Criteria to consider prior to relaxing physical distancing orders within the community.
Are surveillance measures in place to enable robust early identification of future increases in transmission?
Are most new cases coming from among identified contacts?
Are hospitals and health centers able to treat all patients without resorting to crisis standards of care?
Among tests conducted, is the percentage of positive test results declining?
Have hospitals, health centers, and community health worker networks developed sufficient surge capacity to deal with future spikes in case counts?
If a-e are in place, have daily case counts declined for at least 14 consecutive days (at least one incubation period)?
Activation of an emergency operations center (EOC) or similar incident management structure to manage local response efforts.
Is there a clearly designated and empowered incident manager?
Are there clearly designated organizational units in the EOC aligned with principal operational priorities (e.g., testing, hospital capacity, crisis communication, protection of vulnerable populations, etc.)?
EOC staff and key leaders understand principles and practice of the Incident Management System (IMS) structure.
Have they received recent training?
Does community leadership have an accurate understanding of the level of COVID-19 transmission?
Does the general public in the community have an accurate understanding of the status of COVID-19 transmission through daily updates?
An operational crisis communication strategy, including scheduled updates and clear lines of communication with critical local and national stakeholders.
A public risk communication strategy including regular, real-time updates for public receipt.
COVID-19 testing and disease surveillance throughout the community.
Have clinical personnel at all levels been trained on COVID-19 symptoms, protocols, and reporting procedures?
Is COVID-19 testing available at sub-national or local-level facilities? If sufficient testing is not available, have contextually relevant proxy indicators for COVID-19 disease surveillance been identified?
Is access to testing available beyond major urban centers? If not, have other surveillance strategies been initiated in places where access to testing is limited? What percentage of the population is captured by testing capacities?
Are specimen referral and sample transport mechanisms in place?
Are serological (antibody), as well as diagnostic tests available?
Are syndromic (symptom-based) surveillance efforts to report suspected cases in place?
Is the existing pipeline of testing supplies sufficient to sustain an adequate level of testing?
Are testing and surveillance systems linked to contact tracing?
Sustainable measures to slow and reduce transmission
Have special facilities been established to enable supported and safe quarantine and isolation outside of homes?
Infection, prevention, and control practices have been implemented to prevent disruptions in critical services, including:
Food supply and distribution?
Institute protective measures for vulnerable populations as much as possible.
Has a comprehensive list of vulnerable populations been compiled?
Do high-risk locations (slums, prisons, densely packed apartment buildings or migrant worker dormitories, refugee or IDP camps, or other locations where physical distancing is difficult) have sufficient access to hygiene and sanitation, masks, and other infection prevention measures?
Have all gaps identified in high-risk locations been assessed and addressed? If identified gaps cannot be addressed due to resource constraints, have they been flagged as potential risk factors?
Are there strategies, such as low-cost partitions or supported isolation facilities, to protect high risk individuals (including the elderly or people with health complications) who are living in households?
Availability of acute care treatment capacity in the community.
Are the healthcare facilities in the community able to meet current and projected demand for patient care capacity?
Do healthcare workers have the appropriate training and supplies to prevent nosocomial transmission?
Can approximate anticipated bed and supply needs be projected over the next 2 weeks?
Are measures being implemented to expand critical care/intensive care unit capacity?
Where possible, has surge production or purchasing been initiated for oxygen supply systems (concentrators, splitters, consumables, pulse oximeters, etc.) and are trained biomedical technicians available at points of use?
Are local health care facilities able to separate intake for patients with COVID-19 or acute respiratory infection (ARI) from those needing other types of care?
Have user fees for health services been waived for COVID-19 treatment?
Supply of personal protective equipment (PPE) available for health systems. Essential PPE supplies are defined, and PPE reuse strategies and procedures are defined, available to all users, and implementable.t
The costs and benefits of different response tactics will vary from country to country. Community response tactics must be adapted to the specific risks, vulnerabilities, and capacities that exist locally. Tactics suited to a dense urban environment may not apply in a rural setting; tactics that work in a wealthy country with a strong social welfare system may not work in a developing country with a large informal economy. In any setting, the priority is for local leaders to assess their existing capacity and develop a local response strategy that adapts the measures outlined below – operational coordination, slowing transmission, protecting high risk populations, protecting the health system, communicating effectively – to their own particular context. Identifying the most critical priorities will also help local leaders form the partnerships with non-governmental organizations, national leaders, and the private sector that are necessary to bolster existing capacities and to enable a more robust response.
- Conduct a community-level needs assessment using available data
- Identify high-risk sectors of the community and consider all populations and needs within
- Determine the capacity of government and nongovernmental entities operating within the population
- Evaluate the cost/benefit of possible containment measures and the economic and social disruption they may cause
- Develop an Action Plan (while considering the other objectives of this guide) and implement
ResourcesPublic Health and Social Measures for COVID-19 Preparedness and Response in Low Capacity and Humanitarian Settings (IASC)Guide: Undertaking Needs Assessments (Australian Workforce Council)Participant Workbook, Community Needs Assessment (U.S. CDC)Global Humanitarian Response Plan COVID-19 (United Nations Coordinated Appeal) – Particularly the Monitoring Framework on pages 32 – 34Critical Preparedness, Readiness, and Response Actions for COVID-19 (WHO)COVID19 Emergency Response – Local Government Finance (UN CDF)Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study (Lancet)
Controlling a pandemic outbreak is a multi-disciplinary and whole-of-society endeavor, and the leadership and management structure must reflect that. Community leaders should utilize an incident management system to provide empowered operational coordination. Decision making ability should be as devolved as practicable to allow for fast action while balancing reporting and accountability. This is especially important for transmission control in contexts where delays in data reporting at the national level make responsive top-down guidance unfeasible. Activating an Emergency Operations Center as an enabling component of an effective incident management system is a best practice used in previous large-scale outbreaks like Ebola. The EOC should host an incident management structure representative of the community to improve and streamline communication, planning, decision-making, and operational coordination across a wide range of community leaders and stakeholders, including communication and alignment with higher-level (such as the regional or national level) EOC processes and decision cycles. The EOC should also have liaisons to, or representatives from, other levels of government, humanitarian and development partners, public health officials, civil society, religious leaders, the business community, academia, and others.
- Activate or establish local coordinating body (Emergency Operations Center or similar structure) to coordinate the local response and link to higher-level coordination
- Designate an empowered Incident Manager
- Organize functional units/teams around major operational priorities
- Establish liaisons with key government partners local, regional and national stakeholders
ResourcesFramework for a Public Health Emergency Operations Centre (WHO)Handbook for Developing a Public Health Emergency Operations Centre (WHO)Containment of Ebola and Polio in Low-Resource Settings Using Principles and Practices of Emergency Operations Centers in Public Health. (Journal of Public Health Management Practices)Useful Links and Publications (WHO)
Risk communications promote the real-time exchange of information, advice and opinions among relevant experts and communities facing risks to their health, social, and/or economic well-being. The effectiveness of a national response to any major public health event depends heavily on the ability of national and sub-national leaders to communicate with all stakeholders throughout the cycle of an outbreak. Public officials have an obligation to accurately and transparently relay risk information, even (or perhaps especially) when it is alarming. Community trust can make or break an outbreak response, because the effectiveness of physical distancing and other interventions hinges on community compliance, and public trust may be undermined when messages do not align with local practices, capabilities, and beliefs. Risk communication should follow best practices to mobilize informed action rather than inducing panic. Identifying and partnering with community representatives from trusted non-governmental organizations, faith-based groups, and other informal structures is critical to building and maintaining the trust of the community; ideally these stakeholders should be represented in EOC coordination and planning. In rural and other settings where public health messaging typically relies on in-person outreach by community health workers, radio and loudspeaker messages might be considered while adhering to physical distancing. Utilization of existing community health workers from other programs may be especially helpful in hard-to-reach settings.
- Establish regular information sharing in collaboration with the community in local languages and dialects
- Ensure that community-engagement is a two-way process that promotes messaging for safe community behaviors while also channeling community input back into response strategy and decision-makinga
- Build trust between local leadership, business, religious, and other civil society members to effectively inform communities through the co-creation, review, and dissemination of credible materials and campaigns.
- Develop messaging and guidance in light of community centered needs
ResourcesRisk Communication and Community Engagement (WHO) COVID-19 risk communication package for healthcare facilities (WHO)COVID-19 Global Communication Network (Johns Hopkins University) World Health Organization guide for preventing and addressing social stigma associated with COVID-19 (WHO) Best Practices in Public Health Risk and Crisis CommunicationRisk Communication Training (TEPHINET) Qualities of an Effective Spokesperson (US CDC)
A pandemic control strategy is grounded in understanding ongoing transmission risk in the community. This requires continuous disease surveillance, diagnostic testing, and reporting systems that ensure up-to-date information on local spread is available to inform strategy-setting and daily tactical decision-making. While scaling up and sustaining local access to centralized testing resources is an important strategy when feasible, this may be difficult where limited access to healthcare, laboratory facilities, and supplies may prevent widespread testing without targeted capacity building. To understand transmission in the absence of widespread testing, communities can establish or enhance syndromic surveillance (for acute respiratory and influenza-like illness), integrated surveillance systems (by introducing COVID-19 surveillance into existing programs for polio, tuberculosis, or malaria), and other dynamic surveillance tools to gauge disease activity within the community, including community leaders and trusted personnel who can be trained as contact tracers. In the absence of widespread testing or confirmed case counts, countries may want to consider other types of data – such as the percent of tests that return positive for COVID-19, cause-of-death indicators, infections among healthcare workers, and excess mortality - to inform operational decisions. In settings where sample transport, internet connectivity, and data aggregation may impact case reporting, these delays (in addition to the incubation period) should be accounted for when assessing “real-time” transmission.
- Assess existing diagnostic testing capacity and identify alternate resources
- Analyze data from influenza-like-illness (ILI), Severe Acute Respiratory Illnesses (SARI), or other community-based surveillance systems to identify suspected cases
- Link any testing and surveillance data to EOC or established reporting structure
- Conduct and document formal risk assessment based on current level and trajectory of COVID-19 or ILI/SARI spread in the community
ResourcesWorld Health Organization Surveillance Technical Guidance (note: includes a template for epi line listings)Introduction to Public Health Surveillance (U.S. CDC)Integration of Private Sector Laboratories in National COVID-19 Response (Nigeria CDC)Public Health and Social Measures for COVID-19 Preparedness and Response in Low Capacity and Humanitarian Settings. (IASC) – particularly p 15-16 on developing a local testing prioritization strategyPrinciples of Epidemiology in Public Health Practice, Third Edition an Introduction to Applied Epidemiology and Biostatistics. Lesson 6: Investigating an Outbreak (U.S. CDC)World Health Organization Global COVID-19 Clinical Characterization Case Record Form and new data platform for anonymized COVID-19 clinical data (WHO) Note: cities do not need to enroll, but this resource includes a checklist of key COVID-19 epi considerationsImplementation of Mitigation Strategies for Communities with Local COVID-19 Transmission (U.S. CDC)Use of Verbal Autopsy and Social Autopsy in Humanitarian Crises (BMJ Global Health)Fever Screening (IN-Q-TEL)Reporting a PUI or Confirmed Case (U.S. CDC)
Slowing and limiting transmission within a community is central to reducing the near-term human cost of the outbreak and ensuring that healthcare facilities will be able to continue to provide lifesaving and life sustaining care as well as routine medical services. Decisions on measures to slow and reduce transmission should be developed based on the amount of protection they provide and the severity of the secondary disruptions they may impose. Large-scale contact tracing should be a priority in all settings, as identification and isolation of infected contacts offers the best enduring protection against spread of the virus. Widespread wearing of non-medical cloth masks in public settings is likely to reduce transmission from pre-symptomatic individuals as well as symptomatic individuals who cannot physically distance themselves. Cotton masks may be an accessible control measure even in very low-resource settings. Highly disruptive lockdown measures may be merited – for a limited period – if communities have the capacity to mitigate the accompanying economic disruption and can use the lockdown to buy time to reinforce preparedness measures. Countries whose demographics skew younger and which lack the ability to mitigate disruption to livelihoods and basic public services may be able to limit their reliance on lockdown tactics.
- Outline a physical distancing strategy appropriate to the risks and realities of the local community. Assess the net costs and benefits of large-scale lockdowns or other drastic measures.
- If the disruptive impact of a lockdown would outweigh the protective public health benefit, shift to other more sustainable distancing measures.
- Recruit, train, and scale up a contact tracing workforce capable of rapidly identifying and isolating contacts of positive cases
- Reorient Community Health Worker networks to educate the population on COVID-19 protection
- Establish mechanisms for supportive quarantine to minimize livelihood disruptions for quarantined households
- Implement a policy for isolating identified and suspect cases, and quarantining their close contacts, and establish special facilities to enable supported and safe isolation outside of homes
- Clearly outline local physical distancing guidelines to the community, implement, and maintain them
- Establish criteria for essential and non-essential activities
- Assess and mitigate secondary impact of physical distancing measures
- Plan for future reintegration efforts and what will be needed to bring the community back to normal
ResourcesNon-Pharmaceutical Interventions (NPIs): Actions to Limit the Spread of the Pandemic in Your Municipality (PAHO)Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza (WHO)Guidance for School Settings (U.S. CDC)Practical considerations and recommendations for religious leaders and faith-based communities in the context of COVID-19 (WHO) CDC guidance on COVID-19 and mass gatherings (US CDC)
COVID-19 poses extreme risks to older individuals and those with complicating health conditions. Vulnerable groups can also include people living in high-risk settings such as informal settlements and those working in the informal economy without social protections, or those who otherwise live or work in close quarters in factories, dormitories, and similar settings. Groups experiencing widespread food insecurity, malnutrition, and large health burdens from other infectious diseases such as HIV and TB may also be at higher risk of severe illness from COVID-19, although this requires more study. To reduce risks to these groups, community leaders should monitor and engage with specific locations where high-risk populations are concentrated; assess hygiene infrastructure, community practices and leadership, and communication practices; develop local strategies and guidance for group isolation and delivery of health services; and extend basic services (e.g. handwashing stations, masks, cash transfer/mobile money) where possible.
- Establish a comprehensive list of vulnerable communities and the places where they are concentrated (e.g. displacement camps, worker dormitories, temporary settlements, slums, crowded urban centers, prisons)
- Assess available WASH (water, sanitation and hygiene) facilities, infection prevention and hygiene practices and supply needs
- Address identified areas of insufficiency (e.g. PPE, contact tracers, healthcare workers and their training, infection control practices)
- Establish guidance to minimize exposures for vulnerable communities e.g. mask-wearing, physical distancing
- Focus on particular on needs of marginalized populations, including refugees or internally displaced populations and detainees
ResourcesWorld Health Organization protocol for assessment of potential risk factors for COVID-19 infection among health care workers in a health care setting (WHO)Recommendations for Adjusting Food Distribution SOPs in the Context of the COVID-19 Outbreak. (WFP) COVID-19 and Ending Violence Against Women and Girls (UN Women) – Especially p6-7 for example initiatives and specific actionsStrategic Considerations for Mitigating the Impact of COVID-19 on Key-Population-Focused HIV Programs (FHI 360) Preparedness, prevention and control of COVID-19 in prisons and other places of detention (WHO)Coronavirus disease (COVID-19) Technical Guidance: Humanitarian operations, camps and other fragile settings (WHO)Mental health and psychosocial considerations during the COVID-19 outbreak (WHO)
The mortality risk posed by COVID-19 can grow substantially if a healthcare system becomes overwhelmed and regular services cannot be provided or are prevented by strict lockdown conditions. Especially in contexts where transmissible diseases pose a significant health burden, disrupting non-COVID-19 health services - such as maternal and child health, immunizations, and management of noncommunicable diseases - could threaten as many lives as COVID-19 does or more, so urgent action should be taken to minimize disruption to routine healthcare. Measures to prevent transmission in health facilities – such as enhanced triage, improved sanitation and infection prevention and control, and segregation of COVID-19 and non-COVID-19 health services – may all be helpful strategies. Safe and dignified management of the deceased will also be an important consideration if the virus spreads on a large scale. Healthcare facilities should also assess current supply availability and project future needs, forming partnerships with the private sector to strengthen the supply chain.
- Bolster or reassign healthcare workforce to manage increased demand
- Implement strategy to maintain other critical health services such as maternal and child health and immunizations
- Initiate plans to separate screening and intake of potential COVID-19 cases from general health care intake
- Assess availability of critical supplies and project needs across the healthcare system
- Assess and address gaps in infection prevention and control in health facilities
- Track exposure and infections of health workers and assess impact on system capacity
- Reinforce oxygen supply systems
- Implement strategies for safe management of the deceased
ResourcesInfection prevention and control during health care when COVID-19 is suspected (WHO)Infection prevention and control for the safe management of a dead body in the context of COVID-19 (WHO) COVID-19 Operational guidance for maintaining essential health services during an outbreak (WHO) Alliance PPE Supplier Spreadsheet Surgical N95 Whitelist of Trusted Suppliers (US CDC) KN95 Supplier Whitelist (US FDA)Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings (US CDC)Strategies for Optimizing the Supply of N95 Respirators (US CDC)World Health Organization Training for Infection Prevention and Control (IPC) for Novel Coronavirus (COVID-19) (WHO)Crisis Standards of Care (US HHS)
Pandemic outbreaks can cause enormous social and economic disruption. These disruptions are damaging in their own right, but can be particularly problematic if they create economic disincentives to cooperation with physical distancing measures. These disruptions will not fall equally across all sectors of society. Analysis of gender dynamics, informal economies, and social and political marginalization will be critical to ensure that economic mitigation measures, where available, are targeted toward those most in need. Mitigating these disruptions can help to reduce the human cost of the outbreak, beyond the immediate toll of the disease itself. Leaders should also pay careful attention to the impact that both the outbreak itself, and the measures to control it, may have on vulnerable populations.
- Establish mechanisms to assess and address impacts of the pandemic on vulnerable populations (e.g. food insecure families and communities)
- Identify any disproportionate impacts on marginalized communities and develop a strategy for proactively mitigating potential unrest
- Assess and mitigate impact of physical distancing measures on the local economy, including informal economy, and key workforce sectors (health care, public services, etc.)
- If aid organizations are active in the community, engage them toward targeting assistance toward those most at risk of negative impacts related to any lockdown or required distancing measures
- Identify and work to mitigate economic disincentives to physical distancing measures