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

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

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

Introduction

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

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

Figure 1: Goal of Public Health Measures
Figure 1: Goal of Public Health Measures
Figure 1: Goal of Public Health Measures - Text description

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

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

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

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

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

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

Hand hygiene

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

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

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

Respiratory etiquette

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

Environmental cleaning and ventilation

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

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

Social distancing

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

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

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

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

Self-monitoring

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

Use of masks

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

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

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

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

Community-based measures

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

Guidance developed for acute health settings is availableFootnote vii and can be applied to any setting where healthcare is being provided.

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

Avoiding crowding

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

Factors to consider when making decisions:

School and daycare measures

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

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

Table 2: Definition of terms relevant to school measuresFootnote xi
Term Definition
School mitigation measures School remains open and alternative measures are implemented to promote social distancing and decrease density among students and staff.
Class dismissal School remains open with core staff, but most children stay home (similar to a "snow day").
School closure School is closed to all children and staff.
Reactive closure or dismissal School is closed after a substantial incidence of illness is reported among children or staff (or both) in that school.
Proactive closure or dismissal School is closed before a substantial transmission among children and staff. Is only helpful before the peak of an outbreak in the community.

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

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

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

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

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

Workplaces

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

Strategies that workplaces can put into effect include:

Mass gatherings

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

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

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

Public education and communication

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

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

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

Considerations for a communications response

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

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

Appendix 1: Considerations for remote and isolated communities

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

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

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

Provincial/Territorial variations with respect to infrastructure, human resource capacity, and planning principles should be taken into account when reading this document. It is recommended that this guidance be considered in conjunction with relevant federal, provincial and territorial guidance and planning documents, which should take into consideration existing treaties, agreements and relationships.

Public health measures mitigation strategies

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

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

Lack of availability of non-medical supplies

Delivery and transportation of non-medical supplies (e.g. soap, food, household items) in RI communities can be challenging due to limited or disrupted transportation in and out of the community and other factors such as inclement weather and/or illness precluding individuals from being able to access supplies.

Strategies to consider:

Crowded or poor housing conditions

RI communities typically experience higher rates of overcrowding, and housing standards are often below adequacy and suitability standards. This is of concern because overcrowding and inadequate housing conditions contribute to increased likelihood of transmission of communicable diseases. Guidance to address the unique challenges for caring for someone in the home is available in Public Health Management of cases and contacts associated with novel coronavirus disease (COVID-19) guidance.

Limited access to running water

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

Strategies to consider:

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

Where tap water is not immediately accessible, a closed water container with a spigot can be used to store water for handwashing.

When clean water is not available (e.g. during a boil water advisory or when water quality/source is unknown) consider boiling available water (e.g. boiling for one minute to a rolling boil and allow to completely cool).

Alcohol-based hand sanitizer (ABHS) containing at least 60% alcohol can be used for hand hygiene if soap and water is not available. However, if hands are visibly soiled, hand wipes should be used to remove any such soil or organic material; this should then be followed by the use of ABHS.

Transmission of virus in public gatherings

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

Strategies to consider:

Impact of illness in schools

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

Strategies to consider:

Need for Tailored Messaging

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

Strategies to consider:

References

Footnote i

Pan-Canadian Public Health Network Council. Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector. [Online] August 2018. (Accessed on March 2, 2020) https://www.canada.ca/en/public-health/services/flu-influenza/canadian-pandemic-influenza-preparedness-planning-guidance-health-sector.html

Return to footnote i referrer

Footnote ii

Pan-Canadian Public Health Network Council. Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector: Public Health Measures Annex. [Online] February 2019. (Accessed on March 2, 2020) https://www.canada.ca/en/public-health/services/flu-influenza/canadian-pandemic-influenza-preparedness-planning-guidance-health-sector/public-health-measures.html

Return to footnote ii referrer

Footnote iii

Public Health Agency of Canada. Public Health Management of Cases and Contacts associated with novel coronavirus (COVID-19). February 27, 2020. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-cases-contacts.html

Return to footnote iii referrer

Footnote iv

WHO. Q&A on infection prevention and control for health care workers caring for patients with suspected or confirmed 2019-nCoV. [Online] 21 February 2020 [Accessed at: https://www.who.int/news-room/q-a-detail/q-a-on-infection-prevention-and-control-for-health-care-workers-caring-for-patients-with-suspected-or-confirmed-2019-ncov].

Return to footnote iv referrer

Footnote v

ECDC. Guidelines for the use of non-pharmaceutical measures to delay and mitigate the impact of 2019-nCoV. [ONLINE] February 2020. Accessed on February 26, 2020.

Return to footnote v referrer

Footnote vi

WHO. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19). Interim guidance, February 27, 2020. Accessed on February 28, 2020. https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf

Return to footnote vi referrer

Footnote vii

Infection prevention and control for coronavirus (COVID-19): interim guidance for acute health care settings. Accessed February 24, 2020. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-acute-healthcare-settings.html

Return to footnote vii referrer

Footnote viii

PHAC. Risk-informed decision-making for mass gatherings during COVID-19 global outbreak.

Return to footnote viii referrer

Footnote ix

IFRC, WHO, UNICEF. Social Stigma Associated with COVID-19. Accessed February 29 2020. Available at: https://www.epi-win.com/sites/epiwin/files/content/attachments/2020-02-24/COVID19%20Stigma%20Guide%2024022020_1.pdf

Return to footnote ix referrer

Footnote x

PHAC. Public Health Guidance for Schools (K-12) and Childcare Programs (COVID. [Online] February 28, 2020. (Accessed on March 2, 2020) https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/guidance-schools-childcare-programs.html

Return to footnote x referrer

Footnote xi

WHO. Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza. [Online] October 2019. Accessed on February 27, 2020 https://www.who.int/influenza/publications/public_health_measures/publication/en/

Return to footnote xi referrer

Footnote xii

CDC. Interim Guidance for Administrators of US Childcare Programs and K-12 Schools to Plan, Prepare, and Respond to Coronavirus Disease 2019 (COVID-19). [Accessed March 2 2019]. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/guidance-for-schools.html

Return to footnote xii referrer

Footnote xiii

WHO. Getting your workplace ready for COVID-19. [online] February 27, 2020. Accessed on Feb 28, 2020. https://www.who.int/docs/default-source/coronaviruse/getting-workplace-ready-for-covid-19.pdf

Return to footnote xiii referrer

Footnote xiv

CDC. Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19). February 2020. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/guidance-business-response.html

Return to footnote xiv referrer

Footnote xv

WHO. Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza. [Online] October 2019. Accessed on February 27, 2020 https://www.who.int/influenza/publications/public_health_measures/publication/en/

Return to footnote xv referrer

Footnote xvi

Livescience. 'Superspreader' in South Korea infects nearly 40 people with coronavirus. [Online] February 23,2020. Accessed March 2, 2020. https://www.livescience.com/coronavirus-superspreader-south-korea-church.html

Return to footnote xvi referrer

Footnote xvii

WHO. Key planning recommendations for Mass Gatherings in the context of the current COVID-19 outbreak. [ONLINE] February 14, 2020. Accessed on February 26, 2020. https://www.who.int/publications-detail/key-planning-recommendations-for-mass-gatherings-in-the-context-of-the-current-covid-19-outbreak

Return to footnote xvii referrer

Footnote xviii

Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector. Communications and Stakeholder Liaison Annex. 2018. https://www.canada.ca/en/public-health/services/flu-influenza/canadian-pandemic-influenza-preparedness-planning-guidance-health-sector/communications-stakeholder-liaison-annex.html

Return to footnote xviii referrer

Footnote xix

CIFRC, Unicef, WHO. Social Stigma Associated with COVID-19. 2020. Accessed on February 26, 2020. https://www.epi-win.com/sites/epiwin/files/content/attachments/2020-02-24/COVID19%20Stigma%20Guide%2024022020_1.pdf

Return to footnote xix referrer

Footnote xx

National Collaborating Centre for Aboriginal Health. June 2016. Culture and language as social determinants of First Nations, Inuit, and Métis health. Accessed 26 February 2020. https://www.nccih.ca/495/Culture_and_language_as_social_determinants_of_First_Nations,_Inuit,_and_M%C3%A9tis_health.nccih?id=15

Return to footnote xx referrer

Footnote xxi

National Collaborating Centre for Aboriginal Health. 2015. Family is the focus. Accessed 20 February 2020. https://www.nccih.ca/docs/health/RPT-FamilyFocus-EN.pdf

Return to footnote xxi referrer

Footnote 1

The groups at higher risk of developing severe illness from COVID-19 is not well understood; however, according to the World Health Organization, older persons and persons with pre-existing medical conditions (such as hypertension, heart disease, or diabetes) appear to develop serious illness more often than others.

Return to footnote 1 referrer

Report a problem or mistake on this page
Please select all that apply:

Thank you for your help!

You will not receive a reply. For enquiries, contact us.

Date modified: