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.

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.

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.

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.

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.

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.

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.

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.