How to mitigate COVID-19 transmission in densely populated areas globally

Four key mitigation practices for individuals and households

Physical distancing, hand hygiene, cleaning and disinfection, and respiratory etiquette are four of the main things people can do to prevent the spread of COVID-19. This section describes the main principles to follow for each one.

Operational considerations for households

This section describes mitigation measures for households, the materials, activities, and personnel needed to implement those measures, and the potential challenges and considerations in implementing those measures. The measures are presented below in table format in three categories (personal controls to prevent transmission, administrative and engineering controls to prevent transmission between households, and considerations for home-based care of a person who may have COVID-19):

The first two categories include considerations for high risk individuals with the assumption that no member of the household has COVID-19 symptoms.

1. Personal controls to prevent transmission

This section describes considerations that apply to all households, as well as suggestions to protect people at increased risk (older adults or people with certain underlying health conditions). It includes recommendations that both individuals and organizations can take to support households in high-density urban areas.

Hand Hygiene

Personal controls

• Wash hands frequently with clean water as described above.
• Households should ensure they have at least one handwashing station with soap where water flows from a tap or spigot to allow for proper handwashing. The handwashing station may be located inside or outside the home. There should be a handwashing station near the toilet/latrine.

Materials, activities, and personnel needed for implementation

• Distribute handwashing station materials and soap where necessary for households that are unable to purchase.
• Distribute information, education and communication (IEC) materials on construction of handwashing stations and proper handwashing methods
• Conduct communication campaigns (via radio, newspaper, social media, or other platforms) describing guidance on proper handwashing technique and the key times for handwashing. Tips on communicating for hand hygiene during COVID-19 are found herepdf iconexternal icon pdf icon[420 KB, 6 pages]external icon.

Considerations and challenges for implementation

Some areas may face challenges with water quantity or water quality. If clean water is not available, the cleanest water available (e.g. not cloudy and from an improved source) should be used. In areas without access to an improved water supply, household water treatment may be considered for treating water for all purposes, including handwashing; however, priority should be given to treating drinking water where access to household water treatment products is limited.

Costs associated with the development and distribution of communications campaigns.

Costs for households to purchase and maintain handwashing stations and supplies (e.g. soap, water, drying materials). If a handwashing station is not affordable , use a bucket with cup or pitcher. However, this method does not allow individuals to scrub hands under water as recommended without the support of another household member to pour water.

Where individual handwashing stations are not possible, install public handwashing stations, as described below in administrative and engineering controls.

Accessing essential goods and services

Personal Controls

• Leave the household only when it is necessary to obtain essential goods and services. Stock up when possible to help limit the number of trips needed outside the household.
• Designate one person (who is not elderly and who does not have serious underlying medical conditions) to leave the house for essential goods and services.
• Clean hands as described above frequently when in public spaces and when returning home from a public place.
• Wear masks when in public settings where other physical distancing measures are difficult to maintain.

Materials, activities, and personnel needed for implementation

• Conduct communication campaigns (via radio, newspaper, social media, or other platforms) on when families should stay at home and to protect individuals at increased risk.
• Provide food aid and distribution of hygiene materials where necessary for households that are unable to purchase multi-day supplies of food, soap and cleaning supplies.

Considerations and challenges for implementation

Costs associated with the development of communication materials and with the purchase and distribution of food aid and hygiene materials (where needed).

Difficult to determine who qualifies for food aid and distribution of hygiene materials. Ideally, consult with community stakeholders and refer to existing social safety net lists.

Frequently touched surfaces

Personal Controls

• Clean and disinfect frequently touched surfaces and objects at least daily following the directions above and more often when heavily used. These include tables, door and window handles, and sanitation (bathroom/toilet/latrine) surfaces.

Materials, activities, and personnel needed for implementation

• Ensure access of or provide households water and bleach (or other disinfectants), cleaning materials, and personal protective equipment (rubber gloves, thick aprons, and closed toed shoes).
• Provide households communication materials describing how to mix disinfection solutions, how to clean and disinfect, and how to store disinfectants safely.

Considerations and challenges for implementation

Costs associated with purchasing bleach, soap, water, cleaning supplies, personal protective equipment, and printing communication materials. If water supply is not available on site, daily cleaning and disinfection will be more challenging and costly. If no rubber gloves are available, other non-permeable gloves can be substituted. If no aprons are available, people can wear protective clothing (such as long pants and long-sleeved shirts) and launder after use.

Constraints with supply chain and market on soap, bleach and PPE as demand increases with COVID-19 spread.

Ventilation

Personal Controls

• Open windows or doors to increase ventilation within living and sleeping areas. Improving ventilation helps to remove respiratory droplets from the air.

Materials, activities, and personnel needed for implementation

• Communication campaigns (via radio, newspaper, social media, or other platforms) informing households that increasing ventilation is a possible mitigation measure.

Considerations and challenges for implementation

Increased ventilation may not be possible in some households and during some seasons (e.g. when temperatures are cold or it is raining). Do not open windows and doors if doing so poses a safety or health risk to others (e.g. risk of falling or triggering asthma symptoms).

Using a fan without the window or door open may spread contaminated droplets to a safe area or to other occupants.

Increased ventilation may result in increased transmission of malaria or other vector-borne disease, and use of bed nets is recommended in areas where there is transmission of these diseases.

Visitation

Personal Controls

• Follow all local and government guidance on visitors. Limit time and number of guests inside households to essential visitors. Allow outdoor visits where possible.
• Encourage visitors to practice personal mitigation measures (hand hygiene, avoiding touching surfaces when possible, respiratory etiquette, wearing a mask, and physical distancing) and practice those measures when in other households.
• Persons at increased risk should not visit other households and should not receive visitors. If it is essential that a visitor enter a household with someone who is at increased risk, ensure that visitor wears a mask and maintains physical distance as much as possible.

Materials, activities, and personnel needed for implementation

• Conduct communication campaigns (via radio, newspaper, social media, or other platforms) informing households to limit visitation.

Considerations and challenges for implementation

Costs associated with the development and distribution of communication campaigns.

Risk reduction for individuals at increased risk within households

Personal Controls

• People at increased risk for severe illness (people who are elderly or who have serious underlying medical conditions) should stay at home and away from crowds or large gatherings as much as possible.
• Protect high-risk people in households where there is enough space (e.g. a separate bedroom or other room) through physical separation while they are still healthy. The high-risk person needs to stay inside the protected area, or “safe zone,” as long as there is active COVID-19 transmission in the surrounding community. Ideally, this zone would include its own sanitation facilities not used by other members of the household.
• If high-risk people need to use shared sanitation facilities, the high-touch surfaces within those facilities should be cleaned and disinfected before each use.
• All interactions between high-risk people and other members of the household should be at a safe distance of at least 2 meters, including sleeping areas.
• If separate sleeping areas are not available, consider sleeping head to toe.
• Other household members should wear masks when in the household with someone who is at increased risk and physical distancing is not possible.
• Avoid sharing personal items (such as dishes, cups, towels, bedding, etc.) between the household member at increased risk and others.
• High-risk family members should clean hands after coming in contact with high-touch surfaces, and all household members should clean hands before touching the high-risk person or anything in high risk-person’s area.

Materials, activities, and personnel needed for implementation

• Conduct communication campaigns (via radio, newspaper, social media, or other platforms) informing households about risk reduction for high-risk individuals.
• Ensure access or provide masks to other household members.

Considerations and challenges for implementation

Potential for depression and loneliness to household members at increased risk who, under this measure, would need to be isolated for a prolonged period of time (as long as there is active COVID-19 transmission in the surrounding community).

Difficult to maintain safe zone would be very difficult to maintain for all households, especially for people at increased risk who require care from other household members (unless those household members are able to isolate with them) and in households where there is no separate latrine or toilet.

It may be impossible for people at increased risk to stay at home, particularly if they earn money for the household or provide care for others. In these cases, consider financial and other support for these households to enable/encourage the person who is considered high risk to stay at home.

2. Administrative and Engineering Controls to prevent transmission between households

This section describes considerations in high-density urban areas to prevent transmission between households. It provides recommendations for organizations supporting community mitigation activities in high-density urban areas. Additional considerations for public spaces in high-density urban areas can be found here on marketspdf icon and schools.

Water Utilities

Administrative and engineering controls and policies

• Where households are connected to municipal water supplies, advocate for service continuity to ensure adequate water supply for handwashing and cleaning. This may include increasing the volume of water delivered daily (or increasing the time valves are open) to densely populated areas, not disconnecting customers in default, making repairs where necessary, or trucking in water where applicable.

Materials, activities, and personnel needed for implementation

• Develop communication materials for utilities operators describing importance of adequate water supply for handwashing and cleaning.
• Work with community leaders and water utilities to support continuity of water supply.

Considerations and challenges for implementation

Continuity of water supply may not be possible in water scarce areas, requiring scheduling of alternative measures, such as trucking in water or provision of alcohol-based hand rub.

Shared handwashing stations

Administrative and engineering controls and policies

• Consider strategic placement of shared handwashing stationspdf iconexternal icon pdf icon[6.82 MB, 60 pages]external icon, where water access is limited or where cost is prohibitive for all households to have individual handwashing facilities. Secure soap at the handwashing station with a cage, rope, or another device. Where soap and water or alcohol-based hand rub are not available, consider using a 0.05% chlorine solution for handwashing at public handwashing stations if there is proper management and oversight following these instructionspdf icon pdf icon[440 KB, 1 page].
• Operators should manage refilling of soap and water at shared handwashing stations.

Materials, activities, and personnel needed for implementation

• Hire operators to manage shared handwashing stations.
• Ensure access to operators supplies of soap and water.

Considerations and challenges for implementation

Costs associated with purchasing handwashing stations, soap, and water.

Difficult to refill soap and water in handwashing facilities and enforce physical distancing for handwashing stations without on-site operators and where space is limited.

In cases where paying operators is not possible, community health workers or volunteers may be able to manage handwashing stations.

Shared water points and sanitation facilities

Administrative and engineering controls and policies

Example of physical distancing at a water point

• At shared water points and sanitation facilities, operators should place markers at least 2 meters apart, when possible, to show where people should stand when waiting to get water or use the toilet.
• Operators should clean and disinfect frequently touched surfaces like pump handles, spigot knobs, door handles, and toilet surfaces as frequently as possible, between each user with 0.1% bleach solution.
• Handwashing stations should be placed at each water point and at each sanitation facility.
• Operators should manage refill of soap and water at handwashing station.
• Operators (or water committees, where applicable) can set schedules for when households are able to access the water point to avoid large groups of people waiting at the same time, taking care to ensure that community members’ water needs are being adequately met.

Materials, activities, and personnel needed for implementation

• Hire operators to manage shared water points and sanitation facilities.
• Ensure access to or provide operators with soap, water, and bleach (or other disinfectants), cleaning materials, and personal protective equipment (rubber gloves, thick aprons, and close toed shoes).
• Develop communication materials to describe how to mix disinfectant solutions and how to clean and disinfect.

Considerations and challenges for implementation

Costs associated with purchasing handwashing stations, soap, water, and disinfection supplies, and with paying operators.

Difficult to refill soap and water in handwashing facilities, enforce physical distancing, and clean and disinfect between users for water points and sanitation facilities without regular on-site operators.

Difficult to enforce physical distancing with adequate spacing where space is limited.

In cases where paying operators is not possible, community health workers or volunteers may be able to manage handwashing, cleaning and disinfection, and physical distancing at shared water points and sanitation facilities.

Do not overly restrict households’ access to water supply – access to water is critical for maintaining handwashing behaviors.

3. Considerations for home-based care of a suspected or confirmed case of COVID-19

This section describes mitigation measures for households where someone has tested positive for COVID-19 or has symptoms of COVID-19 (fever, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea). The person who is sick should go to a community care center, or isolation shelter, when available. If home-based care is recommended, a trained healthcare worker should conduct an assessment to determine if the household is safe and establish a communication link in case symptoms worsen, as outlined hereexternal icon by WHO. We outline mitigation measures for two scenarios: (1) households where sick members are able to isolate in a separate room and (2) households where sick members are unable to isolate in a separate room. In some communities, community care centers, also known as isolation shelters, or other non-healthcare facility-based care sites may be an option if safe isolation is unrealistic within the home. All information provided below is in addition to the general household precautions described in Section 1 above. Additional guidance can be found here.

Households where sick members ARE ABLE to isolate in a separate room

Personal controls

• The person who is sick should remain in an isolated room within the household for 10 days after symptoms first appeared, 24 hours with no fever, and have respiratory symptoms have improved unless they have to go to a healthcare facility or use a shared sanitation facility. Ideally, they should use their own sanitation facility that is not shared by other members of the household or community.
• All members of the household should take special care to follow the handwashing and respiratory etiquette guidance described above. This includes wearing a mask when not able to physically distance.
• All members of the household who had recent contact with the sick person in the household should stay home for 14 days after exposure. The best way to protect yourself and others is to stay home for 14 days if you think you’ve been exposed to someone who has COVID-19. Check your local health department’s website for information about options in your area to possibly shorten this quarantine period.​
• Avoid having unnecessary visitors to the home, especially those who are at higher risk for severe illness.
• If the sick person must leave the home to seek healthcare, they should wear a mask when they leave the house. They should notify the clinic in advance or upon arrival that they are coming and that they have tested positive for COVID-19 or have symptoms of COVID-19.
• Caregivers should wear masks when caring for those who are sick.
• Caregivers should ideally not be within the high-risk category.
• To limit contact, clean and disinfect around the person who is sick only when needed. If they are able, the person who is sick should clean their own space when needed.
• Avoid sharing personal items (such as dishes, cups, towels, bedding, etc.) between the person who is sick and other household members.
• If using a shared sanitation facility, the person who is sick should clean and disinfect it after each use. If this is not possible, the caregiver should wear a mask and then wait as long as possible before cleaning and disinfecting.
• Isolation room should be appropriately cleaned and disinfected after isolation has ended before other household members use the room.

Materials, activities, and personnel needed for implementation

• Conduct communication campaigns (via radio, newspaper, social media, or other platforms) to explain safety precautions for caregiving.
• Maintain stocks of water, soap, and bleach (or other disinfectants), materials to clean with, and personal protective equipment (rubber or disposable gloves, thick aprons, and close toed shoes).
• Develop communication materials to describe how to mix disinfectant solutions and how to clean and disinfect.
• Develop communication materials to reduce stigma of sick persons and caregivers.

Considerations and challenges for implementation

There will be a cost associated with the development and dissemination of communication materials.

It may be difficult for household if sick member is primary wage earner. In these cases, consider financial support for these households to enable and encourage the person to stay at home.

In cases where sanitation facilities are shared, it could be difficult to ensure that they are adequately cleaned and disinfected after every use by a sick person. It is recommended to wait as long as possible after use by a sick person to clean and disinfect, but this may not be possible when using shared sanitation facilities.

Difficult to ensure adequate handwashing and cleaning and disinfection in areas with insufficient access to improved water supply.

If no rubber gloves are available, other non-permeable gloves can be substituted. If no aprons are available, people can wear protective clothing (such as long pants and long-sleeved shirts) and launder after use.

Households where sick members ARE UNABLE to isolate in a separate room

Personal controls

• All members of the household should take special care to follow the physical distancing, handwashing, cleaning and disinfection, and respiratory etiquette guidance described above.
• All members of the household who had recent contact with the sick person in the household should stay home for 14 days after exposure. The best way to protect yourself and others is to stay home for 14 days if you think you’ve been exposed to someone who has COVID-19. Check your local health department’s website for information about options in your area to possibly shorten this quarantine period.​
• Increase air flow within the room as much as possible by opening doors and windows (when possible).
• When possible, allow for space (2 meters or more) between the person who is sick and the rest of the household throughout the day and at night. Ensure the sick person’s sleeping area is as far as possible (2 meters or more) from the rest of the household. If separate sleeping areas are not available, consider adding a barrier between the sick person and other household members or sleeping head to toe.
• Do not have unnecessary visitors in the home, especially those who are at higher risk for severe illness.
• The person who is sick should wear a mask when around other people, either within the home or in public (e.g. at a clinic).
• If the sick person must leave the home to seek healthcare they should wear a mask, notify the clinic that they are coming, and that they have tested positive for COVID-19 or have COVID-like symptoms.
• Caregivers should wear masks when caring for those who are sick.
• Caregivers should ideally not be within the high-risk category.
• If they are able, the person who is sick should clean their own space when needed.
• Avoid sharing personal items (such as dishes, cups, towels, bedding, etc.) between the person who is sick and other household members.
• If using a shared sanitation facility, the person who is sick should clean and then disinfect it after each use. If this is not possible, the caregiver should wear a mask and then wait as long as possible before cleaning and disinfecting it for them.

Materials, activities, and personnel needed for implementation

• Conduct communication campaigns (via radio, newspaper, social media, or other platforms) to explain safety precautions for caregiving.
• Stocks of water, soap, and bleach (or other disinfectants), materials to clean with, and personal protective equipment (rubber gloves, thick aprons, and close toed shoes).
• Develop communications materials to describe how to mix disinfectant solutions and how to clean and disinfect.
• Develop communication materials should be developed and disseminated to reduce stigma of sick persons and caregivers

Considerations and challenges for implementation

Difficult to prevent the spread of COVID-19 within the home when people who are sick cannot be fully isolated in a separate space. Community care centers should be considered when available.

Costs associated with the development and dissemination of communication materials.

Potential difficulty ensuring shared sanitation facilities are adequately cleaned and disinfected after every use by a sick person. It is recommended to wait as long as possible after use by a sick person to clean and disinfect, but this may not be feasible when sanitation facilities are shared.

Potential difficulties for household if primary wage earner is sick or must quarantine. In these cases, financial support for these households to enable and encourage the person to stay at home should be considered.

Difficult to ensure adequate handwashing and cleaning and disinfection in areas with insufficient access to improved water supply.