hygiene practices, the likelihood of PHM being followed, and need for enforcement of the measures.

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:

• Identifying communities where tailored communication strategies are required, given the local circumstances;
• Considering use of tailored strategies such as mail outs, community radio, posters, and working with neighbouring communities to obtain necessary information. Tailoring may also include messaging from people who are familiar or trusted (e.g., Elders or First Nations, Inuit and Métis physicians); and
• Developing and communicating campaigns in collaboration with community members that are specifically tailored to the circumstances of First Nations, Inuit and Métis communities and remote and isolated communities.

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:

• Crowded accommodation and close interaction between residents;
• Lack of proper ventilation in shared indoor spaces;
• Limited access to facilities for personal hygiene in some settings;
• Communal food or buffet style cafeterias;
• Shared use of items such as utensils, toiletries, or other personal items;
• Resident movement from community to community, especially from communities where there are higher rates of COVID-19 activity;
• Periodic introduction of new individuals into the setting (e.g., through worker rotations in and out of remote work camps or people arriving at shelters);
• Shared transportation to work or recreation/learning sites;
• Lack of adequate facilities to isolate persons who become ill;
• Children or teenagers who are away from their parents/caregivers and may not be able to fully appreciate or mitigate risk; and
• Persons with disabilities who might have limited capacity to understand or follow personal preventive practices.

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.

• Have all individuals in the setting wear a non-medical mask (when awake) and when in a shared space indoors or outdoors with other occupants in the co-living setting.
• Improve indoor air quality in shared spaces through proper ventilation.
• Provide private sleeping quarters wherever possible. If this is not possible, arrange shared sleeping quarters so that beds are at the greatest distance possible (i.e., at least 2 metres apart) and head to toe. If beds cannot be placed the greatest distance possible apart, use temporary barriers between beds, such as curtains or a partition panel.
• Establish protocols to immediately isolate any persons who become ill or who are required quarantine in separate facilities.
• Reduce risks from exposure to high-touch surfaces and objects (i.e., those frequently touched by others) for example, by hiring professional cleaners to clean and disinfect areas typically maintained by occupants (e.g., bedrooms and private washrooms) or ensure that supplies are available for occupants to carry out adequate cleaning and disinfecting of their space.
• Change the way that individuals interact or behave within the setting by having policies and procedure in place to prevent or to reduce the risk of transmission and using technology to facilitate communication. It will be important to take into account the size of the space, the number of individuals (including their ages/sizes), and their needs and abilities to physical distance.
  • Provide training and education in languages that will be understood by staff, volunteers, workers, and occupants.
  • Stagger the use of shared spaces (e.g., shower facilities) and transportation to/from the congregate living setting, as appropriate (e.g., reduce number of people on a bus/van and plan more trips).
  • Stagger mealtimes or increase hours of availability when practical, and limiting the number of people using communal kitchens at one time.
  • Open additional dining areas as necessary to increase spacing between individuals, or provide take-out meals.
  • Discontinue buffet service and remove shared condiment and utensil stations.
  • Avoid in-person meetings and gatherings such as meetings and social events, and limit access to recreational facilities within the congregate living setting where physical distancing cannot be maintained.
  • Limit the need for workers in camps to mix with the surrounding community by providing services and supplies at the work camp.
• Encourage more outdoor activities.

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:

• Guidance for providers of services for people experiencing homelessness (in the context of COVID-19)
• Guidance for post-secondary institutions during the COVID-19 pandemic
• Guidance for employers of temporary foreign workers regarding COVID-19

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 household^{Reference 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.

• Require passengers to sit in the back seat of a taxi or rideshare.
• Encourage physical distancing of passengers who are not from the same household in queues, in waiting areas, on buses, subways, trains, and ferries (e.g., using every other seat or row).
• Install plexiglass shields for service staff at booths, and consider their use between the driver and passengers in taxis and buses.
• Increase ventilation in enclosed waiting areas and vehicles by using a properly operating HVAC system or by opening windows, if possible.
• Require that employees and drivers stay home when ill.
• Screen passengers for symptoms of COVID-19, as appropriate.
• Provide signage to remind passengers to adopt personal preventive practices.
• Clean and disinfect the cockpit between drivers, in addition to regular cleaning and disinfecting of vehicles and waiting areas.
• Provide sufficient vehicles to prevent crowding and considering adding extra vehicles at rush hours.
• Have riders enter a bus through the back doors to avoid proximity to the driver.
• Where private (bus) charter, with one entrance/exit, have passengers enter conveyance with the driver off the vehicle.
• Provide hands-free collection of fares and tolls if feasible.
• Require use of non-medical masks by drivers and passengers on public transportation or similar group transport.

Additional resources

• ECDC. Considerations for infection prevention and control measures on public transport in the context of COVID-19. April 29, 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-public-transport-29-April-2020.pdf [accessed January 19, 2021]
• Canadian Centre for Occupational Health and Safety. Tip sheet on Transportation. April 7, 2020. Available from: https://www.ccohs.ca//images/products/pandemiccovid19/pdf/transportation.pdf [accessed January 19, 2021]
• Canadian Centre for Occupational Health and Safety. Tip sheet on Public Transportation. June 26, 2020. Available from: https://www.ccohs.ca/images/products/pandemiccovid19/pdf/public-transportation.pdf [accessed January 25, 2020]
• CDC. What Rideshare, Taxi, Limo, and other Passenger Drivers-for-Hire Need to Know about COVID-19. January 4, 2021. Available from: https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/rideshare-drivers-for-hire.html [accessed January 19, 2021]
• Toronto Public Health. COVID-19 Guidance for Taxi and Ride Share Vehicles. January 15, 2021. Available from: https://www.toronto.ca/wp-content/uploads/2020/03/8d19-COVID-19-Guidance-for-Taxi-Ride-Share-Employers-Drivers-Vehicle-Owners.pdf [accessed January 19, 2021]

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