The primary source for guidance on physical distancing should be national government guidelines as every country has adopted slightly different measures appropriate to their context. Below we describe some of the measures that have been widely adopted. We define each and explain why there are differences in the recommendations between some countries.
Stay at a ‘safe distance’: This guideline normally means that if leaving the household you should remain at a safe distance from everyone who lives outside of your household. The WHO currently recommends 1 meter (3 feet) as the minimum distance, whereas CDC states 2 meters (6 feet). Variations in global and national guidelines reflect the fact that our understanding of SARS-CoV-2 is still changing and much of the evidence behind these recommendations is related to other similar pathogens. A recent systematic review indicated that staying 1 meter apart reduced the risk of transmission by 82%. However there is some evidence to suggest that recommendations need to be contextualised as under certain conditions (such as shouting, coughing or exercising) SARS-CoV-2 may travel more than 2 meters. It is the responsibility of governments, organisations and businesses to try to facilitate physical distancing in public settings by adjusting physical environments and using cues to demarcate distancing recommendations.
Source: Physical distancing measures in place at a market in Somalia to help people remain at a ‘safe distance’
Avoid gatherings: The WHO has developed this general guidance in relation to mass gatherings. Most countries have set limits on how many people can gather in any one place. Sometimes guidelines are broken down by setting. For example, in many areas some outdoor gatherings are permitted while indoor gatherings need to be smaller or are not permitted at all. Outdoor spaces like parks pose less of a risk for COVID-19 transmission because people are able to maintain a safe distance from each other, and because there are fewer frequently touched surfaces and plenty of airflow which allows the virus to dissipate. Most governments also provide guidance on special events such as concerts, sports events, religious gatherings or special occasions including weddings and funerals. In most settings these types of events are being stopped or are allowed to continue with clear guidance on how they need to be adapted to enable participants to stay safe.
Source: Communication materials developed by Stay Safe Africa to encourage adapted religious practices during Ramadan.
Avoid unnecessary travel: In most countries some travel across national and international borders is permitted according to the WHO. However many nations have decided to suspend all flights or substantially reduce flight routes to permit essential travel only. This map provides updated guidance on national restrictions on flights. Unnecessary travel should also be avoided at a local level. This could include encouraging people to shop or visit markets less regularly and to buy products locally where possible. It may also include closing non-essential services (e.g. clothes shops, restaurants or bars) to discourage people from using these at this time and reducing public transport services. In some countries regional borders have been closed or people have been advised not to travel more than a few kilometers from their home. The application of these guidelines is highly context specific and often comes as a trade-off between what is best for reducing transmission and the longer term socio-economic costs.
Stay at home if you have COVID-19 symptoms: If a person has COVID-19 symptoms then they should stay at home as should all other members of their household. If symptoms remain mild then all household members should remain home for a period of 14 days. If any member of the household develops serious symptoms then healthcare should be sought (preferably by calling COVID-19 hotlines where these exist). This technical brief from the WHO provides detailed advice on providing safe care to people with mild symptoms at home. Many national governments will have developed contextualised guidance on this as well. This document outlines the adaptations that may need to be considered for providing home care in low and middle income country settings.
Avoid physical greetings: All physical contact with people outside your household should be avoided. This includes avoiding shaking hands, hugging or kissing. Many countries have started to promote alternative greeting options such as waving or promoting ‘Namaste’, a greeting often used within South Asia.
Source: Alternative greetings illustrated by Toby Morris
Work from home if possible: Many countries have been requesting people to work from home if possible but this is difficult to do for the majority of people living in low and middle income countries (LMICs). Factors that make this recommendation challenging in LMIC settings are that many families will not have access to sufficient IT equipment and internet to allow working from home and that home environments may be smaller on average. Even in high income nations families have struggled to maintain work responsibilities now that they are often also caring for children and facing other social and economic pressures. The additional stress associated with working from home has been documented to have adverse mental health affects. While few LMIC settings are mandating working from home, some have encouraged employers to be flexible at this time so that employees can make adjustments to their work conditions to suit their current situation. However, for those who rely on daily incomes for survival and who work in manual labor professions or the informal sector, working from home is not likely to be a viable option. Instead these individuals need to be supported to maintain physical distancing, safely use masks and practice frequent handwashing. To allow for this, employers should be required to adjust work environments to make them safer and facilitate these behaviours. This may include providing handwashing stations within buildings and at entrances/exits, providing face masks for staff and adjusting work hours or spaces so that fewer people need to be in the same space at the same time.
School closure: Even though children are at a lower risk of contracting COVID-19 than adults and are less likely to develop severe illness, children are still susceptible to infection and are potential transmitters of the virus. For this reason many countries have decided to close schools or adjust the way schools are managed to enable physical distancing to be maintained. However, school closure can be detrimental to children’s education and can have social and economic effects on the families of these children. As schools start to reopen, a range of physical distancing measures may need to be put in place. We detail these in this resource.
Protect vulnerable individuals: In some countries this is being described as ‘shielding’, ‘self-isolation’ or ‘cocooning’. Basically it means that people who are more vulnerable to severe disease (people who are older or who have pre-existing medical conditions) choose to remain at home with minimal interaction with others within and external to their household. These individuals are typically supported to stay at home by receiving deliveries of food and medicine from family, their community or social support services. In LMIC settings it is likely to be more challenging to apply these principles. This resource outlines a range of options that could be considered by communities or governments in LMIC settings. There are a range of practical challenges with implementing shielding or protective green zones. In particular, it is important that these are introduced in a way that is acceptable within the local context.
The above types of physical distancing measures are likely to be introduced and rolled-back in a phased manner. In this document, the WHO provides further details on physical distancing measures and how they can be implemented in an acceptable way. They also provide criteria to help countries and regions decide about when to introduce or roll-back physical distancing measures. This includes applying measures according to the level of local disease transmission and balancing the benefits and risks of public health measures and social measures.
In this resource we have provided broad definitions of physical distancing behaviours. If your organisation is working on physical distancing then it is important that you clearly define each of the target behaviours according to national guidelines and the local context to make sure populations can easily act on recommendations. Follow the process outlined in this resource for further guidance on this.
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Author: Eva Manzano and Sam Gil (CAWST)