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

Last updated: May 30, 2020

Table of contents

Preamble

The Public Health Agency of Canada (PHAC), in collaboration with Canadian public health experts, has updated this guidance on the use of public health measures (PHMs) to mitigate community transmission as jurisdictions begin to gradually lift their COVID-19 related restrictions over the coming months. The primary audiences for the guidance are federal/provincial/territorial (FPT) and regional/local public health authorities.

The guidance identifies core personal and community-based PHMs to mitigate the transmission of coronavirus disease (COVID-19) that is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The guidance uses a risk-based approach to identify mitigation strategies for various settings including congregate living settings, business, child and youth settings, outdoor spaces and interpersonal gatherings. It considers the Canadian context and is based on currently available scientific evidence, ability status, expert opinion and public health assumptions. The guidance is subject to change as new scientific information emerges, experience is gained with lifting of restrictions in some jurisdictions, or treatment options or vaccine become available. 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. These limitations may necessitate adapted PHM recommendations by public health authorities in some situations.

The guidance should be read in conjunction with relevant PT and local legislation, regulations and policies. For up-to-date and evolving information regarding COVID-19, visit the Canada.ca COVID-19 web site.

Introduction

The goals of Canada's COVID-19 pandemic response and recovery are first to minimize all serious illness and death (due to all causesFootnote 58) and secondly minimize societal disruption, including reducing the burden on health care resources.

Given the current lack of effective therapeutics or vaccine for COVID-19, PHMs are the most important control interventions that exist. PHMs are non-pharmaceutical interventions used to reduce and delay community transmission of the virus, thereby “flattening the curve” and reducing the demand for health care services to a manageable level. They are usually implemented in combination, known as "layered use". This approach is based on the expectation that combinations of PHMs are likely to be more effective than single measures that are less effective on their own.

The PHMs outlined in this guidance include personal practices taken by individuals to protect themselves and others, as well as community-based measures to protect groups and the community at large. While PHMs play a critical role in reducing COVID-19 activity, they have extensive social and economic impacts and can have negative unintended consequences, particularly on vulnerable populations. This continues to be examined by public health authorities, and strategies to minimize the negative unintended consequences are an important consideration in the approach to lifting restrictive measures.

Compliance with recommendations and sustainability over time may be influenced by a variety of factors, including, but not limited to cultural, contextual (e.g., living, working and community conditions), financial, social, and spiritual circumstances. In addition, to promote compliance, messaging may need to be adapted depending on the sex, gender, ability status, parental and caregiving responsibilities, and other socioeconomic or identity factors of individuals. For example, men may be more likely than women to report low levels of concern about the COVID-19 pandemic, including men in the highest risk age groupsFootnote 1, and women may be more likely to have caregiving responsibilities (e.g., for children or elderly family members).Footnote 59 Public education and effective communication that is sensitive to considerations such as these, and tailored to other relevant factors play a key role in promoting compliance. See Appendix A.

Adjusting public health measures over time

In March 2020 as COVID-19 activity was beginning to escalate in parts of Canada, FPT governments put a wide variety of PHMs in place in their respective jurisdictions. These included enforced physical distancing; school and day care closures; closure of non-essential businesses and workplaces, services, and gathering places; limitations on international travel; and discouragement of non-essential domestic travel. The measures used varied somewhat across the country owing to differences in the timing and intensity of COVID-19 activity and jurisdictional considerations.

As pandemic virus activity decreases, FPT governments are planning to lift and adjust their application of PHMs in a phased manner that is carefully designed to gradually ease restrictions while at the same time minimize the risk of a resurgence of COVID-19 activity. The public health aspects of this process are described in Guidance for a Strategic Approach to Lifting Restrictive Public Health Measures. This document provides transition planning that is underway across Canada with a strategic approach to lifting restrictive PHMs in steps. PTs have developed individual plans for lifting their restrictions; resources specific to jurisdictions should be consulted for more information.

As PHMs are lifted, close monitoring is necessary to track COVID-19 activity; if significant increases in cases occur, stricter PHMs might have to be reinstated. Modeling suggests that this cycle of adjusting public health interventions might have to continue for a lengthy period.Footnote 2

Personal practices

Core personal PHMs must be maintained for the duration of the pandemic. These consist of the following:

Public health authorities should continue to educate people about the continuing need for these core personal practices and their appropriate implementation. Fact sheets containing detailed instructions for the public are available.

More information about these core personal practices is provided below.

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. Touching one's eyes, nose, and mouth with unwashed hands should be avoided. 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.Footnote 3

Respiratory etiquette describes a combination of measures intended to minimize the dispersion of large particle respiratory droplets when an infected or ill person is coughing, sneezing, laughing or talking, to reduce virus transmission. Individuals should cough or sneeze into a tissue, or the bend of the arm, not their hand. Tissues should be disposed of as soon as possible in a lined waste container and hand hygiene performed immediately.

Environmental cleaning and ventilation

Environmental cleaning refers to the routine cleaning and disinfection of frequently used surfaces and objects to help prevent the transmission of COVID-19 through self-inoculation after touching contaminated surfaces. SARS-CoV-2 has the potential to survive in the environment for up to several days.Footnote 4 Cleaning and disinfection of frequently touched surfaces kills the virus, making it no longer infectious.

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. In households with children, toys and objects that are frequently touched by children should also be cleaned and disinfected daily.

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 disinfection, 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 disinfection, high-touch electronic devices such as keyboards, tablets, television remotes and smartphones may be disinfected with alcohol (e.g., alcohol prep wipes) at least daily. All used disposable contaminated items should be placed in a lined container before disposing of them with other household waste.

Ventilation – Increasing ventilation (e.g., opening windows when weather permits) may help to reduce transmission. Although evidence is limited as to its effectiveness for COVID-19 prevention, this is a best practice for other respiratory infectious diseases.Footnote 60

Physical distancing

Physical distancing (previously referred to as social distancing) measures are approaches taken to minimize close contact with others in the community. The measures that are being used include the following:

As restrictions are lifted, some businesses and other public places will reopen and the size of gatherings that is allowed may be increased in stages. However, individuals should continue to practice physical distancing when they are outside the home and to avoid non-essential travel. Persons at high risk for severe disease should be encouraged to limit their time in the community as long as SARS-CoV-2 continues to circulate.

Self-monitoring, isolation and quarantine

All individuals should self-monitor for symptoms compatible with COVID-19 and if symptoms develop, they should isolate themselves at home, seek medical attention as required and follow direction of their public health authority. If the individual is unable to self-monitor, such as a child or adult who requires care, caregivers should be responsible for monitoring the person in their care for symptoms compatible with COVID-19 and if symptoms develop, to proceed as above. Public health follow-up will ensure appropriate isolation of cases and quarantine (self-isolation) of contacts according to public health guidance for the management of cases and contacts.Footnote 6 It is recommended that individuals in the community 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 they become ill or are quarantined.

Use of a non-medical cloth mask or face covering

Recent studies provide evidence that COVID-19 can be spread by infected individuals who have not yet, or who may never develop symptoms.Footnote 7 It is not known how much of a role this pre-symptomatic and asymptomatic transmission plays in driving the epidemic; however it is known to be occurring among those with close contact or in close personal settings.

Globally, medical masks are in short supply and their use should be reserved for health care workers. Wearing a NMM or cloth face covering in the community has not been proven to protect the person wearing it. However, it is an additional personal practice that can be taken to protect others by preventing the respiratory droplets of an unknowingly infected person from coming into contact with other people outside the home.

Commercially available or homemade cloth masks or face coverings can play an important role in situations and community settings where physical distancing is not possible or is unpredictable. Benefits of use are greatest when the risk of viral transmission is higher (e.g. local community transmission, busy public settings where contacts with others can’t be controlled), and are marginal when risk of viral transmission is lower (e.g. limited community transmission, private settings where physical distancing can be controlled and contact with others limited).

When the local epidemiology and rate of community transmission warrant it, wearing of NMMs or cloth face coverings is recommended for periods of time when it is not possible to consistently maintain a two-metre physical distance from others, particularly in crowded public settings. These situations could include public transportation, stores and shopping areas, and some group living situations (e.g., group homes, correctional facilities, dormitories or group residences). Advice or direction regarding the wearing of NMMs or cloth face coverings may vary from jurisdiction to jurisdiction based on local epidemiology. Further workplace concerns are discussed under Community-based Measures.

It is important that NMMs or cloth face coverings fit well and are worn safely. The website Canada.ca/coronavirus has information on the appropriate use and construction of NMMs or cloth face coverings, including how to make your own. Non-medical masks can be made at home from readily available materials, ensuring that they are accessible to all who need them. There is ongoing discussion regarding the best materials or best construction methods for NMMs, and the website will be updated as new information becomes available.

NMMs or cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

Community-based measures

Overview

Community-based measures are PHMs that apply to settings where the public gathers, like congregate living settings, businesses and workplaces, child and youth settings, community gathering spaces or settings, outdoor spaces and public transportation. Community-based measures are implemented by planners, local governments, employers and administrators to protect their work force, customers, and the general public.

When the restrictions that have been in place are lifted, even gradually, the risk of COVID-19 transmission will increase. It is important to balance that risk against the individual, societal and economic benefits that are anticipated from re-opening. It is also necessary to reduce the risk of transmission in all settings as much as possible.

Prolonged close contact is felt to be the source for most COVID-19 infections, suggesting that physical distancing combined with emphasis on hand hygiene, respiratory etiquette and environmental cleaning will be the most effective mitigation approaches. Outbreaks have been attributed to large family gatherings, religious services, funerals, and choir practice, and have also occurred in occupational settings including health care facilities and meat processing plants.Footnote 8Footnote 9 Settings such as remote and isolated and First Nations, Inuit and Métis communities have additional risks and considerations and require tailored approaches based on geography, culture and living circumstances. Guidance for those living in remote and isolated and First Nations, Inuit and Métis communities is provided in Appendix B.

Risk assessments should be integrated into decisions about opening or closing settings and how to function as safely as possible for those that are open. A general risk assessment framework has been developed to assist FPT and local public health authorities and others responsible for management of the business, organization or programming with development of their mitigation strategies. The framework also contains suggestions for developing a mitigation plan to reduce the identified risks. The framework incorporates and builds upon the risk framework proposed in a recent report from the Centre for Health Security at the Bloomberg School of Public Health, Johns Hopkins University.Footnote 10

The revised Canadian framework assesses risk along three dimensions and contains potential mitigation measures as a fourth factor:

  1. Local context – defined as the approximate likelihood of the individuals entering the setting being infected with the virus responsible for COVID-19 based on current transmission patterns in the community.
  2. Characteristics of individuals in the setting – defined as the vulnerability of people in a setting to experience more severe COVID-19 disease, whether individuals in the setting are essential workers, and whether individuals in the setting have travelled from other communities.
  3. Setting characteristics – defined by the intensity of contact between individuals, the frequency of contact with potentially infectious high-touch surfaces, and the environmental characteristics of the setting (e.g., ability to open windows in a confined setting). Contact intensity further considers the type of contact (close to distant), duration of contact (brief to prolonged) and number of contacts (few to many).
  4. Risk mitigation potential – defined as the degree to which mitigation measures can be implemented or activities modified to reduce risk. This dimension considers both the type and number of measures that can be put in place.

A detailed guide for public health authorities to implement the risk assessment framework is presented in Appendix C.

The Johns Hopkins reportFootnote 11 also proposes a framework for mitigation strategies according to the familiar hierarchy of controls, adapted for COVID-19 purposes (see Figure 1). The degree of importance of these measures is considered to be from top down, with physical distancing being the most important and personal protective equipment (PPE) and NMMs the least important in terms of preventing transmission of COVID-19. When planning mitigation strategies, a layered approach using a combination of measures is superior to the use of individual measures and is particularly important in settings where implementation of more protective measures is not possible.

The mitigation framework below has been used in this guidance document. There is some unavoidable overlap as physical distancing measures can be enforced by implementing either engineering or administrative controls.

Figure 1. Modified hierarchy of controls

Figure 1

Source: Adapted from John Hopkins University, Bloomberg School of Public Health, Center for Health Security, Public Health Principles for a Phased Reopening During COVID-19: Guidance for Governors, April 2020

Physical distancing — Employers/operators should restructure physical settings and responsibilities to adhere to the distance needed between people (e.g., increasing space between people and/or reducing the number of employees within a space at a given time). In addition, wherever possible people should have the option to work or access businesses, schools and other settings from home.

Engineering controls — creating physical barriers between people when distancing is not possible; increasing ventilation

Administrative controls — redistributing responsibilities to reduce contact between individuals, using technology to facilitate communication

PPE and NMMs — having people wear medical PPE when required (in health care settings) and NMMs or cloth face coverings in the community setting

Setting specific risk assessment tools have been developed for workplaces, child and youth settings, and outdoor settings. These tools are intended for use by setting operators to assist them with assessing the risk of their setting and potential mitigation measures, but they may also be of value to public health authorities. Note that the jurisdiction’s applicable Health and Safety legislation must also be followed.

Core public health measures for all settings

As no targeted therapies or vaccine are available at this time, all community settings need to follow core PHMs to maximize the ability as a society to control the rapid spread of the virus. These core PHMs apply to all community settings, regardless of the specific characteristics of the setting and the individuals who frequent it, and the current level of COVID-19 activity. They consist of physical distancing measures in the community setting, promotion of personal practices and scrupulous attention to environmental cleaning. Details of these community-based measures are provided below. Workplace considerations for NMM use are also discussed below.

Physical distancing measures

Physical distancing measures are the most effective way to reduce the risk of transmitting COVID-19 in community settings. However, physical distancing may be impractical in some settings and in others it may not be sustainable over time. In these instances, layering of other mitigation measures can be as protective as physical distancing on its own.

Key strategies to maintain a two-metre distance between individuals are outlined in the following sections of this guidance. Owners and operators are encouraged to develop additional innovative approaches to physical distancing in their own setting. There may be circumstances when people cannot physically distance themselves properly, e.g., persons with guide dogs (who haven't been trained to the new rules), seniors who require assistance with personal care, or people living in crowded or congregate housing. In addition to the recommended two-metre separation, PT restrictions on the size of gatherings will affect many operations and events. These limitations are expected to be gradually eased as COVID-19 activity declines in communities, allowing people to gather in larger groups over time.

Promotion of personal practices

It is essential for organizers, event planners, owners and operators to promote and facilitate personal practices in all businesses, workplaces and public settings. Steps that should be taken include:

There are various ways to screen individuals before entering a workplace or public setting. Organizers, event planners, owners or operators should consider the local epidemiology and community transmission of COVID-19 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.

Passive screening measures should be put into place at all settings. This usually consists of signage at points of entry to remind people not to enter if they are ill. Similar messaging can be communicated on voicemails and websites.

Active screening (i.e., asking questions about symptoms) should be considered in some circumstances, for example:

Active screening protocols may involve a self-assessment (e.g., using a web-based tool, having an arriving person complete a questionnaire or posing direct questions). If active screening is conducted in person, the screener should maintain the required physical distance or wear appropriate PPE. 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 need to also have a procedure for handling persons who screen positive.

Enhanced environmental cleaning of workplaces and public places

Environmental cleaning reduces the risk of contact transmission of COVID-19, which occurs through touching surfaces or objects contaminated with the virus and then touching one’s eyes, nose or mouth. SARS-CoV-2 has been found to be stable for hours to days on surfaces, depending on the surface type, relative temperature or humidity of the environment. It has been detectable for up to four hours on copper, up to 24 hours on cardboard and up to two to three days on plastic and stainless steel.Footnote 12

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, these 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.

Employers must provide education and training on the safe use of products used for cleaning and disinfection and any PPE that will be used during the process, and must ensure that these measures meet the requirements of the applicable federal, provincial or territorial Health and Safety legislation.

A fact sheetFootnote 13 on procedures for cleaning and disinfecting public spaces (e.g., schools, universities, public libraries, museums, public transit, communal residences and workplaces) is available.

Use of NMMs or cloth face coverings in workplaces and other community settings

As stated previously, depending on the local epidemiology and rate of community transmission of COVID-19, wearing of NMMs or cloth face coverings is recommended for periods of time when it is not possible to consistently maintain a two-metre physical distance from others, particularly in crowded public settings. These situations could include public transportation, stores and shopping areas. NMM use may also be recommended for some congregate living situations (e.g., group homes, correctional facilities, dormitories or group residences).

NMMs or cloth face coverings can also play an important role in some workplace settings where consistent physical distancing or the use of physical barriers or other modification to the work environment or work flow are not possible or available.

When establishing policies for use of NMMs or cloth face coverings in workplaces and other community settings, employers should consider carefully the occupational requirements of their workers and their specific workplace configuration. They must ensure they mitigate against any possible physical injuries that might inadvertently be caused by wearing a face covering (e.g., interfering with the ability to see or speak clearly or becoming accidentally lodged in equipment the wearer is operating). The potential psychological impacts of the NMM or face covering on other employees or clients should also be considered (e.g. design or construction of the mask, messaging, etc.).

NMMs are not considered PPE. Recommendations for use of PPE are based on risk assessments of specific environments and risk of exposure. Although all efforts should be made to preserve the supply of medical masks for healthcare settings, there may be some non-healthcare workplaces in which a medical mask may be a more appropriate choice for the protection of the worker, for example, providing services to a client who cannot wear a non-medical mask or face covering when the two-metre physical distance cannot be maintained, and measures such as plexiglass/transparent barriers are not possible or available. Masks may not be suitable for all types of occupation. Employers should consult with their Occupational Health and Safety team and local public health before introducing mask-wearing policies to the workplace.

Setting specific considerations

The following are specific considerations that can be used to reduce COVID-19 risk in each setting. The core public health measures already described (promotion of personal practices and enhanced cleaning/disinfection) apply to all settings.

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 kitchen or bathroom and they may or may not have private sleeping quarters.

Congregate living settings can include facilities with vulnerable populations at higher risk for severe illness due to age, underlying health conditions or circumstances (e.g., physical or intellectual disabilities) that limit their ability to adopt personal practices. Examples include shelters for persons experiencing homelessness, and closed settings such as long-term care facilities, residential care and correctional facilities. Other examples of congregate living settings include student residences, group homes for persons with disabilities, overnight camps for children and teens, agricultural worker dormitories, industrial camps and construction trailers.

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

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. Strategies are provided in the table below; however, measures must be tailored to each setting. The owners or operators of these congregate living spaces must also consider this guidance in the context of their legal responsibilities under the applicable federal, provincial or territorial Health and Safety legislation.

As separate guidance has been developed for long-term care facilitiesFootnote 14, shelters for people experiencing homelessnessFootnote 15 and correctional facilities (PDF),Footnote 16Footnote 17 those settings will not be further addressed here. Guidance has also been developed for persons with disabilities.Footnote 18

Temporary foreign workers are required to complete a mandatory quarantine period of 14 days following their arrival in Canada. Employer obligations during the quarantine period are available in the Guidance for employers of temporary foreign workers regarding COVID-19 (updated April 22, 2020). The requirements include educating workers on COVID-19 in a language they understand, monitoring their health, providing the tools to practice good hygiene and ensuring that their accommodations are cleaned regularly.

While the quarantine of temporary foreign workers reduces the likelihood of introduction of COVID-19 from areas outside of Canada, measures are also needed to prevent the entry of COVID-19 into congregate settings from persons who have been residing in Canada. Workers entering congregate settings such as mining and industrial camps are not subject to quarantine; however employers should screen individuals for symptoms of COVID-19 prior to travel to or entry into the work setting and not allow entry to anyone who is ill, even if mild. In addition, employers should consider implementing temporary measures for a new worker’s potential incubation period (14 days) to minimize the frequency and intensity of their exposure to other workers (e.g., single quarters or reduced number of roommates, private bathroom, physical distancing during meals).

Examples of mitigation strategies for congregate living settings
Hierarchy of control category Examples of mitigation strategies (in addition to promotion of personal practices and environmental cleaning/disinfection)

Physical distancing

  • Providing private sleeping quarters wherever possible
  • Arranging shared sleeping quarters so that beds are at least 2 metres apart and head to toe where possible. If beds can’t be placed two metres apart, use temporary barriers between beds, such as curtains, to prevent droplet spread while sleeping, and sleep head to toe

Engineering

  • Increasing ventilation by opening windows if possible

Administrative controls

  • Providing training and education in languages that will be understood by staff, volunteers, workers and occupants
  • Hiring professional cleaners to clean and disinfect areas typically maintained by occupants (i.e. bedrooms and private bathrooms) or ensuring that supplies are available for occupants to carry out adequate cleaning and disinfection of their space.
  • Staggering use of shared spaces (i.e., bathrooms and showers) and transportation to/from work or recreation/learning sites (i.e. reduce number of people on a bus/van and plan more trips)
  • Staggering mealtimes or increasing hours of availability when practical and limiting the number of people using communal kitchens at one time
  • Opening additional dining areas as necessary to increase spacing between individuals, or providing take-out meals
  • Discontinuing buffet service and removing shared food/condiment/utensil stations
  • Avoiding in-person meetings and gatherings such as meetings and social events, and limiting access to recreational facilities where physical distancing cannot be maintained
  • Encouraging more outdoor activities
  • Immediately isolating any persons who become ill or persons in quarantine into separate facilities (or removing from a work camp)
  • Having workers in camps stay on site on their days off by having needed supplies brought in as much as possible

PPE and NMMs

  • Using a NMM or face covering in some crowded congregate living settings

Additional resources:

Workplaces

Essential businesses, including essential retail operations, have continued to operate during the COVID-19 pandemic, while following stringent public health rules. Over the coming months additional categories of businesses providing non-essential services and retail operations will be permitted to reopen if they can implement mitigation measures.

Early evidence suggests that the risk of transmission in the workplace depends on the type of activity, physical proximity of workers and the number of people who attend work despite being ill. While most workplace infections have occurred in health care settings, tourism or transportation, a few clusters have been identified in an office setting. In the latter setting all cases had contact with infected individuals, with time spent in an enclosed environment (e.g., meeting room).Footnote 19Footnote 20 Retail clusters have also been described. Footnote 21 Footnote 22 Footnote 23 Footnote 24 Many of these clusters involved index cases who attended work despite being sick. Most of the workplaces in these outbreaks involve professions that have contact with many people, therefore increasing the risk of exposure to an infected person.

Large outbreaks of COVID-19 have also been reported in multiple meat and poultry processing plants across Canada and the United States.Footnote 25 Investigations have found that contributing factors included inability to maintain a two-metre separation between workers, especially on production lines; job demands that made the use of face coverings difficult; working while ill; difficulties in adhering to enhanced cleaning and disinfection routines; need for health and safety information in multiple languages; crowded congregate living arrangements; and shared transportation to and from work for many workers.

Each workplace should take steps to identify possible COVID-19 exposure risks in their operation and consider the feasibility of steps to mitigate these risks when they reopen.This risk assessment involves evaluating the workplace for areas where people have frequent contact with each other and share spaces, surfaces and objects. Additional measures are needed when physical distancing is not possible in the workplace. A tool for businesses to conduct a risk assessment, and help identify potential mitigation measures for their setting is available online. Examples of mitigation strategies for business are provided below. Workplaces must also consider this guidance in the context of their legal responsibilities under the applicable federal, provincial or territorial Health and Safety legislation.

Examples of mitigation strategies for businesses
Hierarchy of control category Examples of mitigation strategies (in addition to promotion of personal practices and environmental cleaning/disinfection)

Physical distancing

  • Continuing telework arrangements wherever possible and feasible, especially for individuals at risk of severe disease (older adults, people with chronic illnesses and immunocompromised individuals)
  • Implementing other adjustments to working arrangements to reduce physical contact, such as flexible work hours, staggered start times, use of email and teleconferencing
  • Increasing the spatial separation between desks and workstations as well as between individuals (e.g., employees, customers) from each other
  • Using visual cues to encourage a two-metre separation (e.g., floor markings)
  • For retail settings – modifying service delivery approach to prevent or limit contact between employees and customers and between customers; restricting customer numbers
  • For restaurants/food service and bars – implementing take/out or delivery options only; wide table spacing when restaurants reopen

Engineering controls

  • Installing physical barriers (e.g., high-walled cubicles, plexiglass/transparent barriers) between reception/tellers/cashiers and customers, or on production lines
  • Increasing ventilation if possible by adjusting the HVAC system or opening windows

Administrative controls

  • Requiring employees to stay home if they are sick (even with mild illness)
  • Adopting sick leave policies that enable ill workers to stay home
  • Preventing the entry of sick customers or clients into the setting
  • Discontinuing or severely limiting business travel
  • Closing or restricting access to common areas where personnel are likely to congregate and interact
  • Adopting contactless payment models (with exceptions for persons who can only pay by cash)
  • Providing special accommodations for vulnerable persons (staff or customers) who are at high risk of severe disease or who have vulnerable household contacts (e.g., adjusted work assignments, dedicated shopping hours for seniors)

PPE and NMMs

  • Using NMMs or cloth face coverings when physical distancing is not easy to maintain in the workplace (e.g., both a therapist or hair dresser/barber and their client, or on a production line)

Additional resources:

Child and youth settings

School and child care closures have been implemented across Canada as part of the initial response to COVID-19, with some exceptions to support essential workers. From the point of view of numbers of attendees and contact intensity, child and youth settings may present risks for transmission of COVID-19.

School mitigation measures such as closures have a high economic and social cost. Schools and child care facilities play many important roles in communities. They provide necessary education to prepare children for adulthood, and long term online education for K-12 is not a substitute for in-person learning and socialization in a school setting. Long-term shutdowns have the potential to lead to education gaps and other consequences for many children. Particular groups may be disproportionately affected, such as children who receive school-based meals or counselling, children who are in situations of domestic violence or abuse, children with disabilities who rely on the certainty of education and social supports to maintain health and community inclusion, and essential workers from low income families or single parents who have not had access to flexible work arrangements or paid leave. As businesses reopen, many workers will be dependent on access to child care, schools and child care facilities.

Children, especially those below 10 years of age, appear to experience less severe illness due to COVID-19 and they form a very small proportion of reported cases to date.Footnote 26Footnote 27 There is concern, however, about whether children are major vectors for COVID-19 transmission as occurs with influenza. Transmission of COVID-19 in children is not fully understood. However, although the data are sparse to date, they are somewhat reassuring in this regard. Unlike influenza, preliminary evidence has not found children to be comparatively significant spreaders of COVID-19.Footnote 27 Footnote 28 Footnote 29 Footnote 30 Footnote 31 In addition, in most household cluster investigations, children were not the index case.Footnote 32

A tool for use in child and youth settings to conduct a risk assessment and help identify potential mitigation measures for their setting is available online.

Examples of high-level mitigation measures for child and youth settings are outlined in the table below. It is anticipated that school boards and operators of other child and youth settings will find creative solutions to the challenges of physical distancing in their setting. The mitigation strategies can also be adapted for summer day camps for children. Child and youth settings must also consider this guidance in the context of their legal responsibilities under the applicable federal, provincial or territorial Health and Safety legislation.

Examples of mitigation strategies for child and youth settings
Control category Examples of mitigation strategies (in addition to promotion of personal practices and environmental cleaning/disinfection)

Physical distancing

  • Maintaining the option of online learning, especially for older children or those at higher risk of severe disease
  • Continue teleworking for administrative staff if possible
  • Staggering the schedule to limit the numbers of children/youth in attendance at one time
  • Staggering the timing of breaks during the day (e.g. lunch break, recess, play time) to limit numbers in the same location at the same time
  • Reducing contact during transportation to and from school (e.g., separation of children on school buses by two metres where possible)
  • Staggering pick-up and drop-off of children/youth
  • Dividing classes/groups into smaller numbers of children/youth
  • Increasing desk distance between students
  • Restricting or managing flow of common areas in the setting including hallways
  • Not allowing assemblies, high-contact sports or extracurricular activities where physical distancing is not possible

Engineering

  • Increasing ventilation if possible by adjusting the HVAC system or opening windows
  • Considering barriers between desks

Administrative controls

  • Ensuring that strict exclusion policies are in place for children/youth, staff and volunteers who are ill
  • Having staff and children/youth at higher risk of severe illness stay at home
  • Teaching children/youth in age-appropriate and non-stigmatizing language how to identify symptoms of COVID-19 and instruct them to speak to a staff member if they are experiencing symptoms
  • Having a procedure for isolating children/youth who become sick in the setting
  • If possible, having classes contain the same children/youth, staff or volunteers each day
  • Cancelling or modifying programs that bring students from different classes/groups together
  • Providing education on hand hygiene and supervised hand hygiene
  • Cancelling or postponing special events or school visitors and guests
  • Moving some activities outdoors if possible

PPE and NMMs

  • Considering use of NMMs or cloth face coverings for teachers and children (older than 2 years of age)/youth based on a risk/benefit analysis. Use of NMMs or cloth face coverings is not recommended for children in child care settings.

Additional resources:

Outdoor spaces

Outdoor spaces include parks, trails, dog parks, playgrounds, beaches, and outdoor recreation spaces. Access to outdoor spaces and participation in outdoor recreational activities are important to the health, well-being, and social connections of Canadians.

Overall, there is limited evidence on the transmission of COVID-19 outdoors, including the presence and survivability of SARS-CoV-2 in the outdoor environment. The evidence available suggests that the potential for transmission may be lower outdoors than it is indoors. One cluster investigation found that transmission of COVID-19 was 18.7 times more likely in closed compared to open air environmentsFootnote 34 and another study found that only one of 138 small COVID-19 case clusters studied occurred outdoors and was attributed to a close conversation with an ill person.Footnote 35

While parks and trails have generally remained open, allowing access to additional outdoor activities in time for summer will provide a resource for healthy physical activity, recreation and stress relief.Footnote 36 Activities where physical distancing can be maintained and physical contact with other persons minimized, for example solitary activities and those enjoyed by household groups, represent the lowest risk for COVID-19 transmission. Low contact sports (e.g., golf, tennis) can also be considered low risk activities if players can maintain physical distancing and minimize sharing of equipment or use of confined spaces (e.g., change rooms) where a two-metre separation distance cannot be maintained. Mitigation strategies can be used to reduce risks associated with use of playgrounds, public swimming pools and campgrounds when they reopen. High contact and team sports are not likely to be allowed until later in the reopening process.

A tool to conduct a risk assessment and help determine potential mitigation measures for different types of outdoor spaces is available online. Specific examples of mitigation strategies in outdoor spaces are available below.

Examples of mitigation strategies for outdoor spaces
Hierarchy of control category Examples of mitigation strategies (in addition to promotion of personal practices and environmental cleaning/disinfection)

Physical distancing

  • Only allowing recreational activities/sports that can maintain physical distancing
  • Discouraging activities that involve physical contact
  • Separation of persons on sidelines
  • Maintaining physical distancing between members of different households when participating in outdoor activities (e.g., picnics, camping)
  • Providing signage and supervision at playgrounds and busy parks to remind users of physical distancing requirements
  • Restricting large gatherings, even outdoors

Engineering controls

  • Installing barriers to reduce bottlenecks and help with physical distancing (e.g., at entrances or exits)
  • Removing or restricting use of equipment (e.g., removing swings or tying them in place) until restrictions against use are lifted
  • Closing streets to vehicle traffic to expand walking space for pedestrians

Administrative controls

  • Limiting number of admissions to parks or recreational facilities to prevent overcrowding
  • Not allowing sharing of equipment or use of common equipment unless cleaned and disinfected between use
  • Removing or closing features that encourage people to gather, e.g., clubhouses (except for washroom access); limiting access to viewing platforms
  • Adjusting rules and methods of play to promote physical distancing

PPE and NMMs

  • Considering use of NMMs or cloth face coverings if the setting is crowded and it is not possible to maintain a two metre distance from others (should seldom apply in outdoor settings)

Additional resources:

National Collaborating Centre for Environmental Health. COVID-19 and outdoor safety: Considerations for use of outdoor recreational spaces. Available from: https://ncceh.ca/documents/guide/covid-19-and-outdoor-safety-considerations-use-outdoor-recreational-spaces

Interpersonal gatherings of families and friends

Interpersonal gatherings of families and friends include weddings, funerals, baptisms, small social gatherings such as birthday parties, and small cultural ceremonies. These events hold cultural and religious significance and often represent important milestones in people’s lives.

The risk associated with these gatherings ranges from low to high, depending on the number and characteristics of participants, their personal interactions and whether mitigation strategies have been put into place. Significant transmission of COVID-19 has been reported at funerals and birthday parties.Footnote 37 Factors associated with transmission have included close interactions in enclosed spaces, hugging or kissing, sharing food and utensils and group singing.Footnote 38Footnote 39

Some examples of mitigation strategies for interpersonal gatherings are shown below. Mitigation measures should respect the cultural value of important events where possible.

Examples of mitigation strategies at interpersonal gatherings
Hierarchy of control category Examples of mitigation strategies (in addition to promotion of personal practices and environmental cleaning/disinfection)

Physical distancing

  • Limiting the size of the gathering as advised by the PT
  • Maintaining strict physical distancing of attendees
  • Considering virtual options (e.g., live streaming the ceremony) or holding the event outdoors
  • Not allowing handshakes, hugging or kissing
  • Not allowing touching or kissing of a deceased person

Engineering controls

  • Increasing ventilation if possible by adjusting the HVAC system or opening windows

Administrative controls

  • Ensuring that ill persons do not attend events, facilities or services
  • Not allowing persons at higher risk to attend, or making special provisions to accommodate them (e.g., special visitation hours)
  • Holding the service/ceremony without a reception to follow
  • Not serving buffet meals; serving single service refreshments only
  • Not allowing group singing

PPE and NMMs

  • Considering use of NMMs or cloth face coverings if the setting is crowded and physical distancing is not possible to be maintained (may seldom apply)

Additional resources:

Public Health Agency of Canada. Interim guidance: Death care services and handling of dead bodies during the coronavirus disease (COVID-19) pandemic. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/guidance-documents/death-care-services-handling-dead-bodies.html

Community gathering spaces

This grouping includes places of worship, libraries, community and recreation centres, drop-in centres, museums, theatres, and cinemas. These community spaces provide important societal benefits and support through their educational, recreational, cultural and religious programs and services. Drop-in centres may service vulnerable populations including those experiencing homelessness. The risk associated with these gathering spaces varies depending on the number and characteristics of participants, their personal interactions and whether mitigation strategies have been put into place. Public worship services have been associated with transmission of COVID-19 and large outbreaks in several countriesFootnote 40 and are considered to be high risk while the virus continues to circulate.

Examples of mitigation strategies for community gathering spaces
Hierarchy of control category Examples of mitigation strategies (in addition to promotion of personal practices and environmental cleaning/disinfection)

Physical distancing

  • Hosting events, programs and religious services online
  • Providing online resources (libraries) and programming (community and drop-in centres)
  • If facilities are open, ensuring physical separation of patrons in gathering and recreation spaces, reading areas and at computer stations
  • Limiting the number of persons in the facility at any one time

Engineering

  • Installing physical barriers (e.g., plexiglass/transparent barriers) between receptionists/librarians and patrons
  • Providing barriers to assist with distancing at entrances and exits
  • Increasing ventilation if possible by adjusting the HVAC system or opening windows

Administrative controls

  • Ensuring that ill persons do not attend events, facilities, programs or services
  • Cancelling or modifying group activities (e.g., story hours and other library programs)
  • Developing procedures for safely handling returned books and other library materials
  • Making special provisions to accommodate patrons who are at higher risk of severe illness
  • Cleaning and disinfecting shared items between users (e.g., computers, telephones, touch screens etc.)
  • Adapting indoor sports to reduce physical contact, and avoiding sharing of equipment

PPE and NMMs

  • Using NMMs or cloth face coverings if the setting is crowded and physical distancing is not possible to be maintained

Additional resources:

Mass gatherings

Mass gatherings include large meetings, conferences, sporting events, cultural/religious events, festivals and national and international events. They are highly visible events with large numbers of attendees and have the potential for serious public health consequences if they are not planned and managed carefully. There is ample evidence that mass gatherings can amplify the spread of infectious diseases and they have been frequently associated with the transmission of respiratory infections such as influenza.Footnote 41 COVID-19 transmission has been documented at several mass gatherings in Canada (e.g., a curling bonspiel and a large dental conference).Footnote 42

Mass gatherings are considered high-risk events because of the number of participants, the contact intensity and the difficulty in mitigating the associated risks. Therefore, it is recommended that mass gatherings not be allowed for the foreseeable future. Event organizers may be able to re-design their events to meet physical distancing guidelines, e.g., by holding virtual conferences.

The risk assessment tool and mitigation strategies have been archived and will be updated at a later date.

Transportation

Public transportation (e.g., taxis, rideshares, buses, subways, rail and ferries) is an essential service that helps to keep communities functioning. 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 regular public transportation but may need help getting in and out of the vehicle.

There are two areas of COVID-19 related risks associated with public transportation. First, for passengers the crowding in public transit and its use by large numbers of people can contribute to transmission of COVID-19, and second, public transit staff are also at increased risk of infection.Footnote 43 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. Strategies should be used that are similar to those described below for public transportation (e.g., using larger vehicles or adding vehicles so that passengers can be spread out and having drivers and passengers use NMMs or cloth face coverings).

Employers and operators of transportation companies must also consider this guidance in the context of their legal responsibilities under the applicable federal, provincial or territorial Health and Safety legislation.

Examples of mitigation strategies for public transportation
Hierarchy of control category Examples of mitigation strategies (in addition to promotion of personal practices and environmental cleaning/disinfection)

Physical distancing

  • Minimizing shared rides in vehicles (e.g., taxis and rideshares)
  • Asking passengers to sit in the back seat of a taxi or rideshare
  • Practicing physical distancing in queues and waiting areas
  • If space permits, encouraging passengers to sit apart from each other on buses, subways, trains and ferries (e.g., using every other seat or row)

Engineering

  • Installing plexiglass shields for service staff at booths, and considering their use between the driver and passengers in taxis and buses
  • Ensuring proper ventilation in closed waiting areas and vehicles at all times

Administrative controls

  • Requiring that employees and drivers stay home when ill
  • Advising passengers not to travel while ill (through active or passive screening as appropriate)
  • Providing signage to remind passengers to adopt personal practices
  • Cleaning the cockpit between driver change-overs, in addition to regular cleaning of vehicles and waiting areas
  • Providing sufficient vehicles to prevent crowding and considering adding extra vehicles at rush hours
  • Having riders enter a bus through the back doors to avoid proximity to the driver
  • Providing hands-free collection of fares and tolls if feasible

PPE and NMMs

  • Recommending the use of NMMs or cloth face coverings by drivers and passengers on public transportation or similar group transport

Additional resources:

Appendix A: Communications and public education

Canadians have heeded the advice to adopt physical distancing and the other core personal PHMs in order to reduce the risks of acquiring and transmitting COVID-19, and this has led to flattening of the curve. As COVID-19 transmission decreases and PT governments begin to reopen their economies, some communications with the public, including messages, will stay the same while others will take on new importance.

Maintaining public trust is vital so that Canadians will continue to support and follow public health advice during the coming months. 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 openness, and commitment and dedication. Trust will be facilitated by continuing to:

Maintaining good relationships with stakeholders and media is vital for:

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

Address stigma at every opportunity. Stigma can undermine social cohesion and prompt possible social isolation of groups, which might contribute to a situation where the virus is more, not less, likely to spread. Guidance on how to address social stigma, including communication tips and messages, is available.Footnote 44Footnote 45

Rumours and misinformation can circulate rapidly and widely via social media. These rumours must be quickly identified and countered by public health authorities.

Community engagement with community leaders and stakeholders is important for:

Messaging that should be avoided by governments and organizations when addressing the public includes:

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

This guidance is intended to support First Nations, Inuit and Métis leaders, local public health departments, regional health authorities and FPT governments as they implement public health measures for the COVID-19 response in remote and isolated (RI) and First Nations, Inuit and Métis communities. The considerations included in this appendix are based on principles outlined in the Canadian Pandemic Influenza Preparedness guidance.Footnote 46

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 and 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.Footnote 47Footnote 48

The overall health of Canadians living in RI and First Nations, Inuit and Métis 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 are important to consider in the context of mitigating the spread and impact of COVID-19.

Many First Nations, Inuit and Métis communities that are RI are particularly susceptible 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.Footnote 49 Being isolated may be protective against exposure to COVID-19; however, the introduction of the virus into communities can lead to outbreaks with disproportionate threats.

PT 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, relationships and capacities within the First Nations, Inuit and Métis communities. Planning for adjustment of PHMs in RI and First Nations, Inuit and Métis communities should be coordinated with First Nations, Inuit and Métis, local, regional and FPT partners.

Public health measures and mitigation strategies

Many RI and First Nations, Inuit and Métis 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 are likely to be maintained for a prolonged period. 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 public health unit and the community public health professionals.

As in other communities, the core personal and community-based measures are also extremely important for RI and First Nations, Inuit and Métis 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. Potential strategies for implementing personal and community-based PHMs in RI and First Nations, Inuit and Métis communities are listed below.

Availability of non-medical supplies

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

Strategies to consider:

Crowded or poor housing conditions

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

Strategies to consider:

Essential travel

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

Strategies to consider:

Limited access to running water

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

Strategies to consider:

Transmission of virus in public gatherings

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

Strategies to consider:

Need for tailored messaging

RI and First Nations, Inuit and Métis 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 and First Nations, Inuit and Métis communities receive is often not suited or tailored to their circumstances (e.g. limited access to water, health care and supplies) and considerations to culture, health literacy, disabilities, and language can present barriers to adoption of public health advice.

Strategies to consider:

Additional resources:

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: A framework for risk assessment and mitigation in community settings during the COVID-19 pandemic

Objective: Provide a framework for assessing risk and risk mitigation potential in community settings during the coronavirus disease (COVID-19) pandemic.

Audience: Public health authorities (PHA)

This document is not applicable to settings where health care is provided. First responders and health care workers should follow the occupational health and safety and infection prevention and control practices within their setting.

In response to the COVID-19 pandemic, many provinces and territories mandated the closure of workplaces, public settings, outdoor recreational activities, schools and childcare, with the exception of settings providing essential services and goods. As provinces and territories lift or adjust restrictive public health measures, this framework can support PHAs in systematically assessing COVID-19 risks for different settings and identifying mitigation measures to recommend when advising owners/operators on safe reopening during the COVID-19 pandemic. Should the need arise to re-implement more restrictive measures, this framework can help to identify settings with greater risks of COVID-19 introduction and spread. PHAs using this framework are encouraged to consider the local context, the setting characteristics, including the nature and duration of interactions, and the characteristics of individuals in the setting, who represent diverse groups based on gender, ethnicity/culture, and other socio-economic and demographic factors. From this risk assessment framework, PHAC has developed setting-specific tools for operators of community settings to help identify appropriate mitigation strategies based on their risks.

This risk assessment framework supports Canada’s collective approach to lifting restrictive public health measures and is based on public health assumptions that reflect the currently available scientific evidence and expert opinion. This framework is subject to change as new information on transmissibility, epidemiology, and effectiveness of public health and risk mitigation measures becomes available.

This framework guides local PHAs through a 3-step process to:

  1. Assess the risk level at different types of settings,
  2. Assess the risk mitigation potential, and
  3. Consider next steps for operating with risk mitigation measures.

In addition to mitigation measures implemented in specific settings, all Canadians should practice core personal practices (listed at the end of this document) in order to maximize our ability as a society to control the spread of the virus during the pandemic. Additionally, it is recommended that people most likely to experience serious illness due to COVID-19 (people of older age, and/or people with immune compromising or underlying medical conditions) should continue to stay at home as much as possible (i.e., should be encouraged to limit their time in the community and in close contact with others) during the pandemic.

Step 1: Assess the risk level

The risk level for a setting is based on the likelihood of the virus being introduced into the setting, the likelihood that the introduction of the virus results in transmission, and the impact of introduction or spread in the setting, and associated community.

The risk level considers two broad categories: (1) the characteristics of the setting, including the number of contacts, the proximity of contacts, the duration of contact, and environmental considerations and (2) the anticipated characteristics of the population in the setting including the vulnerability of the population and expected travel patterns of the population. In addition, the local context and epidemiology (i.e., whether there is COVID-19 transmission in the community surrounding the setting) is an important consideration for assessing risk.

To complete the risk assessment for the specified setting, identify the scenarios in Table 1 that best describe the setting and the characteristics of individuals in the setting. To estimate the risk level for a particular setting, consider the distribution of applicable scenarios across risk levels and the relative importance of the risk attributed to the setting vs. the characteristics of individuals in the setting. For example, if most individuals in the setting are at higher risk of severe illness, the risk level may be considered high even if the risks associated with the setting characteristics are moderate to low.

For settings that are re-opening, the risk assessment may be completed to evaluate the setting specific risk and offer relevant mitigation measures to minimize risk. For settings that have remained open to offer essential services throughout the COVID-19 pandemic, the risk assessment may be completed to re-evaluate the risk and potential mitigation strategies.

Table 1. Tool to assess the risk level
Risk level Setting characteristics Characteristics of individuals in the setting

High

  • Individuals have interactions with many others in the setting
  • Individuals have close contact (within 2 metres) with others
  • Individuals have prolonged (i.e., >15 minutesFootnote 51) interactions with others
  • Individuals frequently have contact with potentially infectious high-touch surfaces (e.g., door handles, service counters, railings)
  • The setting is a confined indoor space with no windows that can open
  • Most individuals are older adults or are known to have underlying medical or immune compromising conditions and are therefore at higher risk of severe illness
  • Most individuals are considered essential workers and critical shortages in workforce or expertise could result if they contract COVID-19 at the setting
  • Most individuals are visiting the setting from outside the community where it is located
  • Few individuals are able to practice core personal practices

Medium

  • Individuals have/may have interactions with some others in the setting
  • Individuals have/may have transient contact (within 2 metres for less than 15 minutes) with others when spending time in the setting
  • Individuals have/may have contact with high-touch surfaces
  • The setting is a confined indoor space, but has windows that can be opened
  • Some individuals may be older adults or are known to have underlying medical or immune compromising conditions and are therefore at higher risk of severe illness
  • Some individuals are considered essential workers and critical shortages in workforce or expertise could result if they contract COVID-19 at the setting
  • Some individuals are visiting the setting from outside the community where it is located
  • Some individuals are able to practice core personal practices

Low

  • Individuals have few to no interactions with others in the setting
  • Individuals are mostly able to avoid prolonged (i.e. >15 minutes) close contact (within 2 metres) with others in the setting
  • Contact with high-touch surfaces is infrequent
  • The setting is not a confined indoor space, or is outdoors
  • Few individuals are older adults or are known to have underlying medical or immune compromising conditions and are therefore at higher risk of severe illness
  • Few individuals are visiting the setting from outside the community where it is located
  • Most individuals are able to practice core personal practices

Note: There is currently insufficient evidence to define exposure risk by quantifying terms such as many vs. some vs. few, or frequently vs. sometimes vs. rarely.

General principles for interpreting the risk level include:

  • Settings with a higher number of contacts are presumed to have greater risk.Footnote 52
  • Settings with close and prolonged contact with others are presumed to have greater risk.Footnote 53
  • Settings with a higher frequency of contact with high-touch surfaces (i.e. surfaces frequently touched by others) are presumed to have greater risk.
  • Settings with a higher proportion of individuals that are vulnerable to severe illness are presumed to have greater risk in terms of impact on the population.
  • Settings with a higher proportion of individuals visiting from outside the community (i.e., from outside the city, town, county, or First Nations, Inuit or Métis community) are presumed to have greater risk in terms of introduction and geographic spread of the virus.

Step 2: Assess the risk mitigation potential

The risk mitigation potential for the setting is based on the types of controls that can be used to mitigate the risk of COVID-19 spread within the setting. The mitigation potential is based on the modified hierarchy of controls, in which measures are considered more protective to less protective in this order: physical distancing, engineering controls, administrative controls, and personal protective equipment (PPE) and non-medical masks (NMM).Footnote 54 In some higher risk settings, more protective measures including physical distancing may not be possible. To maximize risk mitigation potential, all settings should consider a “layered” approach where they implement multiple types of controls and mitigation measures aimed at reducing the risk of COVID-19, including decreasing the number of interactions with others and increasing the safety of interactions. Layering of multiple mitigation measures strengthens the risk mitigation potential overall. Critical components of the risk mitigation plan also include communication about setting-specific risk mitigation measures, and promoting personal preventive practices.

To complete the risk mitigation potential assessment, identify the categories of controls and risk mitigation measures in Table 2 that could likely be implemented in the setting. To estimate the risk mitigation potential of the setting (stronger, moderate, weaker), consider the number of measures that can be put in place and whether they are more or less protective according to the modified hierarchy of controls. The strength of controls and mitigation measures are considered stronger to weaker from left to right in Table 2.

For example, settings with stronger risk mitigation potential can implement more protective measures with physical distancing, and/or multiple engineering, and administrative control measures to eliminate or significantly reduce direct close contact between individuals in the setting and interactions with high-touch surfaces. Settings with moderate risk mitigation potential may be able to implement minimal physical distancing or engineering control measures, and rely mostly on administrative control measures to reduce direct close contact among individuals or with high-touch surfaces. Settings with weaker risk mitigation potential can only implement less protective measures such as minimal administrative controls or mainly rely on personal practices to reduce contact among individuals or with high-touch surfaces.

The measures in Table 2 are not exhaustive and many settings may be able to implement other measures. PHAs are encouraged to work collaboratively with sector-specific partners and stakeholders to identify creative and adaptive ways suited to particular settings to minimize contact duration and proximity among individuals and to reduce contact with possibly contaminated surfaces.

Table 2. Tool to assess the risk mitigation potential
  Physical distancingTable 2 Footnote 1 Engineering controlsTable 2 Footnote 1 Administrative controlsTable 2 Footnote 1 Personal protective equipment (PPE) and non-medical masks (NMM)Table 2 Footnote 1

Descriptions of control categories

Strategies to maintain a 2 metre distance between individuals and reduce time spent in close proximity

Strategies to create physical barriers between individuals and reduce exposure to common surfaces

Strategies to change to the way people interact with the setting in order to reduce risk (e.g., through changes to business policies or practices)

Equipment worn/used by a person to prevent spread of the virus

Mitigation measures

  • Close contact between people can be eliminated (e.g., teleworking, virtual services, contactless business model - delivery, curbside pickup)
  • The number of people that come into contact with another in the setting can be reduced (e.g., by restricting number of people in the setting)
  • Proximity of individuals can be reduced through physical separation (e.g. minimum 2 metres between desks, tables, counters, lineups)
  • Visual cues can be used to encourage a 2 metre distance (e.g. accessible signage, floor markings)
  • Physical barriers can be installed between individuals (e.g., plexiglass shield or high walled cubicle)
  • Windows can be opened or operations/activities can be moved outsideFootnote 55
  • The number of common surfaces that need to be touched can be reduced (e.g., doors propped open, no-touch waste containers)
  • Contactless payment methods can be offered, if possibleFootnote 56
  • Non-essential common areas can be closed
  • Access to non-essential equipment can be restricted
  • Individuals can be isolated from others if they develop symptoms in the setting
  • The frequency of environmental cleaning can be increased, especially for high-touch surfaces
  • Shared equipment can be cleaned and disinfected before and after use
  • Absenteeism policies can be adjusted to enable employees to stay home when ill, in quarantine (self-isolation), or if they are taking care of children or someone who is ill
  • It is possible to stagger when people enter and exit the setting to reduce number of contacts (e.g., staggered start times at work, or spacing between booked appointments).
  • Contact duration can be reduced to less than 15 minutes by changing the way people interact in the setting
  • Gatherings that attract people from longer distances can be limited
  • Access to handwashing facilities can be increasedFootnote 57 (e.g. by placing hand sanitizer dispensers in prominent locations), ensuring accessibility for individuals with disabilities or other accommodation needs
  • Special accommodations for clients from vulnerable groups (e.g. dedicated shopping hours for seniors and people with immune compromising or underlying medical conditions) can be provided
  • It is possible to post accessible signage to discourage individuals who are ill entering the setting
  • Individuals can be screened for known symptoms of COVID-19 before entering the setting (i.e., actively or passively)
  • Contact information for individuals in the setting can be collected so that they could be notified in the event of a known COVID-19 exposure
  • Tissues and no-touch waste containers can be provided to enable respiratory etiquette
  • PPE can be used appropriately as per usual practice or as recommended by the Occupational Health and Safety department or local PHA (e.g., if employees will be within 2 metres of others)
  • Individuals can wear NMMs in the setting when it is not possible to maintain a 2 metre physical distance from others
Table Footnote 1

Categories of controls. The strength of controls and mitigation measures are considered stronger to weaker from left to right.

Table 2 Return to footnote 1 referrer

Step 3: Consider next steps

The assessments of risk level (Table 1) and risk mitigation potential (Table 2) can be used by PHAs to determine a composite result that suggests suitability of the mitigations identified to adequately mitigate risk. These should be interpreted with consideration of other contextual factors that may not be captured by the framework, such as economic and social well-being in a community.

To use Table 3, plot the estimates of the risk level and risk mitigation potential of the setting, and use the result when considering the advice that the PHA will offer. For example, if the result indicates that the setting has a high-risk level with weak or moderate mitigation potential, or medium risk level with weak risk mitigation potential (i.e. falls in the red zone), significant further modifications to reduce risk may be recommended. The risk and modification potential should be continually reassessed.

Table 3. Matrix for determining overall risk of contributing to COVID-19 community transmission and next steps
  Risk mitigation potential (from Table 2)
Stronger Moderate Weaker

Risk level (from Table 1)

High

Moderate risk
of contributing to COVID-19 community transmission. Increase or strengthen mitigation strategies if possible.

Higher risk
of contributing to COVID-19 community transmission. Consider delaying reopening. Increase or strengthen mitigation strategies.

Highest risk
of contributing to COVID-19 community transmission. Consider delaying reopening. Increase or strengthen mitigation strategies.

Medium

Lower risk
of contributing to COVID-19 community transmission. Maintain mitigation strategies.

Moderate risk
of contributing to COVID-19 community transmission. Increase or strengthen mitigation strategies if possible.

Higher risk
of contributing to COVID-19 community transmission. Consider delaying reopening. Increase or strengthen mitigation strategies.

Low

Lowest risk
of contributing to COVID-19 community transmission. Maintain mitigation strategies.

Lower risk
of contributing to COVID-19 community transmission. Maintain mitigation strategies.

Moderate risk
of contributing to COVID-19 community transmission. Increase or strengthen mitigation strategies if possible.

Core personal preventive practices

With no targeted therapies or vaccine available at this time, core personal practices will be needed throughout the pandemic in order to maximize our ability as a society to control the spread of the virus. The following core personal practices are fundamental, and should continue throughout all steps of the COVID-19 response, including at all settings/businesses:

Footnote 1

Abacus Data. COVID-19 and Canadians' state of mind: worried, lonely, and expecting disruption for at least 2 to 3 months. Abacus Data bulletin. March 25, 2020. Available from: https://abacusdata.ca/coronavirus-covid19-abacus-data-mood-polling/

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Footnote 2

Tuite AR, Fisman DN, Greer AL. Mathematical modelling of COVID-19 transmission and mitigation strategies in the population of Ontario, Canada. CMAJ 2020. doi:10.1503/cmaj.200476; early released April 8, 2020.

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Footnote 3

Zivich PN, Gancz AS, Aiello AE. Effect of hand hygiene on infectious diseases in the office workplace: a systematic review. Am J Infect Control 2017;46:448-55. https.//doi.org/10.1016/j.ajic.2017.10.006

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Footnote 4

Van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Eng J Med 2020;382:1564-7. Doi: 10.1056/NEJMc2004973

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Footnote 5

Public Health Agency of Canada. People who are at high risk for severe illness from COVID-19. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/people-high-risk-for-severe-illness-covid-19.html

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Footnote 6

Public Health Agency of Canada. Updated: Public health management of cases and contacts associated with coronavirus disease 2019 (COVID-19). Updated April 10, 2020. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/guidance-documents.html

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Footnote 7

Public Health Agency of Canada. Coronavirus disease (COVID-19): Summary of assumptions. April 13, 2020. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/assumptions.html#a1

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Footnote 8

Yong SEF, Anderson DE, Wei WE, et al. Connecting clusters of COVID-19: an epidemiological and serological investigation. Lancet Infect Dis 2020. Published online April 21, 2020. doi: https://doi.org/10.1016/S1473-3099(20)30273-5

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Footnote 9

Dyal JW, Grant MP, Broadwater K, et al. COVID-19 Among Workers in Meat and Poultry Processing Facilities ― 19 States, April 2020. MMWR Morb Mortal Wkly Rep. ePub: 1 May 2020. doi: http://dx.doi.org/10.15585/mmwr.mm6918e3

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Footnote 10

Rivers C, Martin E, Watson C, et al. Public Health Principles for a Phased Reopening During COVID-19: Guidance for Governors. Johns Hopkins Bloomberg School of Public Health, Center for Health Security: April 17, 2020. Available from: https://www.centerforhealthsecurity.org/our-work/publications/public-health-principles-for-a-phased-reopening-during-covid-19-guidance-for-governors

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Footnote 11

Ibid.

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Footnote 12

Van Doremalen N, et al. Op. Cit.

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Footnote 13

Public Health Agency of Canada. Cleaning and disinfecting public spaces during COVID-19. 2020-04-20. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/cleaning-disinfecting-public-spaces.html

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Footnote 14

Public Health Agency of Canada. Infection Prevention and Control for COVID-19: Interim Guidance for Long Term Care Homes. Updated: April 8, 2020. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevent-control-covid-19-long-term-care-homes.html

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Footnote 15

Public Health Agency of Canada. Guidance for providers of services for people experiencing homelessness (in the context of COVID-19) Updated: April 13, 2020 Available from; https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/guidance-documents/homelessness.html

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Footnote 16

Canadian Centre for Occupational Health and Safety. Correctional facilities. April 20, 2020. Available from: https://www.ccohs.ca//images/products/pandemiccovid19/pdf/correctional_facilities.pdf

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Footnote 17

CDC. Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities. March 23, 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidance-correctional-detention.html

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Footnote 18

Public Health Agency of Canada. COVID-19 and people with disabilities in Canada. 2020-05-07. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/guidance-documents/people-with-disabilities.html

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Footnote 19

Liu YF, Li JM, Zhou PH, et al. Analysis on cluster cases of COVID-19 in Tianjin.2020. Zhonghua Liu Xing Bing Xue Za Zhi 2020;41:654-657. doi:10.3760/cma.j.cn112338-20200225-00165

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Footnote 20

Zhang Y, Su X, Chen W, et al. 2020. Epidemiological investigation on a cluster epidemic of COVID-19 in a collective workplace in Tianjin. 2020 Zhonghua Liu Xing Bing Xue Za Zhi = Zhonghua Liuxingbingxue Zazhi, 2020;41(5): 649-653. doi:10.3760/cma.j.cn112338-20200219-00121

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Footnote 21

Koh D. Occupational risks for COVID-19. Occupational Medicine 2020. doi:10.1093/occmed/kqaa036

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Footnote 22

Lan F, Wei C, Hsu Y, et al Work-related COVID-19 transmission. 2020 Medrxiv 2020.04.08.20058297. doi:10.1101/2020.04.08.20058297

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Footnote 23

Liu YF, et al. Op. cit.

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Footnote 24

Qian H, Miao T, Liu L, et al. Indoor transmission of SARS-CoV-2. 2020 medRxiv preprint. Posted Apr 7, 2020. doi: https://doi.org/10.1101/2020.04.04.20053058

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Footnote 25

Dyal JW et al. Op. cit.

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Footnote 26

Dong Y, Mo X, Hu Y, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics 2020 e20200702. doi:10.1542/peds.2020-0702

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Footnote 27

Ludvigsson JF. Systematic review of COVID-19 in children show milder cases and a better prognosis than adults. Acta Paediatrica 2020. doi:10.1111/apa.15270 [doi]

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Footnote 28

Gudbjartsson DF, Helgason A, Jonsson H, et al. Spread of SARS-CoV-2 in the Icelandic population. N Engl J Med 2020 Apr 14;NEJMoa2006100. doi: 10.1056/NEJMoa2006100. Online ahead of print.

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Footnote 29

Hua, C. Z., Miao, Z., Zheng, J., Huang, Q., Sun, Q., Lu, H., et al. (2020). What we should know about SARS-CoV-2 infection in children. SSRN- Lancet Prepublication. (3/26/2020). Available at SSRN: https://ssrn.com/abstract=3564422 or http://dx.doi.org/10.2139/ssrn.3564422

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Footnote 30

Mehta N, Mytton O, Mullins E, et al. SARS-CoV-2 (COVID-19): What do we know about children? A systematic review. SSRN- Lancet Prepublication (3/18/2020). Available at: SSRN https://ssrn.com/abstract=3558015

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Footnote 31

Sun K, Chen J, Viboud C. Early epidemiological analysis of the coronavirus disease 2019 outbreak based on crowdsourced data: A population-level observational study. Lancet Digital Health 2020;2: e201–08 Published Online February 20, 2020. Available at: https://doi.org/10.1016/S2589-7500(20)30026-1

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Footnote 32

National Centre for Immunisation Research and Surveillance (NCIRS). COVID-19 in schools – the experience in NSW. 26 April 2020. Available from: http://ncirs.org.au/sites/default/files/2020-04/NCIRS%20NSW%20Schools%20COVID_Summary_FINAL%20public_26%20April%202020.pdf

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Footnote 33

Zhu Y, Bloxham CJ, Hulme KD, et al. Children are unlikely to have been the primary source of household SARS-CoV-2 infections. Medrxiv. 2020.03.26.20044826. doi:10.1101/2020.03.26.20044826ootnote33

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Footnote 34

Nishiura H, Oshitani H. Kobayashi T, et al. (2020) Closed environments facilitate secondary transmission of coronavirus disease 2019 (COVID-19). medRxiv preprint. Posted March 03, 2020. doi: https://doi.org/10.1101/2020.02.28.20029272

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Footnote 35

Qian H et al. Op. cit.

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Footnote 36

National Collaborating Centre for Environmental Health, COVID-19 and outdoor safety: Considerations for use of outdoor recreational spaces. Apr 17, 2020. Available from: https://ncceh.ca/documents/guide/covid-19-and-outdoor-safety-considerations-use-outdoor-recreational-spaces

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Footnote 37

Ghinai I, Woods S, Ritger KA, et al. Community Transmission of SARS-CoV-2 at Two Family Gatherings - Chicago, Illinois, February-March 2020. MMWR Morb Mortal Wkly Rep 2020;69(15):446-50. doi: 10.15585/mmwr.mm6915e1.

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Footnote 38

Wei WE, Li Z, Chiew CJ, et al. Presymptomatic Transmission of SARS-CoV-2 — Singapore, January 23–March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:411-5. doi: http://dx.doi.org/10.15585/mmwr.mm6914e1

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Footnote 39

Hamner L, Dubbel P, Capron I, et al. High SARS-CoV-2 Attack Rate Following Exposure at a Choir Practice — Skagit County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. ePub: 12 May 2020. doi: http://dx.doi.org/10.15585/mmwr.mm6919e6

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Footnote 40

CIDRAP. Korean COVID-19 cases double. Feb 22, 2020. Available from: https://www.cidrap.umn.edu/news-perspective/2020/02/korean-covid-19-cases-double-iran-linked-infections-climb

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Footnote 41

World Health Association. Key planning recommendations for Mass Gatherings in the context of the current COVID-19 outbreak. Interim guidance. 19 March 2020. Available from: https://www.who.int/publications-detail/key-planning-recommendations-for-mass-gatherings-in-the-context-of-the-current-covid-19-outbreak

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Footnote 42

National Post. March 27, 2020. How an Edmonton curling tournament became a hotspot for the COVID-19 outbreak in Canada

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Footnote 43

European Centre for Disease Prevention and Control. Considerations for infection prevention and control measures on public transport in the context of COVID-19. 29 April 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-public-transport-29-April-2020.pdf

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Footnote 44

CIFRC, Unicef, WHO. Social Stigma Associated with COVID-19. Feb 20, 2020. Available from: https://www.epi-win.com/sites/epiwin/files/content/attachments/2020-02-24/COVID19%20Stigma%20Guide%2024022020_1.pdf

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Footnote 45

CDC. Reducing stigma. 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/reducing-stigma.html

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Footnote 46

Pan-Canadian Public Health Network Council. Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector. August 2018. Available from: https://www.canada.ca/en/public-health/services/flu-influenza/canadian-pandemic-influenza-preparedness-planning-guidance-health-sector.html

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Footnote 47

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

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Footnote 48

National Collaborating Centre for Aboriginal Health. Family is the focus. 2015. Available from: https://www.nccih.ca/docs/health/RPT-FamilyFocus-EN.pdf

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Footnote 49

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

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Footnote 50

Public Health Agency of Canada. Updated: Public health management of cases and contacts associated with coronavirus disease 2019 (COVID-19). Updated April 10, 2020. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/guidance-documents.html

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Footnote 51

Prolonged exposure is defined as lasting for more than 15 minutes. The 15 minutes can be from one continuous exposure or the cumulative duration of interactions with the same individual while in the setting. (Ref: Updated Public Health Management of Cases and Contacts Associated with Coronavirus Disease 2019. Available at: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-cases-contacts.html)

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Footnote 52

Rivers, C., et al. Public health principles for a phased reopening during COVID-19: Guidance for governors. 2020. [Accessed at: https://www.aei.org/research-products/report/public-health-principles-for-a-phased-reopening-during-covid-19-guidance-for-governors/]

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Footnote 53

Ibid.

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Footnote 54

Adapted from: Rivers, C., et al. Public health principles for a phased reopening during COVID-19: Guidance for governors. 2020. [Accessed at: https://www.aei.org/research-products/report/public-health-principles-for-a-phased-reopening-during-covid-19-guidance-for-governors/]

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Footnote 55

Increasing ventilation (e.g., opening windows when weather permits) may help to reduce transmission, though evidence is limited as to its effectiveness

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Footnote 56

Using contactless payment methods may limit potential exposure; however, the Bank of Canada advocates that retailers continue to accept cash using safe handling practices to ensure Canadians have access to the goods and services they need. Refusing cash purchases outright will put an undue burden on those who depend on cash and have limited payment options.

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Footnote 57

For settings without access to running water, hands can be washed in a large bowl, throwing out the water from the bowl after each individual use. If water is not safe for use, use bottled water with soap, or alcohol-based hand sanitizer containing at least 60% alcohol to clean hands. If the community is on a boil water or do not consume advisory, the water can still be used to wash hands with soap and water.

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Footnote 58

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

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Footnote 59

National Bureau of Economic Research. The impact of COVID-19 on Gender Equality. April 2020. Available from: https://www.nber.org/papers/w26947.pdf.

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Footnote 60

Public Health Agency of Canada. Prevention and control of influenza during a pandemic for all healthcare settings. May 2011. Available at: https://www.canada.ca/en/public-health/services/flu-influenza/canadian-pandemic-influenza-preparedness-planning-guidance-health-sector.html.

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