Framework for Implementation of COVID-19 Community Mitigation Measures for Lower-Resource Countries ​

Purpose

The purpose of this document is to provide ministries (e.g. Ministry of Health (MOH), Ministry of Water (MOW)), sub-national public health authorities, and implementing partners with a practical framework of action to both prepare for and mitigate community transmission of COVID-19. The document does not address how to implement the included actions. Parts of this document are relevant for all environments, but the focus is placed on lower-resource settings.

Community Mitigation

Community mitigation measures ^1,2 are actions taken to slow the spread of infectious diseases. The goals for using mitigation strategies in countries that are experiencing community transmission of COVID-19 are to decrease COVID-19 transmission overall and, in particular, to protect:

• Individuals at increased risk for severe illness ³, including:
  • Older adults (65+ years)
  • People of any age with serious underlying medical conditions (e.g. chronic lung disease, immunocompromising conditions, diabetes)
• Vulnerable populations (e.g. refugees, internally displaced persons, prisoners)
• First responders – healthcare personnel and critical infrastructure workers

Governments, individuals, communities, businesses, and healthcare providers are all part of an overall community mitigation strategy used to minimize morbidity and mortality, as well as the social and economic impact of COVID-19. Countries should consider community mitigation measures and choose which ones to put in place to prepare for and respond to community transmission of COVID-19.

Signals of ongoing community transmission include:

• Detection of confirmed cases of COVID-19 with no epidemiologic link to known cases, or
• More than three generations of local transmission.

Implementation of community mitigation measures is based on:

• Emphasizing individual responsibility to follow recommended personal-level actions
• Emphasizing government and community responsibility to make sure individuals have access to policies and resources required to follow recommended personal-level actions
• Ensuring government, community institutions (e.g. schools, places of worship, marketplaces, childcare providers), businesses, and households put in place the recommended actions, with a focus on actions that protect those at increased risk of severe illness, those who are most vulnerable, and first responders
• Focusing on settings that provide critical infrastructure or services to minimize the risk of disruption to critical infrastructure or services
• Minimizing disruptions to daily life to the extent possible
• Adapting interventions supported by existing public health programs to address the immediate community mitigation needs

Principal Considerations for Implementing Community Mitigation Strategies

• Each community is unique, and appropriate mitigation strategies will vary, and can be scaled up or down, depending on the epidemiology, community characteristics, and public health capacity (refer to Section 7 below).
• Leadership can select appropriate actions to implement after considering all aspects of a community that might be impacted. In particular, leadership should consider populations most vulnerable to severe illness and those at greatest risk for negative social and economic impact to ensure the safety and social wellbeing of those impacted by the mitigation strategies.
• Implementation of mitigation measures may require legal authorities to be in place. Activating emergency plans is critical to provide additional authorities or coordination mechanisms to implement the recommended mitigation interventions (refer to Section 8 below).
• Some activities (refer to Section 8 below) may be implemented at any time, regardless of the level of community transmission, based on guidance from public health officials.
• In situations where mandatory quarantine or stay-at-home orders are put in place, governments should identify ways to make sure that individuals have access to sufficient safety, healthcare, food, water, and sanitation and hygiene products and services.

Transmission Scenarios⁴

Countries or subnational areas will have to respond rapidly to one or more of the following transmission scenarios:

• No cases
• One or more cases, imported or locally detected (Sporadic cases)
• Case clusters in time, geographic location, or common exposure (Clusters of cases)
• Larger outbreaks of local transmission (Community transmission)

Note: Worldwide experience with COVID-19 has demonstrated that in many regions with sporadic cases (one or more cases, imported or locally detected), aggressive testing strategies focused on persons with undiagnosed respiratory infections may reveal underlying community transmission. This can result in a rapid progression to scenario 4 (community transmission). Thus, it is critical that countries prepare aggressively for future transmission scenarios, even as they implement activities for their current situation. Ministries of health, sub-national public health authorities, and implementing partners must act quickly once cases are identified to prevent and prepare for scenario 4 (community transmission).

Priority Community Settings and Groups of People for Community Mitigation

National and sub-national leadership can target community mitigation measures for priority community settings and population groups, which may include but are not limited to:

• Households (urban and rural)
• Informal settlements
• Displaced persons camps
• Homeless populations
• Schools or childcare providers
• Caregivers for the elderly
• Workplaces (formal and informal)
• Critical infrastructure workforce (e.g. water vendors, food market operators, sanitation workers)
• Community gathering points (formal and informal, including public water sources, transport hubs, marketplaces, places of worship)
• Prisons and other closed settings (e.g. orphanages, institutions for the physically disabled or mentally ill)

Activities to Support and Enable Community Mitigation Measures

National and sub-national public health authorities play a critical role in designing and implementing priority mitigation measures in a variety of community settings. Specific areas of focus should include:

• Development of national or sub-national policies, guidance, and plans on implementing community- level priority measures outlined in Section 8 below
• Improving communication and coordination among national and sub-national administrative levels and implementing partners for COVID-19 preparedness and response work (e.g. epidemiology and risk communication)
• Assessment of national and sub-national readiness to implement priority activities and use the results to:
  • Identify geographic areas (e.g. communities with high connectivity to outbreak areas) or settings (e.g. community gathering points) at increased risk for community transmission
  • Identify partners who can provide support for implementing or facilitating community mitigation activities
• Development of guidance for specific community settings (e.g. households, displaced persons camps, workplaces, community gathering points) on how to implement the activities outlined in Section 9
• Development of communication plans to ensure adequate communication regarding COVID-19 and community mitigation measures
• Development of messaging on community mitigation for the general population and targeted population groups, making sure that messages are easy to understand and follow.
• Educating community members on COVID-19 signs and symptoms, what to do when they are sick, and how the disease is impacting their community and communities around them
• Identifying and addressing COVID-19 related rumors and misinformation

Local Factors to Consider for Determining Community Mitigation Strategies

Factor: Epidemiology

Characteristics

• Level of transmission and disease dynamics
• Number, setting (e.g., schools, workplaces), and source of outbreaks (e.g., community gathering points)
• Impact of outbreaks (COVID-19 or other disease outbreaks) on delivery of healthcare or other critical infrastructure or services
• Epidemiology of COVID-19 in surrounding communities, districts, provinces and neighboring countries

Factor: Community Characteristics

Characteristics

• Size of community and population density
• Level of community engagement in or support for public health initiatives
• Size and characteristics of vulnerable populations
• Access to healthcare
• Access to potable water and sanitation
• Transportation (e.g., public, walking)
• Planned large events or mass gatherings
• How connected the community is to other communities or countries (e.g., transportation hub, market or industrial center)

Factor: Public health capacity

Characteristics

• Public health workforce
• Testing capacity
• Availability of resources to implement mitigation strategies
• Ability to monitor and evaluate implementation and impact of strategies
• Available support from other government agencies and partner organizations

Community Mitigation Activities by Epidemiologic Scenario

Potential mitigation activities according to transmission scenario

Personal protective measures ^5,6,7

Scenario 1: No cases

• Provide guidance on implementation of personal protective measures (e.g., staying home when sick unless to seek medical care, handwashing or using alcohol-based sanitizer**, covering mouth and nose when coughing or sneezing, use of masks, cleaning frequently touched surfaces daily, maintaining a distance of 2 meters/6 feet from others ).

Scenarios 2 and 3: Sporadic cases and clusters of cases*

• Direct community members to continue practicing personal protective measures.
• Provide guidance on how to implement physical distancing measures such as reducing the frequency of and participation in large gatherings, altering schedules or operating hours to reduce mixing, increasing physical space between individuals.
• Provide guidance on source control measures (e.g., face mask, if available, or covering), as appropriate based on context.
• Provide guidance on how to take care of sick people and self at home.

Scenario 4: Community transmission

• Direct community members to continue practicing personal protective measures.
• Provide guidance on how to implement physical distancing measures such as cancelling gatherings, altering schedules or operating hours to reduce mixing, increasing physical space between individuals.
• Continue to provide guidance on source control measures (e.g., face mask, if available or covering), as appropriate based on context.
• Continue to provide guidance on how to take care of sick people and self at home.

Water, sanitation, and hygiene ⁸

Scenario 1: No cases

• Identify mechanism for making water, soap, and cleaning and disinfection supplies available to the public.
• Identify at-risk community settings and ensure supply chains are available to enable rapid establishment of handwashing stations or provision of alcohol-based sanitizer**.

Scenarios 2 and 3: Sporadic cases and clusters of cases*

• Prioritize availability of water, soap, and cleaning and disinfection supplies to the public.
• Provide guidance for establishing handwashing stations that include soap and water, alcohol-based hand sanitizers, or chlorine solution**.
• Require every person to wash their hands before entering community settings.

Scenario 4: Community transmission

• Prioritize availability of water, soap, and cleaning and disinfection supplies to the public.
• Continue to provide guidance for establishing handwashing stations that include soap and water, alcohol-based hand sanitizers, or chlorine solution**.
• Require every person to wash their hands before entering community setting.

Cleaning and disinfection ^9,10,11

Scenario 1: No cases

• Provide guidance on cleaning and disinfecting frequently touched surfaces and the importance of ensuring water, soap, and cleaning and disinfection supplies are readily available.

Scenarios 2 and 3: Sporadic cases and clusters of cases*

• Continue to provide guidance on cleaning and disinfecting frequently touched surfaces and importance of ensuring water, soap, and cleaning and disinfection supplies are readily available.
• Provide guidance on how to clean and disinfect home when someone is sick.
• Require thorough cleaning and disinfection of closed community settings.

Scenario 4: Community transmission

• Continue to provide guidance on cleaning and disinfecting frequently touched surfaces, and importance of ensuring water, soap, and cleaning and disinfection supplies are readily available.
• Continue to provide guidance on how to clean and disinfect home when someone is sick.
• Require thorough cleaning and disinfection of closed community settings.

Case investigation and contact tracing ^{12,13,14,15,16}

Scenario 1: No cases

• Identify and train contact tracing workforce
• Develop guidance for monitoring close contacts and implementing movement restrictions, including quarantine
• Determine methods to streamline contact tracing through simplified data collection and monitoring and allocating additional resources if needed (including staffing through field epidemiology training programs, technology etc.).

Scenarios 2 and 3: Sporadic cases and clusters of cases*

• Conduct contact tracing and managing and monitoring of contacts as advised in MOH guidance to maximize containment around cases.
• Monitor close contacts through culturally appropriate and community-based efforts to the extent possible, based on local priorities and resources.
• Isolate confirmed COVID-19 cases until no longer considered infectious according to MOH guidance.
• Consider movement restrictions and physical distancing based on exposure risk level of close contacts of a confirmed COVID-19 case.

Scenario 4: Community transmission

• May reduce contact tracing if resources are limited, prioritizing those in high-risk settings (e.g. critical infrastructure, vulnerable populations)
• Isolate confirmed COVID-19 cases until no longer considered infectious according to MOH guidance.

Risk communication ^17,18

Scenario 1: No cases

• Develop, test, and distribute to community settings COVID-19 risk communication materials (e.g. printed materials, banners, loudspeaker announcements, radio messages).
• Develop, test, and distribute messaging to address rumors and misinformation
• Establish feedback loop on messages and material to refine and adapt.
• Establish clearance process for material before sharing with communities, making sure the materials are appropriate for the community literacy and education levels

Scenarios 2 and 3: Sporadic cases and clusters of cases*

• Continue to develop, test, and distribute COVID-19 risk communication materials that address the change in epidemiologic scenarios and associated community mitigation activities
• Continue to develop, test and distribute messaging to address rumors and misinformation, updating the messaging as rumors and misinformation changes
• Continue to seek feedback on messages and material

Scenario 4: Community transmission

• Continue to develop, test, and distribute COVID-19 risk communication materials that address the change in epidemiologic scenario and associated community mitigation activities
• Continue to develop, test. And distribute messaging to address rumors and misinformation, updating the messaging as rumors and misinformation changes
• Continue to seek feedback on messages and material

Disease education

Scenario 1: No cases

• Educate community members on the signs and symptoms of COVID-19 (i.e. fever, cough, difficulty breathing), what to do if they develop symptoms.
• Provide information on the epidemiology of COVID-19.
• Educate community members on groups at increased risk of severe illness and what additional measures they should take to prevent infection.

Scenarios 2 and 3: Sporadic cases and clusters of cases*

• Continue to provide and update information about COVID-19 disease and epidemiology.

Scenario 4: Community transmission

• Continue to provide and update information about COVID-19 disease and epidemiology.

Community action plans

Scenario 1: No cases

• Provide guidance to community members on how to create and adjust community setting-specific action plans in case of illness in the community or disruption of daily activities due to COVID-19 transmission in the wider community (e.g. implementation of physical distancing measures, securing necessary supplies, special considerations for individuals at increased risk of severe illness).

Scenarios 2 and 3: Sporadic cases and clusters of cases*

• Direct community members to implement the established action plan and adjust as needed based on the epidemiologic situation.
• Provide guidance for provision of services and supplies to individuals at increased risk of severe disease (e.g. medical care, food, and water) while limiting close contact and group gatherings
• Provide guidance for establishing screening (e.g., for temperature, respiratory symptoms, exposure history) of persons entering the community setting.
• Direct community members to limit non-essential travel (personal and work- related).

Scenario 4: Community transmission

• Direct community members to continue following the established action plan and adjust as needed based on epidemiologic situation.
• Direct communities that all individuals should limit community movement, not participate in social gatherings or community events, and adapt to disruptions in routine activities (e.g. school, work, business closures) according to guidance from local officials.
• Direct community members to cancel non-essential travel and non-essential gatherings
• Instruct communities to limit or restrict the number of people allowed to visit the community settings (refer to Section 4 above).
• Provide guidance for provision of services and supplies to individuals required to shelter in place (e.g. medical care, food, and water) while limiting close contact or group settings and exposures

Schools and workplaces ^19,20

Scenario 1: No cases

• Educate community members on the need to stay home when sick.
• Educate administrators on the need for sick leave allowance, and provision of distance learning or working from home, if possible.

Scenarios 2 and 3: Sporadic cases and clusters of cases*

• Provide guidance to implement short-term closures as needed (e.g. if cases in schools) for cleaning and contact tracing.
• Instruct administrators to implement distance learning or work from home arrangements (if possible) for individuals at increased risk of severe illness or those with close family or household members at increased risk of severe illness.

Scenario 4: Community transmission

• Instruct administrators to implement broader or longer- term closures.
• Direct administrators to implement extended distance learning and work from home arrangements (when possible) or ensure appropriate physical distancing between staff at workplaces deemed essential.
• Direct administrators to ensure flexible leave or work schedules for those who need to stay home due to school closures, childcare dismissals, or to care for elderly or ill persons.