PHSM Appendices

Appendix A: Example PHSM Recommendations by Tier

The evidence base supporting the recommendations in this table is available here.

Activity or Sector	Tier 1	Tier 2	Tier 3	Tier 4
School: Early childhood and Primary	All in-person	All in-person Students at desks to extent possible; recess in cohorts 1	All in-person Reduced capacity to maintain 2 metres between students with students at desks; cohorting of students at all times	Staggered2 or partially remote3 if possible Reduced capacity to maintain 2 metres between students with students at desks; cohorting of students at all times
School: Secondary	All in-person	All in-person If possible, maintain 2 metres between students with students at desks, meals in classrooms, cohorting of students at all times	Staggered or partially remote, if possible Reduced capacity to allow 2 metres between students with students at desks; cohorting of students	Staggered or partially/fully remote, if possible Reduced capacity so 2 metres between students with students at desks; cohorting of students
Higher Ed	All in-person	All in-person Maintain 2 metres between students in classrooms and public areas	Staggered or partially remote, if possible Maintain 2 metres between students in classrooms; capacity limit in public and recreational areas	Full remote or consider full-time on campus (i.e., no leaving campus), if possible Maintain 2 metres between students in classroom; capacity limit in public and recreational areas
Premises where alcohol consumed	Open	Indoor: Limit capacity and seated only Minimum 2 metres between parties indoor/outdoor	Indoor: Closed Outdoor: Open with limited capacity, seated only, minimum 2 metres between parties AND early closure	Closed (curbside/pick-up/take-away available)
Restaurants - without liquor sales	Open	Indoor: Limit capacity Minimum 2 metres between parties indoor/outdoor	Indoor: Closed Outdoor: Open with limited capacity, seated only, AND minimum 2 metres between parties	Closed (curbside/pick-up/take-away available)
Indoor workplaces (offices, factories)	Open	Work remotely where possible Limit capacity as necessary to maintain minimum 2 metres between people; minimize movement within workplace	Work remotely where possible, no in-person meetings Limit capacity to maintain minimum 2 metres between people; minimize movement within workplace	Remote or closed except essential staff
Outdoor workplaces (farms, construction)	Open	Limit capacity as necessary to maintain minimum 1 metre between people	Limit capacity as necessary to maintain minimum 1 metre between people	Only essential open Limit capacity as necessary to maintain minimum 2 metres between people
Indoor retail (including grocery stores)	Open	Limit capacity as necessary to maintain minimum 2 metres between people	Open for certain hours, specifically open only for vulnerable populations Limit capacity of large indoor venues (i.e., malls) to 50% and maintain minimum 2 metres between people	Closed except essential: (curbside/pick-up/take-away available for all) Capacity for essential: Maximum 20% AND minimum 2 metres physical distancing
Outdoor market	Open	Limit capacity as necessary to maintain minimum 1 metre between people	Limit capacity as necessary to maintain minimum 2 metres between people	Limit capacity as necessary to maintain minimum 2 metres between people; unidirectional foot traffic
Places of Worship, Weddings, Funerals	Open	Maintain 2 metres distancing between households indoors; outdoors preferred Masks obligatory if singing indoors	No indoor services Limit capacity outdoors AND minimum 2 metres between households; no singing	Remote or virtual if possible; if not, outdoor services only; no singing
Gyms/Fitness	Open Full, as long as 2 metres distancing is maintained while exercising	Limited capacity AND at least 3 metres distancing while exercising Masks must be worn; no indoor group classes; locker rooms closed	Closed for all indoor activities. Open for outdoor exercising with least 3 metres distancing Masks must be worn; no group classes	Closed
Events (concerts, conferences, exhibitions, elections)	Open	Indoor venues: Maintain 2 metres distancing between households Outdoor venues: Limited capacity, masks obligatory	Indoor venues: All closed Outdoor venues: Limited capacity with 2 metres distancing between households Masks obligatory	Closed
Cultural institutions (museums, libraries, zoos, gardens)	Open	Limited capacity outdoor Indoor allowed if 2 metres distancing is possible and masks are obligatory	Indoor: Closed Outdoor: Limited capacity if 2 metres distancing is possible, and masks are obligatory	Closed
Sports and recreation (includes players and spectators)	Open	Limited capacity indoor AND 2 metres between spectator parties Spectators to wear masks Contact sports (football, wrestling, rugby): professional and amateur (non-recreational) athletes only Recreational teams: Non-contact only, outdoor only; teams limited to 10 people; no travel	Individual outdoor exercise allowed Group sports open only to professional athletes; closed to spectators; limited travel, if possible	Individual outdoor exercise only
Personal care (e.g. salon, spa, barber, nails, massage)	Open	Limited capacity AND 2 metres between patrons Masks must be worn	Indoor closed unless 2 metres between patron and service provider possible	Closed
Private social gatherings	Open	Maximum 50 people AND 2 metres distancing between households; outdoors preferred	Outdoor only Maximum 2 households AND 2 metres distancing between households	Own household only
Public transport	Open	Mask required for all passengers and drivers; vehicles max 70% capacity	Mask required for all passengers and drivers; Motorcycles: 1 passenger max Other vehicles: Middle seats empty, max 70% capacity for short trips and max 50% capacity for long-distance trips Private car: 2 passengers or 1 household max; windows open when possible	Mask required for all passengers and drivers; Motorcycles: 1 passenger max Other vehicles: Middle seats empty and max 50% capacity for all trips Private car: 1 household max; windows open when possible

Appendix B: Evidence base for recommendations

Any activity involving close contact between persons can increase risk for transmission of SARS-CoV-2, the virus that causes COVID-19. This risk can be decreased through a variety of public health and social measures (PHSMs) that individuals, establishments and communities may adopt. Public health and social measures include protective measures that individuals can observe such as mask-wearing, physical distancing and hand-washing, as well as environmental controls such as improved indoor ventilation and disinfection protocols. Some of these PHSMs may be more relevant to certain activities and settings than others, but all of them play a role in making activities safer during the COVID-19 pandemic. For example, the risk of transmission on public transportation can be reduced by limiting non-essential travel, maintaining physical distancing in queues and on vehicles, wearing masks especially when distancing cannot be maintained, and disinfecting high-touch surfaces. Similarly, the risk of transmission associated with indoor gyms can be reduced by improving ventilation, disinfecting equipment, wearing masks and enforcing capacity limits that allow for physical distancing. Risks associated with private social gatherings can be mitigated by reducing the number of people involved, socializing outdoors, maintaining physical distance and wearing masks.

The following is an overview of PHSMs that can be used to mitigate risk and the scientific evidence supporting their application to reduce morbidity and mortality from COVID-19. This should serve as a foundation for decisions around risk mitigation during various activities and in various settings during the COVID-19 pandemic. Some PHSMs may be thought of as universal, and some PHSMs are more critical during specific activities. One factor that impacts COVID-19 risk across all activities is the prevalence of the disease in the community. Where COVID-19 is highly prevalent, temporary suspension of some social or economic activities may be prudent to reduce disease spread.

Masks

The correct use of non-medical face masks in the community to prevent transmission of SARS-CoV-2 is recommended by public health authorities. Studies have shown that cloth masks can filter droplets of many sizes. Some cloth masks, especially those made of high thread-count materials that include multiple layers, can efficiently filter even very small droplets. Such masks can be made at home. The benefit of widespread community mask wearing is derived from a combination of two approaches to reducing the spread of COVID-19: “source control,” where the emission of virus-laden droplets from those who may or may not be aware of their infection is blocked, and personal protection for the mask-wearer. The fact that viral loads are high during presymptomatic phases, and that asymptomatic and presymptomatic people may significantly contribute to transmission, provides the theoretical basis for widespread community mask use. Studies have shown that people with COVID-19 who wear masks before they develop symptoms are less likely to transmit the disease to others in their household. There is compelling evidence that masks also protect the people wearing the masks from infection. Studies show that non-medical masks significantly reduce wearer exposure to aerosols, and observational data suggest that masks protect wearers from infection. There is evidence from a variety of settings that widespread mask use in the community, in combination with other personal protective measures, reduces the spread of SARS-CoV-2. Mask use is most important indoors, especially in poorly ventilated areas, and when physical distancing cannot be maintained.

Mask use is also important within households when the risk of transmission is higher such as when a household member has been diagnosed with COVID-19, has symptoms of COVID-19 or has been exposed to someone with COVID-19. In these situations, both the patient and caregiver should wear masks correctly when near each other.

Physical distancing

Physical distancing can decrease the spread of COVID-19. Contacts of people with COVID-19 are at risk of infection in large part because they may be exposed to virus-laden respiratory droplets. Transmission is facilitated by proximity, duration of exposure and number of contacts; physical distancing can reduce these risk parameters. Although it can be difficult to disaggregate the effects of physical distancing from the effects of other mitigation measures, a systematic review and meta-analysis found that physical distancing of at least one metre is associated with a 70% reduction in SARS-CoV-2 infections, and that risk of infection decreased over longer distances. Physical distancing should be widely practiced in the community because presymptomatic and asymptomatic infected people can transmit COVID-19. Within households, living with someone who has been diagnosed with COVID-19 is a significant risk factor for infection, and physical distancing is recommended to prevent transmission. Physical distancing is particularly important indoors, especially where ventilation is limited, many people are present or masks are not consistently worn.

Hand hygiene

Public health authorities recommend that hand hygiene be used in the community to stop the spread of COVID-19. There is a wealth of evidence that hand hygiene can reduce the spread of infectious diseases including those caused by respiratory viruses. In addition, there are data that suggest that SARS-CoV-2 can survive for prolonged periods on human skin. For those who are infected with SARS-CoV-2, including those who are presymptomatic or asymptomatic, hands may be contaminated with virus by breathing or coughing on them and/or by touching contaminated body parts. For those who are susceptible, hands may be contaminated by touching infected people or contaminated surfaces (see “disinfection,” below), and in this way, virus can be transferred to parts of the body where infection can be seeded. This body of evidence makes a compelling argument for the simple practice of hand hygiene which can be practiced effectively by washing hands thoroughly with soap and water or using an alcohol-based hand rub.

Ventilation and outdoor environments

COVID-19 is spread mainly when an infected person breathes out respiratory droplets and particles that contain the SARS-CoV-2 virus. Ensuring good environmental ventilation is recommended by the World Health Organization as an evidence-based strategy to reduce COVID-19 transmission. Multiple studies have shown evidence of increased transmission of respiratory viruses, including SARS-CoV-2, indoors. Ventilation has been shown to decrease the concentration of SARS-CoV-2 in indoor air samples. Enhanced ventilation may be particularly important in crowded indoor spaces, when masks are not worn, or when activities that may generate more respiratory particles are performed (e.g., singing, exercising or speaking loudly). Indoor environments with overcrowding and less ventilation may also be more conducive to superspreader events. Ventilation in indoor environments may be improved by opening doors and windows, and fans may be used to increase the effectiveness of open windows. However, recirculation of indoor air in poorly ventilated spaces should be avoided. Moving activities outdoors when possible is a very effective way to minimize exposure to respiratory particles. In a study of 318 outbreaks in China, no outbreaks involving at least three cases were linked to open-air environments. A review of evidence on SARS-CoV-2 transmission linked to outdoor environments found few examples of outdoor transmission among approximately 25,000 cases considered, suggesting that the risk of outdoor transmission is low. When outdoor transmission did occur, it was often associated with reduced physical distancing, increased crowd density, physical contact and extended durations of contact.

Transmission of SARS-CoV-2 associated with primary and secondary schools

The closure of schools and related programs can detrimentally affect the education and general health and well-being of children. Unfortunately, in the months since many schools have reopened for in-person learning, there has been a surge in COVID-19 cases across the world. However, data suggest that in-person education does not necessarily contribute to the spread of COVID-19 in communities when PHSMs are implemented and that, within school settings, students and staff can be kept relatively safe. Decisions on whether and how to conduct in-person education when there is community transmission of SARS-CoV-2 should consider the local epidemiology of COVID-19, the community control measures in place, the capacity of schools to operate safely and the impact of school closures on the education and general wellbeing of children. There are some evidence-based principles that may be used to guide such decisions. Children under the age of 18 have accounted for a relatively small proportion of cases relative to their population. Fewer cases of severe disease and fewer deaths have been reported among children compared to other age groups. Younger children do not appear to transmit SARS-CoV-2 as efficiently as adolescents or adults. A review of current data on the role of schools in COVID-19 transmission and a summary of epidemiologic data from Europe suggested that community transmission is an important driver of school transmission rather than the reverse; that when school-associated outbreaks occur they typically include few cases; and that the risk of transmission from children, especially primary school-aged children, within school settings is low. In addition, the implementation of PHSMs appears to limit COVID-19 spread within schools, and the school-associated outbreaks that have occurred have been associated with lack of PHSMs in the school setting. Among school-age children, a number of cases have been linked to extra-curricular activities such as overnight camps, high-contact extra-curricular sports and social activities. Households are also important risk environments, as illustrated by contact tracing studies showing that school-attending children with COVID-19 are more likely to have acquired the infection within their households than at school In terms of the risk to school staff, evidence suggests that transmission in schools is more likely amongst adults than children, but teachers may not be at increased risk of COVID-19 relative to adults working other jobs. Ultimately, when there is transmission of SARS-CoV-2 in the community, it may be safe for children, staff and the community to keep schools open as long as appropriate safety measures are in place.

Appendix C: African Union Member States with tiered PHSM or alert-level systems

Country	Website
South Africa	https://www.gov.za/covid-19/about/about-alert-system