Community-based measures to mitigate the spread of coronavirus disease (COVID-19) in Canada

The Public Health Agency of Canada (PHAC), in collaboration with Canadian public health experts has developed this guidance for federal/provincial/territorial (F/P/T) public health authorities (PHA) on the use of public health measures (PHM) to reduce and delay transmission of COVID-19 in the community.

Canada's pandemic goals, which are first, to minimize serious illness and overall deaths, and second to minimize societal disruption among Canadians^{Footnote i}, will guide Canada's response to COVID-19. This guidance considers the Canadian context and is based on currently available scientific evidence, expert opinion and public health assumptions. This guidance incorporates relevant advice from the CPIP Public Health Measures Annex^{Footnote ii} throughout. Given the evolving nature of COVID-19 epidemiology, the intent of this guidance is to prepare PHAs in the event of community-based spread recently seen elsewhere in the world. This guidance is subject to change as information emerges on transmissibility and epidemiology, and if treatment options or new information on clinical management becomes available. It is expected that the timing and intensity of virus activity will vary across Canada and within provinces and territories, i.e., some regions may be experiencing sustained community transmission while others are only having isolated cases with limited person to person transmission. The focus of this guidance is to delay and mitigate the community transmission of COVID-19; however, the containment approaches outlined in Public Health Management of cases and contacts associated with novel coronavirus disease (COVID-19)^{Footnote iii} are applicable as Canada is still in the containment strategy given the limited number of cases in Canada. This guidance should be read in conjunction with relevant P/T and local legislation, regulations and policies. For information regarding COVID-19, visit the Canada.ca and WHO web sites.

Introduction

Public health measures (PHM) include non-pharmaceutical interventions that can be used to reduce and delay community transmission of the novel coronavirus that causes COVID-19. Implemented early, PHM seek to reduce the speed with which cases are occurring to delay and to reduce the peak of virus activity in the community (see figure 1)^{Footnote ii} and reduce the demand for health care services. Some measures are used commonly in Canada for seasonal influenza and other communicable disease outbreaks, while others will likely only be considered during a more severe pandemic. Given that there is currently no effective vaccine or specific treatment (e.g. antiviral medication) for COVID-19, public health measures will be the only tools available to mitigate the impact of the virus. A crucial aspect of PHM is effective communications by PHA to promote and support public trust. Refer to the section below on public education and communication for additional considerations.

Public health measures are usually implemented as combinations of two or more measures, which is sometimes referred to as "layered use". The theoretical rationale for layering public health measures is based on the expectation that combinations are likely to be more effective than the partial effectiveness of a single measure.

Figure 1: Goal of Public Health Measures - Text description

Figure 1 illustrates how public health measures influence the number of cases and when the peak number of cases will occur during an outbreak.

It suggests that, with no public health interventions, the number of cases will be higher, and will occur earlier. However, with public health interventions, there will be substantially fewer cases and that the peak number of cases will occur later.

Source: Adapted from: CDC, Interim pandemic guidance community strategy for pandemic influenza mitigation in the United States-early, targeted, layered use of nonpharmaceutical interventions, Atlanta, GA: US Department of Health and Human Services, CDC; 2007.

Public health measures outlined in this guidance include actions taken by individuals (healthy, those potentially exposed, and those with COVID-19) designed to protect themselves and others as well as community-based approaches whereby planners, employers, community organizers can implement strategies to protect groups and the community at large. Compliance with recommendations and sustainability of them over time may be influenced by a variety of factors, including, but not limited to cultural, financial, social, and spiritual circumstances. Some communities may require tailored approaches based on geography, culture and living circumstances. Additional measures for those living in Remote and Isolated Communities is provided in Appendix 1, as their unique circumstances may require additional considerations.

Guidance for individuals who are self-isolating or caring for someone in the home or co-living setting (including university dormitories, shelters, communal living facilities) has been developed: Public Health Management of cases and contacts associated with novel coronavirus disease (COVID-19).^{Footnote iii}

Public health measures such as hand hygiene, respiratory etiquette and environmental cleaning in the home are the cornerstone public measures to protect individuals, their families and others against seasonal influenza and other respiratory viruses. The same measures are also effective when COVID-19 is circulating in the community. The application of these principles will help prevent and control transmission of any respiratory infectious disease, including COVID-19.

Hand hygiene

Refers to hand washing with soap and water or hand sanitizing with alcoholic solutions, gels or tissues to maintain clean hands and fingernails. It should be performed frequently with soap and water for at least 15-20 seconds:

• Before and after preparing food;
• Before and after eating;
• After using the toilet;
• After coughing/sneezing into a tissue (or if non compliant with respiratory etiquette);
• Before and after using a surgical/procedure mask and after removing gloves;
• After handling body fluid-contaminated waste or laundry;
• Whenever hands look dirty.

If soap and water are not available, hands can be cleaned with an alcohol-based hand sanitizer (ABHS) that contains at least 60% alcohol, ensuring that all surfaces of the hands are covered (e.g. front and back of hands as well as between fingers) and rubbed together until they feel dry. For visibly soiled hands, soiling should be removed with an alcohol-based hand wipe first, followed by use of ABHS.

Touching one's eyes, nose, and mouth with unwashed hands should be avoided.

Respiratory etiquette

Describes a combination of measures intended to minimize the dispersion of large particle respiratory droplets when an ill person is coughing, sneezing and talking to reduce virus transmission.

• Cover coughs and sneezes with a surgical/procedure mask or tissue. Dispose of tissues in a lined waste container and perform hand hygiene immediately after a cough or sneeze

  OR

• Cough/sneeze into the bend of your arm, not your hand

Environmental cleaning and ventilation

Refers to routine cleaning of frequently used surfaces and objects to help to prevent the transmission of COVID-19 to help to mitigate the risk of people becoming infected through self-inoculation after touching contaminated surfaces. The virus that causes COVID-19 has the potential to survive in the environment for up to several days.^{Footnote iv} Cleaning, particularly of frequently touched surfaces, can kill the virus, making it no longer possible to infect people.

• Cleaning the home and co-living setting: Frequently touched areas such as toilets, bedside tables, light switches and door handles should be first cleaned (to physically remove dirt) and disinfected daily with water and regular household cleaning products or a diluted bleach solution (0.5% sodium hypochlorite). If they can withstand the use of liquids for disinfection, frequently touched electronics such as phones, computers and other devices may be disinfected with 70% alcohol (e.g. alcohol prep wipes). All used disposable contaminated items should be placed in a lined container before disposing of them with other household waste.
• Cleaning public spaces: Cleaning of high traffic public spaces (e.g. malls, airports, public transportation) should follow regular cleaning and disinfecting regimes, both in terms of products used and surfaces targeted, as it is not likely practical/sustainable to increase the frequency of cleaning. Community settings are encouraged to develop protocols for cleaning public spaces if they currently do not have an established cleaning routine.

  Workplaces and other similar community settings are encouraged to clean highly touched surfaces (e.g. phones, elevator buttons, washrooms, tables) frequently and to recommend and facilitate increased hand hygiene. It is also recommended that items that cannot be easily cleaned (e.g., newspapers, magazines, stuffed toys) be removed.

Increasing ventilation (e.g. opening windows when weather permits) may help reduce transmission, though evidence is limited as to its effectiveness. Simulation studies show that increased ventilation was shown to reduce influenza transmission and is usually simple and feasible in many locations.

Social distancing

Social distancing measures are approaches taken to minimize close contact with others in the community and include: quarantine and self-isolation at the individual level as well as other community based approaches (e.g. avoiding crowding, school measures and closures, workplace measures and closures, public/mass gathering cancellations) which are further described in the section titled community-based measures below.

Social distancing measures are likely to have secondary consequences for individuals, families and communities, such as loss of income, an elevated need for support services, and potentially reduced availability of certain services. Some measures require extensive preparation and engagement across sectors. During a pandemic of lesser severity, the infection control benefits of implementing some community measures (e.g., proactive school closures) may not be offset by the cost and societal disruption caused by these measures.

Whenever public health authorities impose restrictions on individual freedoms, the intervention should be proportional to the magnitude of the threat. This principle of 'least restrictive means' should always be a consideration when enacting social distancing measures. The CPIP Public Health Measures Annex outlines the ethical considerations with respect to the selection and use of PHMs in a pandemic.^{Footnote ii}

It is crucial that individuals follow quarantine and self-isolation recommendations properly to prevent transmission of COVID-19 to others in the home setting or in the community. It is recommended that all individuals in the community plan ahead by maintaining a supply of essential medications, home supplies and extra non-perishable food in the event they require voluntary quarantine or self-isolation.

• Isolation is recommended for a symptomatic individual that is suspected of having, or known to have, COVID-19. They are directed by PHA to isolate themselves in the home-setting and avoid contact with others until PHA has advised that they are no longer considered contagious. Isolation includes:
  • Not going out of the home setting. This includes school, work, or other public areas
  • Not using public transportation (e.g. buses, subways, taxis)
  • Identifying a "buddy" to check on and do errands for each another, especially for those who live alone or at high risk for developing complications.^{Footnote 1}
  • Having supplies delivered home instead of running errands (supplies should be left on the front door or at least a 2 metre distance maintained between people)
  • If leaving the home setting cannot be avoided (e.g. to go to a medical appointment), wear a mask (if not available, cover mouth and nose with tissues) and maintain a 2 metre distance from others. The health care facility should be informed in advance that the person may be infectious.
• Voluntary home quarantine ("self-isolation") is recommended for an asymptomatic person, when they have a high risk of exposure to the virus that causes COVID-19, (i.e., through close contact with a symptomatic person or their body fluids). They are asked to self- isolate in the home-setting to avoid contact with others in order to prevent transmission of the virus at the earliest stage of illness (i.e., should they develop COVID-19).
• Protective self-separation is recommended for a person who is at high-risk for severe illness from COVID-19^{Footnote 1} (e.g., older adults, those with chronic underlying medical conditions or immunocompromised) when the virus is circulating in their community.
• Voluntary avoidance of crowded places is recommended for a person who is asymptomatic and who is considered to have had a medium risk of exposure to the virus that causes COVID-19. This involves avoiding crowded public spaces and places where rapid self-isolation upon onset of symptoms may not be feasible. Examples of these settings include mass gatherings, such as concerts and sporting events; not including hospitals (for HCWs) and schools.
• Mandatory quarantine is the imposed separation or restriction of movement of individuals, groups or communities, for a defined period of time and in a location determined by the PHA. As local circumstances will vary across Canada and within regions, quarantine may be used to contain, delay or mitigate COVID-19, although its effectiveness once there is widespread community transmission is unknown. An individual in mandatory quarantine is asymptomatic but may have been exposed to the virus causing COVID-19. A decision to implement mandatory quarantine requires careful consideration of the safety of the individual/group/community, the anticipated effectiveness, feasibility and implications.

Self-monitoring

Self-monitoring is implemented when individuals are potentially exposed to the virus and includes monitoring for the occurrence of symptoms compatible with COVID-19. If symptoms develop, the individual should follow the recommended public health actions regarding convalescing at home versus seeking medical care, depending on severity of symptoms and the presence of underlying medical conditions.

Use of masks

Masks should be used by a symptomatic individual, if available, to provide a physical barrier that may help to prevent the transmission of the virus by blocking the dispersion of large particle respiratory droplets propelled by coughing, sneezing and talking. A face mask should always be combined with other measures such as respiratory etiquette and hand hygiene. They can be worn by people suspected or confirmed of having COVID-19 when in close contact with other people in the home-setting or if they must leave the home-setting for medical attention.

The use of a mask by a healthy person who is providing direct care for a person with COVID-19 should always be combined with eye protection and gloves and other droplet/contact prevention measures including hand hygiene and environmental cleaning. Refer to Case and Contact Management Guidance for additional advice.

There is no evidence on the usefulness of face masks worn by healthy/asymptomatic persons as a mitigation measure, therefore it is not recommended.^{Footnote v} Globally masks are in short supply and the current demand for masks cannot be met; therefore, appropriate use of face masks should be encouraged.^{Footnote vi}

Table 1: Recommended individual public health measures

N/A	Asymptomatic, not at high risk of complications, without COVID-19 or any exposure risk	Asymptomatic, at high risk of complicationsFootnote 1 without any exposure risk	Asymptomatic high risk of exposure (e.g. close, unprotected contact)	Asymptomatic medium risk of exposure (e.g. protected contact, traveller from affected area)	Symptomatic, suspected of having or know to have COVID-19Footnote ii
Hand Hygiene
Respiratory Etiquette
Use of face masks	N/A	N/A	N/A	N/A	+ any caregiver(s)
Cleaning
Self-Monitoring	N/A	N/A			for worsening
Social distancing
Isolation	N/A	N/A	N/A	N/A
Voluntary home quarantine (self- isolation)	N/A	N/A		N/A	N/A
Protective self-separation	N/A		N/A	N/A	N/A
Voluntary avoidance of crowded places	N/A	N/A	N/A		N/A
Mandatory quarantine	N/A	N/A	Depending on circumstances	N/A	N/A

Community-based measures

Community-based measures are actions taken by planners, administrators, and employers to protect groups, employees and the population. The measures outlined below are relevant to all non-health care settings and aim to reduce transmission within the community settings such as workplaces, schools, public transportation, communal living settings, spiritual and cultural settings, community centres and other places where people gather such as shopping centres, camps and entertainment facilities. These measures will always be layered with personal protective measures described above.

Guidance developed for acute health settings is available^{Footnote vii} and can be applied to any setting where healthcare is being provided.

Many of these community-based actions require extensive preparation and engagement across sectors, and secondary consequences (e.g. financial implications, interruptions in social supports, reduction in services, societal disruptions) may be anticipated and should be considered in planning. The implementation of some public health measures may be more disruptive (e.g., school closures) and their use should be based on a risk assessment^{Footnote viii} in collaboration with local authorities, which may result in jurisdictional variations across Canada. These measures are usually associated with pandemics of moderate to high impact given their societal and economic costs. As much as possible, a harmonized pan-Canadian approach should be taken. It is recognized that some individuals, groups, or communities may adopt or decline to adopt measures that are inconsistent with public health advice or are based on cultural norms (e.g., healthy individuals wearing masks). PHAs should reinforce the rationale for the recommendations, avoid stigmatization^{Footnote ix} of these groups or communities, and plan communications and stakeholder outreach accordingly.

Avoiding crowding

Measures taken to reduce the amount of time individuals spend in large crowds or in crowded spaces can be effective to reduce the transmission of COVID-19 in a community. It is recognized that while this intervention may reduce the viral transmission, some measures (e.g. closing public transit) could also have significant impact on societal function and compliance may be challenging. Restrictions on non-essential gatherings could pose a barrier to accessing group support and personal freedoms (e.g., cancelling church services, closing community centres). It may also have cultural or religious implications (e.g. funerals, religious services, weddings). The feasibility of avoiding crowds is uncertain as crowding occurs in large cities daily (e.g. public transportation, subways, airports, shopping centres, movie theatres). Discretionary gatherings, like churches and theatres, might be left to individual groups, rather than PHAs. Refer to mass gatherings, which provides advice related to mass gathering events in the context of COVID-19.

Factors to consider when making decisions:

• The likelihood that people will comply with crowd avoidance;
• People who are suspected or confirmed of having COVID-19 who are self-isolating, should isolate in the home setting and not go out in public;
• People who are self-monitoring for symptoms (see section above) should always avoid crowded settings (e.g. sporting events, concerts, airplanes, subway) and places where rapid self-isolation may not be feasible should symptoms develop;
• When in crowded settings, people should practice personal protective measures (e.g., frequent hand hygiene, avoid touching eyes/nose/mouth);
• Employers/businesses could consider implementing staggered work hours to reduce crowding on public transit during peak commuting hours and in large workplaces during normal work day hours;
• Voluntary quarantine of a community can be considered based on the local epidemiologic and social assessment of the situation;
• If public transportation is shut down, transportation alternatives may need to be considered for emergency medical services or medical treatments (dialysis, chemotherapy), as well as for critical infrastructure workers.

School and daycare measures

Public health measures implemented in schools and daycare settings are intended to provide a safer school environment by encouraging personal protective measures, communication to teachers and parents, and environmental cleaning. Public Health Guidance for Schools (K-12) and Childcare Programs (COVID-19) is available^{Footnote x}. Given the current epidemiology of the virus, it is unknown what role children play in community transmission of COVID-19, therefore the impact of school mitigation measures on community transmission of COVID-19 is uncertain, though strategies such as more frequent hand washing, respiratory etiquette and separation of ill students from healthy students is always prudent.

School/daycare measures can vary in scope from very simple measures (e.g. increasing distancing between desks) through to more extensive measures, such as closures.^{Footnote xi} Widespread school closures as a control measure have the potential of coming at a high economic and social cost since school closures would impact the many families that have one or both parents working outside of the home. School closures can reduce virus transmission, but the timing and duration of the closure is critical (before the peak of the epidemic), and later closures could be ineffective and be socially disruptive. Consideration also needs to be given to the likeliness that students will congregate elsewhere in less controlled environments, thus reducing the intended benefits of school closures and potentially shifting the transmission of the virus to other community settings.

Table 2: Definition of terms relevant to school measures^{Footnote xi}

Term	Definition
School mitigation measures	School remains open and alternative measures are implemented to promote social distancing and decrease density among students and staff.
Class dismissal	School remains open with core staff, but most children stay home (similar to a "snow day").
School closure	School is closed to all children and staff.
Reactive closure or dismissal	School is closed after a substantial incidence of illness is reported among children or staff (or both) in that school.
Proactive closure or dismissal	School is closed before a substantial transmission among children and staff. Is only helpful before the peak of an outbreak in the community.

School mitigation measures are implemented to reduce the unintended consequences of school closures or dismissal. The following strategies can be considered:

• Strict exclusion policies for students exhibiting symptoms of COVID-19
• Increasing desk distance between students
• Cancelling or postponing after-school events
• Restricting access to common areas
• Staggering the school schedule to limit the numbers of students/children in attendance at one time (e.g. staggered lunch breaks, recesses)
• Reducing mixing students during transport to and from school (separation of children on school buses by 2 meters where possible)
• dividing classes into smaller groups
• cancelling classes that bring students together from multiple classrooms

Class dismissal is intended to serve the purpose of mitigating some of the unintended consequences resulting in school closures e.g. parents/caregivers who miss work to take care of children can have negative financial implications and students/children who access free school meals could be negatively impacted if those meals are not otherwise available.^{Footnote xi} Additionally, keeping facilities open will allow teachers to consider delivering lessons and material remotely, maintaining continuity with teaching and learning.^{Footnote xii}

School closure decisions should be made in consultation with local public health authorities and based on a risk assessment. Closure considerations should include:

• The priority goal of minimizing social disruption and child safety
• Epidemiology and transmissibility of the disease
• Contact patterns in the school/childcare program
• Amount of contact between individuals within the environment
• Size of classrooms
• Interaction of students between classes
• The impact of certain programs (e.g., school meal programs) on families who access them.
• Innate protective factors built into schools and childcare settings including:
  • A forum to educate, inform and communicate with students/ children and their families in an efficient and timely manner.
  • A defined structure to support the economic and social elements of the community by allowing parents to continue to work and volunteer.

Reactive school closures are in response to virus activity (i.e. a consequence of disease activity) impacting the safe functioning of the school due to increased staff absenteeism and co-infection potential among students. Considerations should include:

• The number of ill students/children and staff.
• The impact of school absenteeism and/or staff shortages on schools/childcare operations.

Proactive school closures may be considered to interrupt the transmission amongst children and indirectly protect other age groups who may be vulnerable to COVID-19. The decision about the school closure at local/regional/national level will largely depend on the timing and epidemiological situation. Considerations should include:

• The timing of school/daycare closures in relation to the epidemic peak is an important consideration.
• School closures of less than 2 weeks have been shown to have minimal impact on disruption of virus transmission in communities.
• Holiday schedules should also be considered as opportunistic (i.e. early closures).

Workplaces

Public health measures implemented in workplaces can be taken to prevent the spread of the virus causing COVID-19 in workplaces and other similar community settings. Further information on preparing workplaces for COVID-19 is available from the WHO.^{Footnote xiii}

Strategies that workplaces can put into effect include:

• Increased awareness about and communication to staff about COVID-19.
• Encouraging the use of individual measures described above such as frequent hand hygiene, respiratory etiquette and self-isolation when ill.
• Evaluate the workplace for areas where people have frequent contact with each other and share spaces and objects.
• Workplaces/community settings should identify possible COVID-19 exposure risks and mitigation approaches.^{Footnote xiv},^{Footnote xv} Although not conclusive, there may be benefit to increasing the spatial separation between desks and workstations as well as individuals (e.g., employees, customers) from each other, ideally a 2 metre separation should be maintained, unless there is a physical barrier (e.g., cubicle, Plexiglas window).
• Workplaces and other similar community settings are encouraged to increase frequency of cleaning of frequently touched surfaces (e.g., phones, elevator buttons, computers, desks, lunch tables, kitchens, washrooms, cash registers, seating areas, surface counters, customer service counters, bars, restaurant tables/menus).
• Provide access to handwashing facilities and place hand sanitizing dispensers in prominent locations throughout the workplace, if possible.
• Consider providing additional tissues should someone develop respiratory symptoms. If symptoms develop the person should immediately be separated from others, instructed on respiratory etiquette and sent home (not using public transit, if possible).
• Where feasible, adjustments to policies and procedures may be put in place to reduce social contact, such as teleworking arrangements, flexible hours, staggering start times, use of email and teleconferencing.
• For business travel, employers should be aware of the latest information on COVID-19 affected areas and any travel health advisories. The risks and benefits related to upcoming business travel should be assessed and consideration given to alternative approaches such as virtually attending meetings. Returning international business travellers returning from affected areas should self-monitor for symptoms and follow advice provide PHAs regarding the recommended actions.
• Consider relaxing sick leave policies that support employees in self-isolating when ill. This includes suspending the need for medical notes to return to work (reduces the burden on an already stressed health care system).
• Employers should prepare for increases in absenteeism due to illness among employees and their families or possibly school closures. Employers should access their business continuity plans, which should include a plan for how to maintain key business functions if faced with high absenteeism. Consideration should also be given to the need for cross-training personnel to function in key positions. This is an important element of Business Continuity Planning.
• Workplace and community setting closures may be considered, based on local conditions and a risk assessment in an exceptional circumstance, such as if COVID-19 evolves into one with high severity and if many employees must be off to prevent transmission. The selection of measures will depend on the company and the type of work; some measures (e.g. cancellation or closures) may have significant economic consequences and decisions made based on a risk-benefit analysis.

Mass gatherings

Mass gatherings are highly visible events with the potential for serious public health consequences if they are not planned and managed carefully. They can amplify the spread of infectious diseases and have the potential to cause additional strain on the health care system when held during outbreaks. The transmission of respiratory infections such as influenza has been frequently associated with mass gatherings. There have been examples of COVID-19 transmission during mass gatherings.^{Footnote xvi} Such infections can be transmitted during a mass gathering, during transit to and from the event, and in participants' home communities upon their return. ^{Footnote xvii} Examples of mass gatherings include large meetings, conferences, sporting events, religious events, national and international events. It is recognized that while cancelling a mass gathering may reduce the viral transmission, it may also pose a barrier to personal freedoms. Mass gatherings may have cultural or religious implications (e.g. pilgrimages, large religious events) and cancelling such events may have significant cost considerations for jurisdictions, organizations and individuals. Decisions about whether to proceed with, restrict, cancel or postpone a mass-gathering event be based on thorough risk assessment undertaken by event organizers in consultation with all relevant PHAs (e.g., local, provincial, federal).

Considerations used in the risk assessment generally include: transmission dynamics, severity of illness, periods of communicability, incubation period, treatment options, potential for prevention (e.g., available vaccine, pharmaceuticals). Organizers should also consider the type of event (crowd density, nature of contact between participants, whether the event will be attended by registered on non-registered participants) and the host communities' capacity to respond to and mitigate the impacts of virus activity (e.g. health system capacity). A tool has been developed to assist planners with the risk assessment.

Measures to reduce the risks posed by mass gathering events include:

• Providing clear communication to participants before attending about the risks and advice on how to protect themselves and others to reduce virus transmission to inform individual decision making about attending the event
• Encouraging personal protective, individual and environmental measures by all attendees
• Increasing interpersonal distancing (ideally separation of at least 2 metres, not shaking hands, avoiding communal sleeping areas)
• Eliminating self-serve buffet style eating at social/religious gatherings
• Support frequent hand hygiene by providing hand sanitizers dispensers in prominent locations
• Discourage attendees from sharing food or drinks
• Requiring that ill be excluded people or those with high-risk medical conditions not to attend gatherings and ensuring event organizers have arrangements in place to safely isolate and transport people who become ill on-site remain the most important measures to prevent transmission.
• Implementing organizational measures for the event such as cancellation, postponement, or rearrangement of the event (e.g., offering virtual participation, live streaming to allow participation from a distance, moving venue from indoors to outdoors)

Public education and communication

Public education aims to promote and support the implementation and adoption of public health measures at the individual and community levels. Communication of information and advice is often the first and most important public health intervention during an emergency, especially where behaviour change is essential for an effective response.^{Footnote xviii} Providing clear and consistent information about COVID-19 through authoritative sources and the use of public health measures is an essential component of their successful implementation. Messages should include ways to reduce risk as well as rationales for decision-making to encourage trust and adherence to advice. Tailoring approaches to specific audiences (e.g. high-risk groups, Indigenous communities, homeless, socially isolated, new immigrants, non English-French speaking) will be needed, especially for those who may not be able to use or access standard resources.

Conveying the basis for, and value of, public health measures and recommendations (e.g. reducing transmission, reducing burden on health care systems), uncertainties (e.g. timing, extent of their use) and limitations (e.g. effectiveness of preventing transmission) should be incorporated into the public health communications strategy.

When faced with uncertainty and unpredictability, communicating early during a crisis can be critical to building essential trust. Misinformation that is spread through social media is a significant concern. Building trust in institutions and spokespersons in advance of a pandemic can mitigate the potential risks of misinformation, along with creating a clear focal point for accessing information about the pandemic. It is important to ensure that F/P/T governments are using common messaging to ensure that there is not conflicting public health measures advice being messaged across the country.

Considerations for a communications response

• Proactively communicate when information (or even limited information) is available that Canadians can use to protect themselves.
• Anticipate that higher transmissibility will heighten public concern and increase demand for information from the public and media.
• Anticipate that public risk perception plays an important role in taking public health advice. Early, pro-active communications by public health authorities is important to influence early decisions and establish public health authorities as a trusted source of expert guidance and advice.
• Engage community leaders and non-public health groups to transmit accurate messages where there is a trust-based relationship with the community (e.g. Elders, spiritual leaders, educators, and community leaders/organizations)
• Leverage opportunities to use stakeholder networks and information vehicles to share information (and obtain feedback on) the relevance and value of these materials. Consider using existing networks (e.g. those already in place for seasonal influenza messaging)
• Rumours and misinformation can circulate rapidly and widely via social media. Communicate with audiences early, with a commitment to provide additional information when it becomes available and as the situation evolves. Monitor social media and identify rumours, adapt messages and strategies as needed.
• Address stigma at every opportunity through general education about the disease, considering tailored messages to schools and workplaces. 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^{Footnote xix}on how to address social stigma, including communication tips and messages, is available.
• Develop communications tools/products to empower people and reinforce public health measures (e.g. hand hygiene, social distancing measures) and caring for the ill. Tailor information products and tools to the specific needs and capacities of target audiences and ensure materials are culturally relevant.
• Anticipate that more disruptive social distancing measures (e.g. cancellation of large/popular public events) may be met with resistance. Ensure public health risk analysis and rationale (including local circumstances, which are taken into account) is included in the communication.

For additional public information on COVID-19, please refer to the Coronavirus disease (COVID-19): Outbreak update web page, as well as the jurisdictional websites.

A list of Frequently Asked Questions can also be found on the Coronavirus disease (COVID-19): Frequently asked questions (FAQ) web page.

Appendix 1: Considerations for remote and isolated communities

This guidance is intended to support indigenous leaders, public health departments, regional health authorities and federal, provincial and territorial governments in their COVID-19 preparedness efforts for remote and isolated (RI) communities. The considerations included in this appendix are based on principles outlined in the Canadian Pandemic Influenza Preparedness Guidance.^{Footnote i}

A multitude of factors can influence the health status of an individual or a population. For many indigenous communities, culture and tradition are integral components of a holistic approach to health and well-being and it is critical to recognize their unique strengths which contribute to their resiliency e.g. teachings from Elders, nurtured relationships of family and community, revitalization of language and culture, connections to the land, traditional healing and cultural ceremonies.^{Footnote xx},^{Footnote xxi}

The overall health of Canadians living in RI communities can be affected by social, environmental and economic factors, including housing, water quality or access, food security, pre-existing health conditions, limited access to health care, education and income. These factors, in addition to limited accessibility to health care are important to consider in the context of mitigating the spread and impacts of COVID-19.

Provincial/Territorial 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 federal, provincial and territorial guidance and planning documents, which should take into consideration existing treaties, agreements and relationships.

Public health measures mitigation strategies

RI communities, and in particular indigenous communities, can be at risk of infectious disease outbreaks due to multiple predisposing factors (e.g. overcrowded or poor housing conditions, poor water quality or lack of clean water access, food insecurity, pre-existing health conditions, limited access to health care). As such, even in the absence of confirmed cases, it is important to prepare for the potential importations into and rapid spread within RI communities. It is recommended that early outbreak investigation and management occur collaboratively with the local public health unit. Community-based public health measures, such as voluntary self-isolation for ill persons, travel advisories and, if necessary, school closures and cancellation/postponement of public gatherings may be considered, depending on the local circumstances. Guidance for caring for someone at home with COVID-19 has been developed and includes considerations with may be applicable for remote and isolated communities.

Challenges and potential strategies for implementing community-based public health measures in remote and isolated communities are listed below:

Lack of availability of non-medical supplies

Delivery and transportation of non-medical supplies (e.g. soap, food, household items) in RI 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.

Strategies to consider:

• Encourage and increase awareness of individuals, families and communities to (where feasible considering economic resources and storage space) have a backup of supplies to maintain their needs (e.g. soap, household cleaning products, non-perishable food and fluids, tissues).

Crowded or poor housing conditions

RI communities typically experience higher rates of overcrowding, and housing standards 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. Guidance to address the unique challenges for caring for someone in the home is available in Public Health Management of cases and contacts associated with novel coronavirus disease (COVID-19) guidance.

Limited access to running water

Some RI communities have limited access to running water or clean running water for hand hygiene.

Strategies to consider:

Increase the awareness of individuals and families in RI communities for alternative means for effective hand hygiene if they lack clean running water.

• It is recommended that the container be cleaned prior to filling (no special disinfectants are required for cleaning the container - regular household or commercially available cleaning products are sufficient). The container should be dedicated to water used for hand washing (and not drinking).
• Hold hands under the spout of a water container, wetting, washing with soap and rinsing.
• A pail can be placed below the container to catch the flowing water.

• In this case, use two separate containers (e.g. container for holding water supply and bowl for washing one's hands).
• Moving hands around to mimic running water to wet, wash with soap and rinse (additional water may be required for rinsing).
• The container used for hand washing should be cleaned and dried after each use.

Transmission of virus in public gatherings

The potential for spread of infection during public gatherings may put undue strain on already limited resources in RI communities.

Strategies to consider:

• Communities should consider the presence of illness in the community, as well as the availability of health care providers, basic medical supplies, medications, isolation beds/rooms to assist them in deciding whether or not to cancel or postpone public gatherings.

Impact of illness in schools

School closures in RI areas may have a significant impact on a community. Given limited qualified substitute staff in the community, the school may not be able to implement a business continuity cycle if there is a high attack rate and staff are off sick. Hence, the school closure may be longer than in urban communities.

Strategies to consider:

• Where systems are in place, schools in coordination with the public health authority should participate in active school based illness surveillance in order to identify outbreaks or unusual situations such as when absenteeism of students/children or staff is greater than would be expected, or severe illness is observed.
• Schools should develop business continuity plans specific to their unique community needs.
• Refer to school guidance^{Footnote x} for prevention and mitigation strategies in school settings.

Need for Tailored Messaging

RI 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 RI 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, and language preferences can present barriers to adoption of public health advice.

Strategies to consider:

• Identify communities where tailored communication strategies are required given the local circumstances.
  • Tailored strategies could include: mail outs, community radio, working with neighbouring communities to obtain necessary information, posters, door-to-door messaging, and community meetings.
  • Tailoring may also include messaging from people who are familiar or trusted (e.g. Inuit elders or Indigenous physicians).
• Develop and communicate campaigns that are specifically tailored to the circumstances of RI communities.