Guidance for a strategic approach to lifting restrictive public health measures

Introduction

The status of the COVID-19 epidemic varies across Canada, affecting diverse groups based on gender, ethnicity/culture, and other socioeconomic and demographic factors. Nationally, we are seeing the impact of public health measures on the flattening of the epidemic curve and slowdown in the growth of new cases of COVID-19. The nature and phase of the COVID-19 epidemic is different across and within provinces and territories. This document provides guidance to public health authorities for transition planning that is underway across Canada as well as a strategic approach to lifting restrictive public health measures that can be tailored to jurisdictions. It builds on the Federal Provincial Territorial (FPT) Special Advisory Committee on COVID-19’s Recommendations on Foundations for Living with COVID-19 in Canada.

Goals

The goals of the COVID-19 pandemic response are to first minimize all serious illness and death, (due to all causes) and secondly minimize societal disruption, including reducing the burden on health care resources. These goals speak to the need to strike a balance between the positive and negative impacts of restrictive public health measures.

As some public health measures are lifted, some degree of COVID-19 transmission will be unavoidable; therefore, implementing a strategic approach that maintains protective measures for those most likely to experience serious illness due to COVID-19 is paramount. Consideration must also be given to the mental health impact of lifting public health measures – both positive and negative. Until targeted therapies or a vaccine is available, the aim will be to carefully balance the risks associated with spread of COVID-19 with the unintended social and health consequences of restrictive public health measures, including among vulnerable groups.

Objectives

The objectives of this strategic approach are as follows;

• Mitigate the risk of increased transmission due to lifting of restrictive public health measures
• Protect vulnerable/high-risk populations (e.g. older Canadians, people with underlying or immune-compromising health conditions, people living in crowded conditions, people with low incomes or insecure employment) and settings (e.g. long-term care facilities, homeless shelters, rural and remote regions, co-living spaces such as dormitories, Indigenous communities).
• Maintain the health care and public health capacity demands below critical levels.
• Increase social and economic activity with appropriate conditions and controls in place
• Monitor impacts to inform decision-making regarding modifications to approach.
• Frequent and transparent communication to the public to highlight their role in reducing the risk of COVID-19.

Principles

The following nationally agreed upon principles are the basis for the approach to lifting restrictive public health measures in Canada.

• Science and evidence-based decision-making – Decisions to ease and/or reinstate measures should be based on current public health situations as advised by public health officials.
• Coordination and Collaboration – Strong collaboration to date has served Canadians well and continued collaboration is key to ongoing success. Governments agree to support the continuation of supply chains across borders to maintain economic activity, access to protective equipment and food security for all Canadians. Governments will continue to share information about challenges and opportunities. Since provinces, territories and the Government of Canada may need to move forward at different times and in potentially different ways, it will be important to maintain the coordination and collaboration that has taken place throughout the pandemic (e.g., consistent guidance on occupational health and safety requirements).
• Accountability and Transparency – Each government will continue to be accountable to its residents, and will monitor the impacts of measures to restart the economy and provide updates on progress. Data sharing is critical to understanding the situation across Canada and is essential to informing efforts to reopen segments of the economy.
• Flexibility and Proportionality – Public health measures should be relaxed based on the level of threat and in a controlled and phased manner based on information that may change over time. This includes information on risks around the disease and health of Canadians, as well as social and economic benefits to them. It also includes local and sectoral contexts (e.g., different workplaces, educational institutions, and social activities). It is recognized that there will be differences within jurisdictions on approaches taken and that measures may need to be re-imposed if the understanding of the information changes.

Strategic approach

This document proposes a strategic approach that addresses the goals and objectives while keeping in mind the nationally agreed upon principles. The approach includes: an assessment of readiness, a core set of personal public health practices for individuals to follow that should be maintained throughout the COVID-19 response, recommendations for monitoring and risk assessment, and progressive steps for lifting restrictive public health measures. Provinces and territories will determine which steps to include in their respective phased transition plans.

The provision of steps is intended to facilitate a logical, cautious and gradual progression to fewer restrictions on currently affected societal and economic activities. In order to provide a starting point and example of the conditions and modifications that could be implemented when lifting a measure, an initial approach with five “first step” actions has been provided.

Readiness criteria and indicators for living a new normal with COVID-19

The FPT Special Advisory Committee (SAC) has agreed on a set of criteria and indicators to assess readiness for lifting restrictive public health measures in Canada. These seven criteria and thirteen indicators will also be used to assess the need for re-introduction of specific measures as the pandemic progresses.

1. COVID-19 transmission is controlled
   Indicator 1.1: Number of cases (linked and non-linked), hospitalizations, intensive care unit (ICU) admissions and deaths per day
   Indicator 1.2: Reproduction number, absolute and relative changes in cases, hospitalizations and deaths
2. Sufficient public health capacity is in place to test, trace and isolate all cases
   Indicator 2.1: Testing capacity
   Indicator 2.2: Resources to trace contacts
   Indicator 2.3: Ability to isolate all cases
   Indicator 2.4: Ability to quarantine all contacts
3. Expanded health care capacity exists: the incidence of new cases should be maintained at a level that the health system can manage including substantial clinical care capacity to respond to surges
   Indicator 3.1: Critical care capacity
   Indicator 3.2: Availability of personal protective equipment (PPE)
4. Supports are in place for vulnerable groups/communities and key populations to minimize outbreak risks
   Indicator 4.1: Availability of guidance for staff and residents to prevent transmission among vulnerable groups/settings
   Indicator 4.2: Number, size, and status of outbreaks in high vulnerability settings
5. Workplace preventive measures are established to reduce risk
   Indicator 5.1: Availability of guidance for workers and employers to prevent transmission of COVID-19 in the workplace
   Indicator 5.2: Number of workplace outbreaks
6. Avoiding risk of importation of cases
   Indicator 6.1: Number of international travel-related cases
7. Engage and support communities to adjust to the new normal
   Indicator 7.1: Communications strategies in place

This set of criteria and indicators provide a data and evidence-driven basis for decisions to lift or adjust restrictive public health measures. Together these indicators could help determine, objectively, each government’s readiness for the gradual, coordinated lifting (or re-instating) of restrictive measures that will ultimately facilitate the safe re-launch of our economies and societal activities.

Core personal public health practices

With no targeted therapies or vaccine available, core personal public health practices will need to become the “new normal” in order to maximize our ability as a society to control the spread of the virus for the long term. The following core personal public health practices are fundamental, and should continue throughout all steps of the COVID-19 response:

• Staying informed, being prepared and following public health advice
• Continuing to practice good hygiene (hand hygiene [i.e., washing or sanitizing], avoid touching face, respiratory etiquette [e.g., coughing into elbow])
• Staying at home and away from others if symptomatic/feeling ill – not going to school/work and following jurisdictional/local public health advice
• Maintaining physical distancing as much as possible when outside of the home (i.e. from non-household members)
• Cleaning and disinfecting your surfaces and objects
• Staying at home as much as possible if at high risk of severe illness
• When the local epidemiology and rate of community transmission warrant it, the wearing of non-medical masks (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^{Footnote a}
• Wearing a medical mask or, if not available, a NMM or cloth face covering, if experiencing symptoms, and if will be in close contact with others or going out to access medical care
• Reducing personal non-essential travel

Frequent and transparent communication to the public will be important to help engage Canadians on their role in reducing the risk of COVID -19 by adopting these practices. These communications should be incorporated into an on-going community and engagement strategy with the public and should emphasize the continued importance of these core personal practices as restrictive public health measures are lifted. This includes a need to engage and partner with Indigenous communities to co-develop a culturally appropriate, gradual phased re-opening plan to prevent workers from bringing the virus to their home community.

Engagement strategies should also consider and address challenges, barriers and opportunities to maintain these practices at the population level and in certain vulnerable populations in ways that avoid stigma and discrimination. For example, some people may live in crowded conditions or lack access to clean running water, making it difficult for them to follow guidelines for social distancing or hygiene practices.

Recommendations for monitoring and risk assessment

Provincial/territorial and/or local surveillance and capacity assessment data will inform the need for any adjustments to the implemented strategy based on the previously listed criteria and indicators. Routine, daily, monitoring of indicator data is needed, recognizing that a 'waiting period' is often required to be able to detect any impact of lifting of restrictive measures, due to natural delays in diagnosis and reporting. Risk assessments examining likelihood of transmission and the consequences of that transmission should be conducted on a routine basis and prior to any additional lifting of restrictive measures. Jurisdictions should consider conducting risk assessment at a minimum every 28 days (2 maximum incubation periods), in order to allow sufficient time to pass to assess the impact of the lifted restrictions. Regardless, the need to possibly re-implement measures should be recognized and proactively communicated.

Ongoing protection of high-risk individuals and Indigenous communities

A protective approach for those most likely to experience serious illness due to COVID-19 is also expected to be maintained throughout the pandemic response. Currently, this applies to older adults and/or people with immune compromising or underlying medical conditions. The risk to these individuals should be assessed based on their specific situation and the epidemiology of COVID-19 (e.g., age-based hospitalization rates).

In current and near-term periods, it is recommended that these people should stay at home unless needing urgent medical services. Teleworking, if possible, is encouraged throughout the response and return to a workplace only where/when specific protective conditions for high-risk individuals have been put in place including the ability to get to and from the workplace without the use of mass transit. In general, as restrictive measures are lifted, these individuals should continue to stay at home as much as possible (i.e., should be encouraged to limit their time in the community) so that they have a high degree of control over their environment and interactions with others.

It is important to consider the potential impact these measures may have on individuals’ physical, social, mental and emotional health and wellbeing. Mental health support services and resources are available, such as the Wellness Together Canada: Mental Health and Substance Use Support portal. For work sites (e.g., mines, factories) close to Indigenous communities, especially in remote and isolated areas, extra cautions need to be taken to prevent and detect COVID-19 infections among the workforce to prevent COVID-19 within the communities. If there is an outbreak, workers should be strictly self-isolated for 14 days before they return to their community.

Consultation and collaboration with First Nations, Inuit and Metis leadership and elders is a necessity when planning for the lifting of restrictive public health measures. In many cases, the potential measures and timelines for lifting restrictive public health measures within remote, isolated and Indigenous communities will need to be adapted to their specific context and environment, even if these are different than the measures and timelines applied throughout the broader public jurisdiction where these communities are located.

Often these communities are considered “vulnerable” due to circumstances such as geographic location, access to health care resources, demographics, living conditions or prevalence of underlying medical conditions that place community members at higher-risk for severe COVID-19 outcomes. In these cases, it is critical that public health measures are taken through collaboration, dialogue and consultation with these communities, including First Nations, Inuit and Metis. Consultation and collaboration, between the public health officials of the provincial and territorial jurisdictions where these communities are located and the local governance structures, is of vital importance in making, communicating, monitoring and reporting back to communities on these decisions and their impacts.

Progressive steps for lifting restrictive public health measures

This is a pan-Canadian approach that can be implemented regionally/provincially based on local circumstances. Transition should be slow, gradual and tailored to jurisdictional contexts including remote and isolated communities, with sufficient time between each step of transition to evaluate the impact of changes in measures. Jurisdictions will also be monitoring the effectiveness (harms and benefits) of specific measures, including their unintended consequences such as disproportionate health, social, and economic impacts for certain population groups. As new information becomes available, less effective measures will be adjusted as appropriate.

The proposed initial phase includes five “first step” actions along with associated conditions and modifications that could be recommended when lifting each of these measures, as an example of the type of guidance to be provided in phased transition plans.

First step actions and specific conditions for lifting public health measures

Five first-step actions have been identified for consideration by governments for inclusion in their respective first phases of transition. These particular actions have been identified for the following reasons: their interconnectedness with other measures (e.g., work and childcare), feasibility of physical distancing and required specific conditions , seasonality, need to reduce unintended consequences of restrictive measures, and ability to decrease societal disruption and stimulate economic activity.

Specific conditions for the lifting of the restrictive measures have been recommended for each of the five first-step actions These conditions or modifications should be met in order to reduce contact intensity and number of contacts and, thereby, the risk of transmission. Meeting these conditions will increase the ability to mitigate the risks associated with lifting measures. Based on the seven criteria indicators outlined by the special advisory committee above, it is recommended that governments consider beginning with the following 5 actions to lifting the restrictive public health measures:

1. Some non-essential businesses able to open
   
   • Core personal practices supported to the extent possible (e.g. hand hygiene stations, tissues/wastebaskets)
   • Maintain physical distancing whenever possible (e.g., telework when possible, signage, floor markings, appropriate spacing of restaurant tables)
   • Support for staff to stay at home if they are sick
   • Efforts are made to prevent the entry of sick individuals (e.g. signage about not entering if symptomatic at entrance to business or when booking appointment)
   • Employ physical barriers (e.g., plexiglass at checkout) and other engineering controls (e.g., increasing ventilation)
   • Increase environmental cleaning (e.g., increase the frequency of cleaning/disinfecting high-touch surfaces)
   • Offer special options for persons at high-risk of severe illness (e.g., online/phone ordering, curbside pick up, special hours)
2. Daycare and education settings/camps to operate/open
   • Maintain the provision of online learning as an option for students with conditions that place them at higher risk of severe illness from COVID 19 and to support students to stay at home if they are sick (e.g. immune-compromised)
   • Core personal practices supported (e.g. provide hygiene education, supervised hand hygiene)
   • Screening of all staff and students/campers
   • Maintain physical distancing as much as possible (e.g., separation of desks, no assemblies, no high-contact sports, limit extracurricular activities)
   • Staff and students/campers at higher risk of severe illness remain at home
   • Environmental cleaning (e.g., increase the frequency of cleaning/disinfecting high-touch surfaces)
   • Non-medical masks may be considered; however, they are not recommended for children < 2 years of age.
3. Additional outdoor activities/recreation to resume
   • Core personal practices supported to the extent possible
   • Maintain physical distancing between members of different households when participating in outdoor recreation (e.g. picnics, camping).
   • Support staying at home if you are sick (e.g., participate in part of a camp, provide a refund if cannot attend due to illness)
   • No large gatherings, even outdoors and when appropriately physically distanced
   • Sports – allow only sports that can maintain physical distancing (e.g., low/no contact, separation on sidelines)
   • Equipment - no sharing, cleaning common sporting equipment in between use
4. Non-urgent health care services to resume
   • Core personal practices supported (e.g. hand hygiene supplies, tissues)
   • Physical distancing measures in place (e.g. tele-medicine, no waiting in waiting room, call in from car)
   • Screen for symptoms and reschedule or implement infection control measures at point of assessment
   • Scheduling to protect patients at higher risk of severe illness (e.g., certain days, beginning of day)
   • Environmental cleaning (e.g., increase frequency of cleaning/disinfecting high-touch surfaces, between patients)
5. Small critical cultural ceremonies (such as funerals) to take place
   • Core personal practices supported (e.g. hand hygiene supplies, tissues)
   • Screening of personnel and mourners prior to entering the gathering
   • Persons at higher risk of severe illness should not attend
   • Physical distancing maintained
   • Limit size of gathering (e.g., number of participants)
   • No receptions or buffet meals; single-serving refreshments only
   • Ceremonies are held outdoors when possible

Next steps for progressive lifting of restrictive public health measures

Core personal public health practices need to be maintained throughout the transition to the point where there is a significant level of population immunity due to widespread infection or use of an effective vaccine; or the threat the virus poses is reduced due to the availability of effective therapeutics/medical treatments or, possibly, a reduction in severity of illness due to viral mutation (i.e., Step 5).

The section below on recommended progression by setting, service or activity provides guidance regarding the sequential lifting of restrictive public health measures. Some activities are interdependent, for example permitting more people to return to work outside of the home and the provision of childcare. These interdependencies need to be considered by jurisdictions when determining the elements to include in each phase of their transition plans. The columns in this table reflect the sequence of steps for the activity in each row. They are not meant to determine which activities should be included in each phase as these need to be determined by each jurisdiction based on their local epidemiological, societal and economic context and priorities, including the status of stakeholder consultations in transition planning.

In order to proceed in a cautious manner it is crucial that public health authorities provide direction to the public, business owners/operators, event organizers and service providers regarding the conditions or modifications that should be in place and sustained as they start to operate again or increase their activities.

Gradually lifting restrictive public health measures for COVID-19 in Canada: Recommended progression by setting, service or activity

Implementation timing for each setting, service or activity is contingent on meeting criteria to be determined by jurisdiction.

Settings with vulnerable populations

Setting, service or activity	Current state of measure April 2020	Step 1 Near-term	Step 2 Short-term	Step 3 Medium-term	Step 4 Longer-term	Step 5 Significant population immunity
Closed settings, with populations at higher risk for severe illness (e.g., long-term care facilities, residential care, prisons)	Restrictions on visitors; protective measures in place	Continue (as per current state)	Continue (as per previous step)	Open to visitors with conditions. [1,2,3,4,5,7,8,9] Restrictions/protective measures continue	Continue (as per previous step)	Lift all conditions or restrictions
Other congregate living environments (e.g., shelters for homeless)	Restrictions on access; protective measures in place	Continue (as per current state)	Continue (as per previous step)	Lift some restriction (e.g. permit greater access to shelter) with conditions [1-9] Protective measures continue	Continue (as per previous step)	Lift all conditions or restrictions

Workplaces, businesses and services (interdependency with childcare and public transit)

Setting, service or activity	Current state of measure April 2020	Step 1 Near-term	Step 2 Short-term	Step 3 Medium-term	Step 4 Longer-term	Step 5 Significant population immunity
Workplaces/businesses providing essential services	Open with conditions [1-9]	Continue (as per current state)	Continue (as per current state)	Continue (as per current state)	Continue (as per current state)	Lift all conditions
Non-urgent healthcare services (e.g. elective surgeries, physiotherapy, non-emergency dental care)	Closed	Open with conditions [1-9]	Continue (as per previous step)	Continue (as per previous step)	Continue (as per previous step)	Lift all conditions
Workplaces/businesses providing non-essential services Decisions on which non-essential businesses to re-open depends on specific characteristics of different industries and sectors, including: the vulnerability of a sector’s workforce (e.g. average age, proportion with underlying health conditions), importance of sector to the local economy, and impact of the sector on the well-being of vulnerable populations.	Closed	Open those businesses able to meet conditions [1-9] Telework continues where possible	Expand to more non-essential businesses with conditions [1-9] Telework continues where possible	Expand to more non-essential businesses with conditions [1-9] Telework continues where possible	Continue (as per previous step) Telework continues where possible	Lift all conditions

Schools and child care settings

Setting, service or activity	Current state of measure April 2020	Step 1 Near-term	Step 2 Short-term	Step 3 Medium-term	Step 4 Longer-term	Step 5 Significant population immunity
Childcare and child oriented settings (e.g. day camps, daycares) (Interdependency with workplaces)	Most are closed Childcare for essential workers only	Open with conditions [1,3,4,5,7,8,9]	Continue (as per previous step)	Continue (as per previous step)	Continue (as per previous step)	Lift all conditions
Schools (K-12) (Interdependency with work places)	Closed	Open with conditions [1,3,4,5,7,8,9]	Open with fewer conditions (e.g. assemblies are allowed)	Continue (as per previous step)	Continue (as per previous step)	Lift all conditions
Colleges and Universities (Interdependency with public transportation)	Closed for all on-campus activities	Continue (as per previous step)	Continue (as per previous step)	Open with conditions Fall 2020 [1,3,4,5,7,8,9]	Continue (as per previous step)	Lift all conditions

Outdoor spaces

Setting, service or activity	Current state of measure April 2020	Step 1 Near-term	Step 2 Short-term	Step 3 Medium-term	Step 4 Longer-term	Step 5 Significant population immunity
Outdoor spaces and activities/recreation Group A: physical distancing can be maintained, e.g., walking, running, biking; skateboarding, skating, playgrounds, parks, campgrounds, beaches	Allowed for individual and members of same household; most spaces are closed	Continues with conditions [1,3,7]	Continues with expanded contacts (2 other households)	Continue with further expanded contacts [1,3,7]	Continue (as per previous step) with conditions	Lift all conditions
Group B: Physical distancing can be maintained; more modifiable, e.g., low contact sports (golf, tennis), throwing a Frisbee, kicking/throwing a ball between distanced partners, splash pads, public pools	Not permitted for those in quarantine (self-isolation) for 14 days	Allowed with conditions [1,3,7]	Continues with conditions [1,3,7]	Continues with conditions [1,3,7]	Continue (as per previous step) with conditions	Lift all conditions
Group C: Physical distancing is difficult to maintain; less modifiable, e.g., soccer, rugby, baseball, basketball, amusement parks	Not permitted for those in quarantine (self-isolation) for 14 days	Not permitted	Not permitted	Allowed with conditions [1,3,4,5,7,9]	Continue (as per previous step) with conditions	Lift all conditions

Indoor sports, recreation and community spaces

Setting, service or activity	Current state of measure April 2020	Step 1 Near-term	Step 2 Short-term	Step 3 Medium-term	Step 4 Longer-term	Step 5 Significant population immunity
Group A: Physical distancing can be maintained low contact sports, e.g., indoor golf, tennis, gymnastics, art programs Group B: Physical distancing is difficult to maintain, e.g., hockey, ringette, soccer	Closed	Closed	Group A with conditions [1,3,4,5,7,8,9]	Group B allowed with conditions [1,3,4,5,7,8,9]	Continue (as per previous step) for A and B with conditions	Lift all conditions
Indoor settings, e.g., libraries, community centres, places of worship, museums, theatres	Closed	Closed	Allowed with conditions, where physical distancing can be maintained [1,3,4,5,7,8,9]	Allowed with conditions where physical distancing is more difficult to maintain [1,3,4,5,7,8,9]	Continue (as per previous step)	Lift all conditions

Gatherings of families and friends, mass gatherings

Setting, service or activity	Current state of measure April 2020	Step 1 Near-term	Step 2 Short-term	Step 3 Medium-term	Step 4 Longer-term	Step 5 Significant population immunity
Gatherings of family and friends: e.g., weddings, funerals, baptisms, small social gatherings such as birthday parties, small cultural ceremonies	Prohibited	Small critical cultural ceremonies allowed with conditions [1,3,4,5,7,8,9]	Allow small social gatherings with members of 2 households with conditions [1,3,4,5,7,8,9]	Allow larger gatherings (50-100 people) with more than 2 households with conditions [1,3,4,5,7,8,9]	Allowed with conditions [1,3,4,5,7,8,9]	Lift all conditions
Mass gatherings: highly-visible events with large numbers of attendees e.g. concerts, sporting events, conferences, cultural/ religious events, festivals, large national or international events	Prohibited	Prohibited	Some allowed with conditions based on risk assessment Size limit = 25-50 [1,3,4,5,7,8,9]	Some allowed with conditions based on risk assessment Size limit = 50-100 [1,3,4,5,7,8,9]	Some allowed with conditions based on risk assessment Size limit =100-250 [1,3,4,5,7,8,9]	Lift all conditions

Transportation and travel

Setting, service or activity	Current state of measure April 2020	Step 1 Near-term	Step 2 Short-term	Step 3 Medium-term	Step 4 Longer-term	Step 5 Significant population immunity
Public transportation (e.g., taxis, rideshares, buses, subways, and rail) Interdependency with workplaces and schools	Allowed with conditions	Allowed with conditions [3,4,5,6,7,8,9]	Allowed with conditions [3,4,5,6,7,8,9]	Allowed with conditions [3,4,5,6,7,8,9]	Allowed with conditions [3,4,5,6,7,8,9]	Lift all conditions
Domestic Inter-jurisdictional travel: Provincial/territorial, remote/isolated/Indigenous communities	Some restrictions in place at P/T and/or community level	Travel restrictions lifted based on jurisdictional risk assessment	Travel restrictions lifted based on jurisdictional risk assessment	Travel restrictions lifted based on jurisdictional risk assessment	Travel restrictions lifted based on jurisdictional risk assessment	All restrictions lifted

Table 1 legend of conditions and modifications

1. Core personal practices supported (e.g., provide access to soap and water or an alcohol-based hand sanitizer
   (at least 60% alcohol) tissues/waste baskets, public washrooms, showering before entering swimming pool)
2. Personal protective equipment: includes medical masks/N95 respirators (as per guidance or employer
   policy), eye protection, gloves and /or gown; level and type is determined based on a risk assessment by an
   employer or individual
3. Physical distancing measures added (e.g., size limit, accessible floor markings and or signage, telework, live
   streaming)
4. Non-medical mask use as per local recommendations ^{Footnote a}
5. Screening/assessment (active or passive) in place for symptoms of COVID-19
6. Physical barriers in use (e.g., plexiglass)
7. Environmental cleaning increased (common spaces, high-touch surfaces, shared equipment)
8. Ventilation increased
9. Increased protective measures for vulnerable populations