Public health management of human cases of avian influenza and associated human contacts

On this page

• 1.0 Introduction
• 2.0 Background
  • 2.1 Signs and symptoms
• 3.0 Detection and surveillance
  • 3.1 Laboratory testing
  • 3.2 Notification/reporting
  • 3.3 Case definitions
• 4.0 Public health management of cases (including person under investigation, probable case, confirmed case)
  • 4.1 Public health authority activities
  • 4.2 Isolation
  • 4.3 Public health measures for cases
  • 4.4 Clinical management/treatment
  • 4.5 Contact investigation/tracing
• 5.0 Public health management of contacts
  • 5.1 Public health authority activities
  • 5.2 Exposure risk assessment of contacts (high/intermediate/low) and associated recommendations
  • 5.3 Public health measures for all contacts
• 6.0 Other public health measures
  • 6.1 For caregivers
  • 6.2 When seeking medical care
• 7.0 Health equity and psychosocial considerations
  • 7.1 For isolation
• 8.0 Acknowledgments
• 9.0 Footnotes
• 10.0 References

1.0 Introduction

The Public health management of human cases of avian influenza and associated human contacts (AI CCM) guidance provides non-subtype/-strain -specific recommendations for case and contact management of avian influenza (AI) in Canada. Public health recommendations are made to manage human cases of AI (including person under investigation (PUI), probable case, confirmed case) – regardless of the source (avian/animal/environmental/human/unknown) or locality (inside/outside Canada) of exposure – and their human contacts.^{Footnote a}

This guidance is intended for use by public health authorities (PHAs) when a human case of avian influenza A virus infection is suspected or confirmed in Canada while human health risks are still limited. Therefore, the public health activities and measures outlined in this guidance aim to minimize opportunities for human transmission of AI and thus prevent/delay progression to human-to-human transmission (i.e., containment). Restricting opportunities for the AI virus to undergo reassortment with other avian, animal or human influenza viruses (subtypes/strains) is another objective of this guidance.

This AI CCM guidance is complementary to the Guidance on human health issues related to avian influenza in Canada (HHAI), which provides recommendations for PHAs and stakeholders (e.g., federal agencies and departments, non-governmental organizations) involved in the management of human health issues related to AI outbreaks in animals (wild, commercial or domestic) or their environments. The HHAI guidance provides prevention and treatment recommendations and serves as a reference for the mitigation and management of an outbreak related to the human health concerns of AI.

At the time of development and publication, there is very limited evidence and epidemiological data available to support the public health management of human cases of AI and associated human contacts in Canada. Therefore, the AI CCM guidance is informed by the latest epidemiology, available scientific evidence, and expert opinion regarding AI; knowledge of seasonal influenza and other respiratory infectious diseases; and general epidemiological principles. The recommendations in this guidance follow a precautionary approach given some uncertainty surrounding the associated public health risk of the rapidly evolving A(H5N1) outbreak in animals. Set in the Canadian context, this guidance is subject to change as new information becomes available and the situation in Canada unfolds. Other guidance, including recommendations for specific AI subtypes/strains (e.g., H5) and use of medical countermeasures (e.g., vaccines), may also be developed.

The AI CCM guidance should be interpreted and applied in conjunction with relevant provincial/territorial (P/T) and municipal legislation and policies. It is recognized that PHAs may adjust recommendations/activities detailed in this guidance according to a risk assessment that would include factors such as local context, epidemiology, and other jurisdiction-specific considerations. It is not intended to replace tailored public health advice provided to individuals or groups of individuals, based on clinical judgment and comprehensive individual risk assessments conducted by PHAs.

2.0 Background

AI is a contagious viral infection that mainly affects birds but can, on occasion, infect humans and other mammals.

Reports of human infections with AI are rare. Historically, human infections of AI have been associated with close contact with domestic or wild birds (e.g., handling infected poultry or other birds), exposure to highly contaminated environments (e.g., poultry farms, live animal markets), or exposure to higher risk environments (e.g., backyard/small poultry flocks). Individuals can be exposed to the virus through contact with various sources, including: infected animals (e.g., birds, wildlife, livestock, domestic mammals); animal feces, litter or secretions containing high concentrations of the virus; contaminated surfaces; and contaminated vehicles, equipment, clothing, and footwear used at involved sites (e.g., infected farms, areas with infected wildlife).

Transmission of the virus occurs via inhalation or contact with mucous membranes (e.g., eyes, nose, mouth). In addition, as per the evidence available at the time of publication, transmission of AI from human-to-human is extremely rare and has not been sustained. Despite anecdotal reports of potential foodborne AI infection following consumption of raw poultry products (e.g., raw duck organs and duck blood), to date, there have been no confirmed human cases of AI acquired through the consumption of food. All evidence to date also indicates that thorough cooking will kill the AI virus.

AI viruses are designated as highly pathogenic AI (HPAI), or low pathogenic AI (LPAI), based on the molecular characteristics of the virus and the morbidity and mortality in birds. Although disease severity and outcomes may vary based on AI subtype/strain, there is no correlation between the pathogenicity of AI viruses in birds and the infectious and pathogenic potential in humans and other mammals; both HPAI and LPAI viruses have caused mild to severe illness and death in humans and non-human mammals, and precautions are therefore warranted regardless of pathogenicity in birds. Note: Mild human illness has predominantly been associated with e.g., H3N8, H7N3, H7N7, H9N2, and severe human illness has predominantly been associated with e.g., H5N1, H5N6, H7N9, H10N8.

During the current global outbreak of avian influenza A(H5N1) (fall 2020 to present), human infections with A(H5N1) reported internationally have been associated with close contact with infected poultry, contaminated environments and potential exposure to infected cattle. To date, there have been no human cases of A(H5N1) detected in Canada. Information on the current avian influenza A(H5N1) outbreak can be found in the Latest bird flu situation - inspection.canada.ca

2.1 Signs and symptoms

Signs and symptoms of AI reported in humans have included:

• mild illness: fever (which may not be present in young children, older persons, people who are immunocompromised), cough, sore throat, runny nose, fatigue, muscle pain, joint pain, headache, red eyes
  • Digestive symptoms such as diarrhea, nausea, and vomiting are possible, although less common.
• moderate to severe illness: shortness of breath, altered mental status, seizures

Reported complications of AI have included: pneumonia, acute respiratory distress syndrome, respiratory failure, shock, multi-organ failure, meningoencephalitis, secondary bacterial or fungal infection.

3.0 Detection and surveillance

3.1 Laboratory testing

Information pertaining to specimen collection, handling, transportation, and testing is beyond the scope of this document.

Guidance relevant to the diagnosis of AI in humans can be found in the Protocol for Microbiological Investigations of Severe Acute Respiratory Infections (SARI). Technical information on certain avian influenza A virus subtypes can be found in the Influenza A virus subtypes H5, H7, and H9: Infectious substances pathogen safety data sheet.

3.2 Notification/reporting

Frontline health care providers (HCPs) and laboratories should notify local PHAs of any human case of AI (PUI, probable, or confirmed), in accordance with jurisdictional reporting requirements. Local PHAs should:

• advise and facilitate coordination between HCPs and provincial laboratories regarding the management and notification/reporting of PUI, probable, confirmed cases of AI (including novel subtypes) and Severe Acute Respiratory Illness (SARI)
  • P/T PHAs must report probable and confirmed cases, regardless of severity, to the Public Health Agency of Canada (PHAC) within 24 hours of their own notification via the Emerging respiratory pathogens and Severe Acute Respiratory Infection (SARI) case report form.
• use established inter-jurisdictional notification processes to enable timely case and contact management
  • This would be relevant if the case investigation reveals that the exposure occurred in another jurisdiction, the case was identified in another jurisdiction, the case travelled between jurisdictions during their infectious period, or contacts reside in a different jurisdiction than does the case.

PHAC acts as the International Health Regulations (IHR) national focal point, which is the national centre designated to communicate with the World Health Organization (WHO) and the Pan American Health Organization (PAHO) on the Canadian situation. PHAC must notify the WHO, within 24 hours of assessment of public health information, of any event related to a human case of AI under Article 6 of the IHR (2005).

Detailed roles and responsibilities of federal/provincial/territorial (FPT) and local stakeholders can be found in Section 3.0 of the HHAI guidance.

3.3 Case definitions

National surveillance case definitions facilitate standardized case classification and reporting to PHAC from the provinces and territories. This enables accurate interpretation of epidemiologic analyses to inform public health response activities. They also ensure common and consistent communication both nationally and internationally.

In the event of an outbreak, national case definitions should be developed promptly to address the specific characteristics of the outbreak. National case definitions for avian influenza A(H5N1) virus and avian influenza A(H7N9) virus have been established and can be adapted as necessary.

The development of a national case definition relies on clinical presentation and associated laboratory techniques for illness identification. The clinical presentation may evolve as more epidemiologic information emerges, necessitating updates to enhance sensitivity, specificity, and alignment with event response objectives.

National surveillance case definitions that include categories for PUI, probable and confirmed cases are most suitable. The first two categories aid in investigating and managing potential cases, serving as placeholders should the confirmed case definition be updated to include asymptomatic or atypical infections.

Since the case definitions are intended to be used nationally, their development should be through consensus and in collaboration with FPT working groups to assist with issues surrounding national surveillance.

4.0 Public health management of cases (including person under investigation, probable case, confirmed case)

4.1 Public health authority activities

Upon notification of a human case of avian influenza A (PUI, probable, or confirmed), the PHA should initiate a case investigation which includes confirming the exposure occurrence, human infection, and exposure source. The PHA should then implement appropriate public health activities to prevent and/or limit transmission and protect human health.

Activities include:

• assessing and facilitating the case's ability to adhere to recommended public health measures
• facilitating isolation of cases
• active monitoring (i.e., through regular communication) of the case
  • Monitoring can support learning about the clinical evolution of the infection, address emerging issues, as well as encourage isolation compliance (e.g., by connecting the individual to community supports as appropriate).
  • The mode and frequency of monitoring may vary according to PHA and local context.
• providing information on the importance, including the public health rationale, and proper practice of recommended public health measures
• providing education on signs/symptoms, including the need for daily temperature checks
• instructing on self-care, steps to take if signs/symptoms worsen, and how/when to seek medical care
• facilitating prompt clinical assessment of a case by a HCP for laboratory diagnostic testing, potential post-exposure prophylaxis and/or potential for any medical emergencies
• facilitating access to supportive care and early antiviral treatment, as applicable
• determining seasonal influenza vaccination status of the case
• identifying all contacts during the case's infectious period, including persons identified specifically by the case and (groups of) individuals potentially exposed to the case during an event or while at a location, depending on the activities practised while at those sites
• identifying (groups of) individuals with the same potential avian/animal/environmental/human exposure as the case. This includes individuals exposed to AI via activities associated with their occupation, study, leisure/recreation, etc.
  • PHAs are encouraged to develop working relationships and clear processes (e.g., information-sharing agreements) within their respective jurisdictions with their animal health and environment/wildlife counterparts and occupational health authorities, to facilitate timely, two-way communication to coordinate the response and management of these types of events. Details on communication between human, animal and environmental partners can be found in Section 4.0 of the HHAI guidance.

4.2 Isolation

When care in a hospital is not required, cases should:

• not go to school, work, or other public places
• convalesce in a suitable environment where effective isolation can be maintained, and not leave unless required or directed to seek medical care
• have their own room (separate from household members or domestic animals) with access to a separate washroom, if possible
• isolate for 14 days^{Footnote b} from onset of first sign(s)/symptom(s) or until AI infection is ruled out by laboratory testing (for PUIs)
  • There may be exceptions to these criteria for which PHAs and/or HCPs may determine a longer isolation period is warranted (e.g., immunocompromised individuals, those hospitalized due to AI).
• self-monitor for onset or progression/worsening of signs/symptoms of AI infection, including daily temperature-taking and recording, while:
  • avoiding the use of fever-reducing medication (e.g., acetaminophen, ibuprofen) as much as possible as it may mask the onset or progression/worsening of signs/symptoms of AI (and advise the PHA if taken)
    • Should signs/symptoms develop or progress/worsen, notify their HCP and/or local PHA for additional instructions.

4.3 Public health measures for cases

While in isolation, cases should:

• unless required for assistance (e.g., human caregivers, service/support/therapy animals) avoid the following with others, including household members, visitors, and animals:
  • close contact activities (e.g., watching television, dining, or playing games together) and
  • sharing indoor/outdoor spaces
• if sharing a space with others is unavoidable, maintain physical distance (and separate with dividers such as curtains, if possible) and wear a well-fitting respirator or medical mask^{Footnote 1Footnote 2Footnote 3}, regardless of whether others are present at the time, and especially when around others who are at risk of more severe disease or outcomes (e.g., individuals who are immunocompromised, individuals who are pregnant, young children) and/or in a crowded or poorly ventilated setting
  • others in the same space as the case should also maintain physical distance and wear a well-fitting respirator or medical mask^{Footnote 4}, especially if they are:
    • at risk of more severe disease or outcomes (e.g., individuals who are immunocompromised, individuals who are pregnant, young children)

To further reduce the risk of spread, cases should implement the following additional public health and personal protective measures (which are also applicable to contacts):

• avoid direct contact with domestic or wild birds and other susceptible animals (e.g., wild mammals, swine, farmed fur animals)
• avoid sharing personal items with other humans and animals (e.g., unwashed towels, bed linen, eating utensils)
• practise respiratory etiquette, including covering coughs and sneezes
• take steps to improve indoor ventilation by:
  • opening windows and doors to the outside, if possible, depending on weather, outdoor air quality, and safety (e.g., no fall hazards), especially in shared spaces (e.g., dining areas, hallway, kitchen, particularly), regardless if others are present
    • for shared washrooms, also turning on the exhaust fan and closing the toilet lid before flushing
  • ensuring the mechanical ventilation system (e.g., heating, ventilation and air conditioning (HVAC) system) is functioning properly and continuously on, if possible
• perform frequent hand hygiene by:
  • washing hands with soap and running water for at least 20 seconds (preferable, especially when hands are visibly dirty), or
  • using a hand sanitizer containing at least 60% alcohol^{Footnote 5} for 20 seconds or until dry
    • if hands are visibly soiled, remove as much residue as possible before using hand sanitizer
• clean and disinfect high-touch surfaces and objects (e.g., toilets, taps, kitchen countertops) frequently with household cleaner followed by household disinfectant with efficacy against influenza
• wash clothes and bed linen with regular laundry soap and water

4.4 Clinical management/treatment

Clinical management in the community, including antiviral treatment, is based on the case's condition and at the discretion of the case's HCP.

Detailed antiviral treatment recommendations can be found in Section 11.0 of the HHAI guidance.

4.5 Contact investigation/tracing

Early identification of human contacts is a key component of rapid case identification and management to limit human-to-human transmission of AI.

Contacts are individuals who have been in near proximity^{Footnote cFootnote 6Footnote 7Footnote 8Footnote 9Footnote 10Footnote 11} of a human case of AI during the infectious period, which may span from 1 to 2 days^{Footnote 12} leading up to the case's sign/symptom onset^{Footnote 13Footnote 14Footnote 15Footnote 16} to 14 days after the case's sign/symptom onset. Please refer to Table 1: Classification of contacts by exposure risk level for descriptions and examples of contacts. Once a case (PUI, probable or confirmed) is identified, PHAs should consider initiating contact tracing, based on a risk assessment, using available epidemiological and clinical information.

Contact tracing facilitates:

• rapid identification of secondary cases of AI (i.e., individuals who become infected after exposure to the human case)
• rapid identification of other (groups of) individuals with the same potential avian/animal/environmental/human exposure to AI as the case
• swift initiation of active/passive monitoring
• early implementation of public health measures, as appropriate
• better understanding of the epidemiology of AI

5.0 Public health management of contacts

5.1 Public health authority activities

The public health approach to AI contact management largely focuses on interrupting chains of transmission by identifying individuals at risk of AI infection from exposure to a human case of avian influenza A (PUI, probable, or confirmed) and/or to the same exposure source as the case.

Once human contacts are identified, PHAs should:

• conduct active/passive monitoring (as indicated by exposure risk assessment) of the contacts
• assess and facilitate the contact's ability to adhere to recommended public health measures
• provide information on the importance, including the public health rationale, and proper practice of recommended public health measures
• provide education on self-monitoring for signs/symptoms, including need for daily temperature checks
• offer information on when, where and how to access diagnostic testing, should signs/symptoms develop
  • In the absence of a sufficient evidence base on the incidence/prevalence and transmissibility of asymptomatic avian influenza A in humans, laboratory testing of asymptomatic individuals exposed to human AI cases is not recommended as part of routine contact management. Based on local experience, PHAs may, in concert with their local clinicians and public health laboratory, consider testing of asymptomatic contacts to expand collective understanding of asymptomatic infection and the subsequent human health risks.
  • Further guidance on laboratory testing may be available in the future, once developed and triggers for implementation are finalized.
• instruct on self-care, steps to take if signs/symptoms develop (i.e., immediately isolate and contact their HCP or local PHA), and how/when to seek medical care
• facilitate access to antiviral prophylaxis, as appropriate, and advise HCPs on appropriate usage
  • Information regarding prophylaxis considerations and dosage recommendations can be found in Section 11.0 of the HHAI guidance.
• facilitate access to seasonal influenza vaccination, as appropriate
  • Individuals should be offered inactivated seasonal influenza vaccine after the monitoring period has ended, if not already received.
    • This can decrease the likelihood of dual infection and thus prevent the possibility of genetic reassortment in an individual infected with both seasonal influenza and AI strains, which could theoretically result in a novel pandemic strain.
  • Up-to-date vaccination recommendations can be found in the National Advisory Committee on Immunization (NACI)'s current statement on seasonal influenza vaccine.
    • General vaccination contraindications and precautions for acute respiratory infections can be found in the Canadian Immunization Guide's section on Contraindications and precautions associated with specific conditions: Acute illness.

5.2 Exposure risk assessment of contacts (high/intermediate/low) and associated recommendations

It is recommended that all individuals who are contacts of a human case of AI (PUI, probable, or confirmed) be rapidly identified by PHAs. The risk assessment will determine the contact's risk of exposure and appropriate public health measures to follow.

Table 1 provides guidance for classifying contacts as either high, intermediate or low -risk, depending on their exposure to a human case of AI, for the purpose of determining appropriate public health measure recommendations. This information is not intended to replace more personalized public health advice provided to contacts, which is based on clinical judgment and a comprehensive risk assessment conducted by PHAs, proportionate to the risk within their jurisdiction.

The risk assessment completed by local PHAs should consider individual-level risk mitigation measures, including adherence to personal protective measures (e.g., mask use, hand hygiene, physical distancing) by both the case and the contact. In addition, local PHAs should consider individual-level health risks, including whether the contact is an individual who is at risk for more severe diseases or outcomes (e.g., individuals who are immunocompromised, individuals who are pregnant, young children), and whether the contact has received their seasonal influenza vaccination.

When determining the exposure risk level, setting-specific considerations would include those places where a contact was potentially exposed, including whether the exposure was indoors (higher risk) or outdoors (lower risk), ventilation quality, the size and number of people in the setting, etc. Although outdoor settings are generally considered lower risk, the potential for transmission still exists under certain circumstances (e.g., conversations when individuals are in near proximity and are not wearing masks), all of which should be taken into account when conducting the risk assessment. Note: there is no defined duration of exposure for contacts, with current evidence supporting the general principle that respiratory transmission is more likely to occur with a longer duration of exposure.

Note: Contacts can be considered cases (and should be managed as such) upon sign/symptom development.

5.3 Public health measures for all contacts

All contacts should:

• monitor for signs/symptoms, including daily temperature taking and recording, while:
  • avoiding the use of fever-reducing medication (e.g., acetaminophen, ibuprofen) as much as possible as it may mask early symptoms of AI (and advise the PHA if taken)
• Should signs/symptoms develop, isolate away from others, and notify their HCP and/or local PHA for additional instructions.
  • This includes information on:
    • when, where and how to access diagnostic testing
    • when to seek medical care

To further reduce the risk of spread, contacts should implement the following additional public health and personal protective measures (which are also applicable to cases):

• avoid direct contact with domestic or wild birds and other susceptible animals (e.g., wild mammals, swine, farmed fur animals)
• avoid sharing personal items with other humans and animals (e.g., unwashed towels, bed linen, eating utensils)
• practise respiratory etiquette, including covering coughs and sneezes
• take steps to improve indoor ventilation by:
  • opening windows and doors to the outside, if possible, depending on weather, outdoor air quality, and safety (e.g., no fall hazards), especially in shared spaces (e.g., dining areas, hallway, kitchen, particularly), regardless if others are present
    • For shared washrooms, also turning on the exhaust fan and closing the toilet lid before flushing
  • ensuring the mechanical ventilation system (e.g., HVAC system) is functioning properly and continuously on, if possible
• perform frequent hand hygiene by:
  • washing hands with soap and running water for at least 20 seconds (preferable, especially when hands are visibly dirty), or
  • using a hand sanitizer containing at least 60% alcohol^{Footnote 5} for 20 seconds or until dry
    • If hands are visibly soiled, remove as much residue as possible before using hand sanitizer.
• clean and disinfect high-touch surfaces and objects (e.g., toilets, taps, kitchen countertops) frequently with household cleaner followed by household disinfectant with efficacy against influenza
• wash clothes and bed linen with regular laundry soap and water

6.0 Other public health measures

6.1 For caregivers

Some cases or contacts (e.g., children, individuals who require support with activities of daily living, individuals who are ill with AI or another acute or a chronic illness) may need direct care from a household member, family member or friend.

If a support person is required, one individual should be appointed to fulfill caregiver duties. The caregiver should:

• not be a person who is at risk for more severe disease or outcomes
  • This includes anyone who is at high risk of respiratory infectious disease-related complications or hospitalization.
• understand the risks of and prevention measures for AI

When providing care, the caregiver should:

• limit physical contact with the case/contact to the greatest extent possible
• wear a well-fitting respirator (or medical mask)^{Footnote 1Footnote 2Footnote 3} and appropriate eye protection when providing care, if contact is unavoidable
• cluster care activities in one instance to minimize repeated exposures with the individual
• perform frequent hand hygiene
  • before putting on and after taking off personal protective equipment (e.g., respirator or medical mask, eye protection)
  • before and especially after providing care or handling the case/contact's belongings
• have the case/contact handle their own laundry, utensils and dishware, and clean and disinfect their own home, if possible
  • If this is not possible, handle the case/contact's belongings carefully to avoid self-contamination.
• self-monitor for symptoms for 10 days after their last exposure to the case/contact

Note: Caregivers of a case would be identified as a contact but with reduced transmission risk if they had proper and adequate use of personal protective measures/personal protective equipment when providing care. Therefore, whether they are managed as a contact is based on the PHA's comprehensive risk assessment and the caregiver's circumstances.

Should signs/symptoms develop, the caregiver should isolate away from others, and notify their HCP and/or local PHA for additional instructions. This includes information on:

• when, where and how to access diagnostic testing
• when to seek medical care

To further reduce the risk of spread, the caregiver should implement the following additional public health and personal protective measures (which are also applicable to cases and contacts):

• avoid direct contact with domestic or wild birds and other susceptible animals (e.g., wild mammals, swine, farmed fur animals)
• avoid sharing personal items with other humans and animals (e.g., unwashed towels, bed linen, eating utensils)
• practise respiratory etiquette, including covering coughs and sneezes
• take steps to improve indoor ventilation by:
  • opening windows and doors to the outside, if possible, depending on weather, outdoor air quality, and safety (e.g., no fall hazards), especially in shared spaces (e.g., dining areas, hallway, kitchen, particularly), regardless if others are present
    • For shared washrooms, also turning on the exhaust fan and closing the toilet lid before flushing
  • ensuring the mechanical ventilation system (e.g., HVAC system) is functioning properly and continuously on, if possible
• perform frequent hand hygiene by:
  • washing hands with soap and running water for at least 20 seconds (preferable, especially when hands are visibly dirty), or
  • using a hand sanitizer containing at least 60% alcohol^{Footnote 5} for 20 seconds or until dry
    • If hands are visibly soiled, remove as much residue as possible before using hand sanitizer.
• clean and disinfect high-touch surfaces and objects (e.g., toilets, taps, kitchen countertops) frequently with household cleaner followed by household disinfectant with efficacy against influenza
• wash clothes and bed linen with regular laundry soap and water

6.2 When seeking medical care

When accessing necessary medical care, cases and contacts should, if possible:

• alert the HCP of their AI infection/potential exposure in advance
• not use public transportation

When using a private vehicle to seek medical care, individuals should:

• call ahead to inform the facility that they have (or have been exposed to) AI, and follow any directions provided
• minimize the number of occupants in the vehicle (e.g., only the driver and themselves, if possible)
• maximize the distance between themselves and other vehicle occupants (e.g., case/contact in the back seat, diagonal to the driver in the vehicle, or in the third row of larger vehicles)
• open all windows, if possible and safe to do so
• wear a well-fitting respirator or medical mask^{Footnote 1}, if breathing difficulties or contraindications to doing so are not present
  • This applies to all occupants in the vehicle.
• properly clean and disinfect any surfaces or objects in the vehicle that they may have touched (e.g., door handle, seatbelt)

In the event of a medical emergency, individuals or their caregiver should:

• contact emergency medical services (EMS: 911) or the local emergency helpline for medical assistance, including transportation to a facility if necessary
• inform the dispatcher that the individual requiring medical care has (or has been exposed to) AI so that appropriate infection prevention and control measures can be implemented

Case and contacts and anyone assisting with transport should strictly adhere to public health measures to help reduce the risk of transmission. EMS personnel and other HCPs assisting with transport should follow their employer's infection prevention and control recommendations. Note: Information regarding infection control practices and guidance for healthcare settings can be found in Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings.

7.0 Health equity and psychosocial considerations

As with other infections, AI may have a greater impact on certain population groups, in terms of illness experience (e.g., duration, severity), due to social, economic, health, and/or other risk factors (e.g., older age, chronic medical condition, poverty, living in a remote and isolated community or crowded setting).

PHAs should consider health equity and psychosocial implications when implementing public health measures to minimize human transmission of AI. Taking individual context into consideration may influence how cases and contacts accept and adhere to public health measure recommendations.

An individual's ability and willingness to practise recommended public health measures, including isolation, may be impacted by various factors, including:

• social and economic challenges, such as inflexible working conditions, employment or housing instability, food insecurity, domestic violence or abuse
• individual skills, abilities and vulnerabilities, such as:
  • reading, speaking, comprehension or communication challenges
  • physical or psychological difficulty undertaking public health measures
  • need for assistance with personal or medical care activities or supplies
  • need for ongoing supervision
• social or geographic isolation, such as:
  • insufficient family, friends, or community resources for support
  • residence in an area with limited services or supports, including telecommunications and for mental health and addictions
• limited availability of/access to plain-language and multilingual guidance
• limited availability of/access to personal protective equipment and supplies

Public health messaging should be clear, consistent and sensitive to the needs of populations with social, economic, cultural or other vulnerabilities.

7.1 For isolation

PHAs may need to modify isolation approaches based on each individual's unique circumstances; however, the primary goal of containment remains paramount. Local PHAs should help to determine the location where a case isolates in collaboration with the individual and their HCP, as appropriate, and facilitate/provide the necessary supports for successful isolation. The suitability of an environment for isolation will depend on the individual's living situation, and may vary depending on the sex, gender, or other socioeconomic or identity factors of the individual.

Factors to consider include:

• physical layout, such as availability of space for a dedicated room and private washroom (which some settings may lack, such as student residences, overcrowded housing and temporary emergency accommodations)
• housing conditions, such as access to potable water and the state of repair of the home
• safety of the setting, such as potential for occurrence of gender-based or family violence or other abuse
• access to necessities for the duration of isolation, such as food, water for drinking/cooking/cleaning, over-the-counter and prescription medication, personal protective equipment, cleaning and disinfecting supplies, educational and entertainment resources
  • Remote and isolated communities may consider stockpiling necessities if the supply chain is likely to be interrupted or unreliable.
• other factors, such as whether the individual requires care (e.g., is a child or older adult), has child/elder/pet -care responsibilities, or lives in a multigenerational household
  • In situations where childcare is shared between two homes, caregivers may consider having the child stay in one home, if possible, for the duration of the isolation period.

Situations in which there are challenges accessing necessities or where individuals live alone or in a home where all household members are in isolation together may require community and social supports (e.g., family, friends, community and social services) to assist with essential needs. PHAs should facilitate contact with local leadership and organizations that can provide direct support.

In addition, isolation can have financial, social, and psychological impacts, which can be substantial. For example, for Indigenous Peoples, isolation away from home may trigger re-traumatization associated with historical colonial experiences of forced removals; there is also the potential for new trauma if the ability to be with their community, and practise cultural and/or spiritual activities, is limited.

PHAs should encourage communities to create a supportive environment to help individuals preserve their mental wellbeing, and minimize stress and hardship, during their isolation period.

8.0 Acknowledgments

This technical guidance was developed in consultation with FPT partners and stakeholders with an interest in this subject matter.

9.0 Footnotes