COVID-19 Guidance for Pharmacy Professionals

December 21st, 2020

 

The guidance provided on this page is intended to support pharmacy professionals with information and advice for providing pharmacy services during the COVID-19 pandemic. This page will be updated as required.

Recent Updates

April 19, 2021 Added new section pertaining to COVID-19 vaccination”
March 4, 2021 Updated information from NACI regarding extended dose intervals for COVID-19 vaccination added under “Pharmacy professionals’ role in informing the public”
Dec 21, 2020 Information pertaining to COVID-19 vaccination added under “Pharmacy professionals’ role in informing the public”


Please click the link below to bring you to the appropriate section:


 

Please review the following websites for the latest updates:

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General

There are several things that pharmacists-in-charge can do to help prevent themselves, their staff, and patients from becoming infected with COVID-19.

Reduce the risk of exposure within the pharmacy environment

  • The number of individuals permitted inside your pharmacy at one time should be limited. Set a maximum number of customers and staff allowed in the location at one time. Individuals may be expected to wait outside the pharmacy until it is safe to enter.
  • Ensure signage is posted at all entrance(s) to the pharmacy area and other appropriate locations throughout the pharmacy. Signage should:
    • require individuals to self-identify if they:
      • are experiencing symptoms including fever, cough, difficulty breathing, or extreme tiredness;
      • have a travel history outside of Canada in the last 14 days; or
      • have had contact with a person who has either the above travel history or has been confirmed to have COVID-19.
    • direct patients who meet the above criteria or who have tested positive for COVID-19 to:
      • not enter the pharmacy;
      • immediately self-isolate;
      • contact the 811 HealthLine for further advice; and
      • contact the pharmacy from a telephone or email (if applicable) to arrange access to their prescriptions.
    • direct patients who enter the pharmacy to maintain an appropriate distance (at least 2 metres) from others who are not in their party.
    • direct patients to cover their sneezes and coughs, and provide guidance on hand hygiene, including handwashing and hand sanitizer use.
  • Sample Signage:
  • Those entering the pharmacy should have access to alcohol-based hand sanitizer as they enter the site and be encouraged to use it. Alcohol-based hand sanitizer must be greater than 60% alcohol content. Tissues and lined waste containers should also be available.
  • In accordance with government directives, all areas of the pharmacy, including counters, washrooms, and employee common areas, should allow for physical distancing. Stores may need to be re-arranged and customer flow managed to allow for physical distancing. Consideration may be given to the installation of physical barriers at counters if 2 meter spacing between employees and customers cannot be maintained.
  • Pharmacy owners are also reminded that the “Special Measures Order (Masks)”, issued by the Chief Medical Officer of Health on August 18, 2020, applies to all businesses operating in Newfoundland and Labrador. This would include pharmacies unless otherwise exempted. If pharmacy owners or delegates have questions about how this applies to their particular operation, they should reach out to the COVID-19 Business Response Team (email: covid19info@gov.nl.ca; phone: 1-833-771-0696) for specific guidance on what is required for their business.

Pharmacy cleaning guidance

Pharmacists-in-charge should implement regular cleaning and disinfecting procedures to mitigate the risk of COVID-19 infection and ensure that pharmacy staff members understand the need for enhanced environmental cleaning and disinfection. All registrants share responsibility for ensuring proper cleaning and disinfecting occurs.

While cleaning removes visible soil and removes germs from surfaces, it does not kill germs. Disinfecting using a chemical is required to kill germs on a surface and is only effective after surfaces have been cleaned. Important factors to consider when developing a cleaning and disinfecting policy for your pharmacy include:

  • Use appropriate cleaners and disinfectants:
    • ​Use products with a Drug Identification Number (DIN) and that are labeled as a broad-spectrum virucide.
    • Effective agents against COVID-19:
      • 70% ethyl or isopropyl alcohol
      • A mixture of 1-part household bleach to 9-parts water
      • Accelerated hydrogen peroxide 0.5% (Virox®)
  • Clean more often:
    • Clean general areas a minimum of TWICE DAILY (desks, counters, swinging doors leading to the dispensary, tables, seating areas)
    • Clean frequently touched surfaces​ EVERY 30-60 MINUTES and IMMEDIATELY after interaction if dealing with a patient who has screened positive for COVID-19 (telephones, pill counting machines, faucets, debit machine keypads, cash registers, pens, door handles, patient buzzers, computer keyboards and mouse, switches)
  • Other tips:
    • Set timers/alarms as reminders to clean
    • Establish a cleaning log
    • Use disposable gloves when cleaning; once cleaning is completed, discard the gloves and wash hands with soap and water for 20 seconds or use hand sanitizer
  • Poster: Pharmacy Cleaning Guidelines
  • Pharmacy staff protection

    The best defence against the spread of COVID-19 is proper hand hygiene and cleaning procedures. Pharmacy professionals should be familiar with infection prevention and control guidelines, and ensure policies and procedures are in place for staff and that they are followed. The following references may be helpful:

    Front-line pharmacy staff could possibly be exposed to the SARS-CoV-2 virus as they are interacting with patients who may be infected; therefore, personal protective measures should be in place. The Government of Canada website for health professionals indicates that health care workers should use a risk assessment approach before and during each patient interaction to evaluate the likelihood of exposure.

    As noted above, pharmacy professionals should aim to prevent exposure; however, if a pharmacy professional is in a position where they need to be in physical contact with a patient who may be experiencing COVID-19, they should follow the recommended contact and droplet precautions for health professionals. This includes the appropriate use of the following personal protective equipment (PPE):

    • gloves
    • a long-sleeved gown
    • facial protection, such as surgical/procedural mask and eye protection, face shield, or surgical/procedural mask with visor attachment

    Keep in mind that hand hygiene should be performed during and after the removal of PPE and after leaving the patient care environment.

    Pharmacists-in-charge should obtain reasonable quantities of PPE supply from their suppliers to have on hand if or when it is required. It is not recommended to stockpile PPE as this may lead to immediate shortages.

    Remember your duty to report notifiable communicable diseases

    Registrants are reminded that the Public Health Protection and Promotion Act (PHPPA) and its associated regulations include measures for the early detection and management of health risks to the population of Newfoundland & Labrador, including measures to help monitor and minimize the spread of communicable disease.

    In order to do so, the PHPPA mandates that healthcare professionals, including pharmacists, report SUSPECTED or CONFIRMED diagnosis of notifiable communicable diseases. Registrants are advised to review the Notifiable Disease List (linked below) where COVID-19 would be included under “all disease outbreaks, unusual disease clusters and unusual disease occurrences.” As a front-line healthcare professional, you may be the first one to suspect the presence of COVID-19 in a patient and you should be familiar with your duty to report.

    Please review the documents below for more information:

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    Pharmacy professionals’ role in informing the public

    Pharmacy professionals have a responsibility for informing and educating the public on health and other issues, including those related to the COVID-19 pandemic.

    Pharmacists should advise patients who are showing symptoms consistent with COVID-19, including fever, cough or difficulty breathing to self-isolate and contact the 811 Healthline for further direction.

    Current evidence suggests that those most at risk of serious complications from COVID-19 include the elderly, those with compromised immune systems, and those with underlying conditions. Pharmacy professionals who work in settings with these individuals should be especially vigilant to protect the safety and security of these populations. This includes:

    • Providing direction to these patients on when and how to reach out for assistance.
    • Encouraging at-risk patients, whenever practical, to access pharmacy services by telephone, use of a patient agent, home delivery, or other means that minimize direct contact.
    • Providing elderly patients and those with more complex medical conditions or chronic illnesses with additional support to ensure their well-being and maintaining their access to an adequate level of patient care from the pharmacy.

    You can also refer the public to NLPB’s COVID-19 Guidance for the Public page that is now available. It is being updated regularly with helpful pharmacy information on how to safely navigate through the pandemic as it evolves.

     

    COVID-19 vaccination

    As COVID-19 vaccinations begin to be approved for use in Canada, pharmacy professionals and the public may have questions about the vaccines, how they work, how they will be administered, possible side effects, and on-going safety monitoring. The following resources may be helpful in having these conversations:

    On March 24, 2021, the Government of NL announced that starting on March 26, pharmacists who are interested in participating in the administration of COVID-19 vaccinations could identify themselves and also indicate whether they want to be vaccinated themselves by completing the COVID-19 Immunizer Registration Form in either HEALTHeNL (see Guidance from NLCHI). If you have indicated that you wish to be vaccinated, you will be contacted by the Regional Health Authority in your area to arrange for COVID-19 vaccination appointments. Non-vaccinating pharmacists and other pharmacy staff members will be eligible to be vaccinated in Phase Two.

    The provincial government has also established a COVID-19 Vaccine Resources for Health Professionals page, which can be found at: https://www.gov.nl.ca/covid-19/vaccine/resources-for-health-care-professionals/.

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    Ensuring adequate access to medication

    Pharmacist prescribing

    Pharmacy professionals are expected to assist their patients with obtaining prescriptions for necessary medications and maintaining a sufficient supply of medication.

    There may be situations arising from COVID-19 where patients are unable to access their usual prescriber for prescriptions. Pharmacists should utilize their full prescribing scope to assist patients with their medication needs, consulting with primary health care providers by phone or other means, where necessary and possible.

    Pharmacists may be faced with situations where they will need to use their professional judgement to make the best decision they can under the circumstances, in the interests of meeting the healthcare needs of patients. In these situations, pharmacists should document the rationale for their prescribing and dispensing decisions, supporting why a specific action was taken.

    Managing medication supply

    Pharmacists-in-charge should also manage their pharmacy’s inventory appropriately to avoid stockpiling as all pharmacies need to be able to provide medications to their patients during this time.

    Patients should also be informed about the risks of stockpiling medications, as well as other critical health products such as diabetic supplies, as this could restrict access to vulnerable populations as well as trigger widespread shortages.

    Prescription pick-up and delivery

    If self-isolated patients require medications, they should arrange for someone who is not ill or required to self-isolate to pick up their medications on their behalf.

    If this is not possible, medications may be delivered to the patient, but processes should be developed to prevent direct contact with the patient, while maintaining the security of the drugs and patient confidentiality. NLPB requirements for prescription delivery are outlined in Section 2.2 of the Standards of Pharmacy Operation-Community Pharmacy, and section 2.8 of the Standards of Pharmacy Operation-Hospital Pharmacy. In cases where pharmacy professionals need to release medications to someone other than the patient, they may collect information about designated agents from patients by phone or email and document the communication in the patient’s file accordingly. The usual written delegation of authority to a patient’s agent may not be possible or appropriate during the pandemic situation.

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    Pharmacy service disruptions

    During the course of the pandemic, pharmacy services may be disrupted. There may be human resource challenges related to self-isolation protocols or staff illness, or service delays related to increased demand for pharmacy services.

    The gov.nl.ca website indicates that individuals* should self-isolate at home if they:

    • have been diagnosed with COVID-19;
    • are a close contact of someone diagnosed with COVID-19;
    • have been assessed by Public Health for COVID-19 and/or are waiting to hear the results of a laboratory test for COVID-19;
    • have travelled anywhere outside of Newfoundland and Labrador (self-isolate for 14 days upon return to the province); or,
    • have been advised to self-isolate for any other reason by Public Health.

    *This guidance applies equally to members of the public and pharmacy staff members.

    If pharmacy staff members are experiencing COVID-19-related symptoms such as fever, cough, difficulty breathing, or extreme tiredness they should not enter the pharmacy until they seek advice related to COVID-19. In this situation, pharmacy staff should immediately contact the 811 Healthline, identifying themselves as someone who works in a pharmacy. Health authorities will then provide the next steps with respect to COVID-19 testing and assessing risk to other staff and patrons of the pharmacy. The advice of Public Health officials must always be followed.

    If it becomes apparent that an individual who has worked in or visited the pharmacy has tested positive for COVID-19, the pharmacy should immediately close temporarily in order to perform the necessary cleaning protocol. The Centre for Disease Control has valuable guidance on cleaning healthcare settings where an individual with COVID-19 has visited: Cleaning and disinfection for community facilities. Also, see NLPB’s “pharmacy cleaning guidance” above.

    The pharmacist-in-charge should also notify NLPB if/when they have pharmacy staff members that test positive for COVID-19 so we can be aware of the situation and any potential impacts on pharmacy services.

    Changes to hours of operation

    Due to issues related to the COVID-19 pandemic, pharmacists-in-charge may determine that it is necessary to change the pharmacy’s hours of operation, or, potentially, close temporarily.

    • If hours of operation are changed, revised hours must be posted in full view at the public entrance of the pharmacy, and, at the dispensary, if different. NLPB office does not need to be notified of this temporary change.
    • If a temporary closure is required, the pharmacist-in-charge must follow the NLPB Temporary Pharmacy Closure policy.

    In these situations, patients should be notified of the changes to pharmacy services at the earliest opportunity, and continuity of care must be considered.

    When presented with a patient whose pharmacy is closed and the pharmacy staff and records are inaccessible, pharmacists are advised to utilize the information contained within Healthe NL to inform their prescribing and dispensing decisions. Please contact the NL Centre for Health Information (NLCHI) if you need assistance with accessing information or utilizing functions within Healthe NL or the Pharmacy Network.

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    Practice specific issues

    Patient consultation

    Pharmacy professionals will need to exercise their professional judgement regarding the best way to communicate health and medication information to patients. Wherever possible, social distancing measures should be employed. Medication counselling may be best completed by telephone to reduce exposure of pharmacy staff and patients. NLPB supports pharmacy professionals in making the necessary adjustments to their practices in order to manage personal protective measures alongside patient needs.

    Prescriptions for controlled substances

    NLPB recognizes that the pandemic situation presents patient care challenges for both prescribers and pharmacy professionals. During this time, it may not be possible to fully meet some of the prescription requirements for controlled substances (which include narcotics, controlled drugs, benzodiazepines and targeted substances). Pharmacists are encouraged to work with other care providers to identify the best possible solution to practice issues on a case-by-case basis, with the best possible outcome for the patient top of mind.

    Pharmacists may encounter patients requesting access to refills for controlled substances earlier than their usual interval, while public health restrictions are in place. Pharmacists are encouraged to use their professional judgement with respect to early release, considering the issues the pandemic presents and individual patient situations, consulting with primary health care providers (where necessary and possible). As a reminder, pharmacists should document the rationale for their prescribing decisions in the patient record.

    Health Canada Subsection 56 (1) Class Exemption for Patients, Pharmacists Prescribing and Providing Controlled Substances in Newfoundland and Labrador

    Please be advised that Health Canada has issued an exemption for certain provisions of the Controlled Drugs and Substances Act (CDSA) and its regulations, in light of the COVID-19 pandemic.

    To help put this exemption into context, both Health Canada and NLPB have prepared answers to anticipated questions. See the FAQs below:

    This exemption expires on the earliest of the following dates:

    • September 30, 2021
    • The date that it is replaced by another exemption
    • The date on which it is revoked

    For the duration of this exemption, pharmacists CAN:

    • Prescribe controlled substances for continued therapy (within the framework of the NLPB Standards for Prescribing by Pharmacists)
      • NOTE: The prescription must be filled at the pharmacy where the prescribing pharmacist is located and at the time it is written
    • Transfer a prescription for a controlled substance to another pharmacist within NL; prescriptions for narcotics and controlled drugs cannot be transferred to or from another province
    • Transfer a prescription for a benzodiazepine or targeted substance (“BZ/TS”) more than once
    • Delegate another appropriate individual to deliver prescriptions for controlled substances to patients, providing the documentation requirements outlined in the exemption are followed.

    A pharmacist CANNOT:

    • Initiate treatment with a controlled substance
    • Accept verbal orders for medications subject to the Tamper Resistant Prescription Drug Pad (TRPP) Program (due to provincial legislation restrictions)

    PLEASE NOTE:

    • Only pharmacists who are authorized to prescribe by NLPB can continue prescriptions for controlled substances during the duration of the Health Canada exemption.
    • Only pharmacists who are authorized to participate in opioid maintenance treatment (OAMT) services by NLPB can continue prescriptions for OAMT medications. Certain restrictions apply – see the COVID-19 OAMT Guidance Document for specific details.

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    Opioid Agonist Maintenance Treatment (OAMT)

    During the COVID-19 pandemic, individuals who require OAMT may face unique challenges with medication access, and with managing their opioid use disorder.

    To aid with the provision of OAMT during this time, NLPB has developed a detailed COVID-19 OAMT Guidance Document (revised August 2020).

    Pharmacists involved in the provision of OAMT should review this document and also consider the following:

    • The Centre for Addiction and Mental Health (CAMH) has provided updated clinical and pharmacy-specific guidance for management of opioid use disorder during COVID-19. Refer to the CAMH website for the most up-to-date recommendations. In addition, the College of Physicians and Surgeons of NL released an adapted version of CAMH’s clinical guidance document on April 3, 2020. Review these practice guidelines to assist with OAMT decision-making during this time. If a pharmacist receives a prescription for OAMT that is inconsistent with these documents, they should consult with the prescriber, and document the conversation and the rationale for their decisions in the patient record.
    • Pharmacists are encouraged to collaborate with OAMT prescribers and other members of the care team to prioritize both continuity of care and patient safety. Patients who need to self-isolate will still need access to their OAMT medications. Where possible, a pharmacist may elect to deliver such medications to patients, keeping personal protective measures in mind. However, this may not be a viable option for all pharmacies. Pharmacists who determine other solutions to this issue should contact the NLPB office to discuss the situation.
    • Contact information for the Regional Opioid Treatment Centres throughout the province can be found under “Mental Health and Addictions” on the Government of NL website. These centres may be able to assist patients with treatment of opioid use disorder, including counselling services.
    • Pharmacy professionals can assist with other harm reduction measures, which are particularly important during times of increased stress; such as, providing take-home naloxone kits (or referring the patient to distribution sites for the government program), and advising patients on supports available in the community.

    The Government of NL has produced information for individuals who need assistance related to opioid use disorder or OAMT. At this time, individuals should not be directed to go to their local emergency department in order to receive methadone or buprenorphine/naloxone, unless they are seriously ill. Please see the COVID-19–Supporting people requiring opioid dependence treatment document for a list of recommended contacts.

    As of April 13, there is now a toll-free Provincial Opioid Dependence Treatment line available for those seeking support for their opiate use, for their families, and for healthcare providers. The number is 1-844-752-3588 and is available Monday-Friday 8:30 am – 4:30 pm.

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    Compounding hand sanitizer

    Due to the urgent need for disinfectants and hand sanitizers during the COVID-19 pandemic, pharmacists may be called upon to compound hand sanitizer. The bulk preparation of hand sanitizers and disinfectants would normally require authorization from Health Canada. However, while shortages continue to exist, Health Canada has informed pharmacy regulators that it will not prioritize enforcement of the restriction that compounded hand sanitizer can only be distributed as part of a practitioner-patient relationship. Registrants are reminded that compounding of disinfectants or hand sanitizers must be based on a reputable formula, such as one published by the World Health Organization, and NLPB’s Standards for Pharmacy Compounding of Non-Sterile Preparations must still be followed.

    Administering injections

    It is expected that pharmacists will continue to be asked to provide administration of routine injections. When deciding whether or not to administer an injection to a patient, pharmacists should consider the following:

    • Prior to deciding to administer an injection, pharmacists should practice social distancing principles while screening the patient for symptoms and/or exposure criteria consistent with COVID-19.
    • Any patient presenting with symptoms and/or exposure criteria consistent with COVID-19 should be directed to immediately self-isolate, call the 811 Healthline and await further instructions.
    • For patients who do not exhibit symptoms and/or have exposure criteria consistent with COVID-19, pharmacists should use a risk assessment approach to determining whether or not it is appropriate to administer the injection:
      • Consider postponing the administration of injections that are part of a series which have a possible range of time (“2-6 months”, “6-12 months”) to later in the schedule.
      • Prioritize injections that are part of a regular schedule and require continuity of care or where the patient may be negatively impacted if they do not receive the injection (such as antipsychotics and medroxyprogesterone).
    • If the decision is made to administer the injection, while the risk to pharmacists administering an injection to a healthy patient is low, pharmacists should still approach the interaction with caution, practicing good hand hygiene, and paying particular attention to the proper use of personal protective equipment (PPE).

    It is also important to consider that pharmacists may have unknowingly come in contact with COVID-19 and protective measures are necessary to protect patients. If pharmacists do not have access to the required PPE, they should not administer the injection and refer the patient to another pharmacist or health professional who can safely assist.

    Influenza vaccination considerations

    In addition to the information provided above under “Administering injections”, pharmacists should consider recently published guidance from Health Canada on the delivery of influenza vaccinations in the presence of COVID-19. This guidance is intended to provide direction for health professionals for the fall of 2020, when ongoing COVID-19 activity may continue to stress public health capacity and affect influenza clinic operations and attendance. The guidance was developed by the Public Health Agency of Canada (PHAC) in consultation with the Canadian Immunization Committee and the National Advisory Committee on Immunization (NACI). It includes recommended adjustments to usual immunization procedures such as screening, physical distancing, the use of technology, and the use of appropriate personal protective equipment.

    Pharmacists are also reminded that administration of the influenza vaccine must be done in accordance with the Standards for the Safe and Effective Administration of Drug Therapy by Inhalation or Injection.

    During the pandemic, the requirements detailed in these Standards have not changed.

    Pharmacy team members playing a role in the provision of influenza vaccines must receive appropriate training relevant to the role they will undertake. Pharmacists-in-charge must ensure that all staff providing injection services in their pharmacy have the skills and authorization required to do so.

    Prescribing/dispensing medications for treatment of COVID-19

    Pharmacists across Canada have reported seeing an increase in prescriptions for certain drugs for COVID-19, which have not yet been proven to be beneficial for preventing or treating this condition. Pharmacists are advised to continue to use their professional judgment to assess the appropriateness of all prescriptions, particularly if they seem to be outside the usual indications and treatment recommendations. This is important to ensure patients receive appropriate treatments, to protect patients from unnecessary adverse effects, and to protect the supply of medications for those that require them.

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    Electronic/alternative prescribing methods

    Under normal circumstances the following is acceptable:

    • Prescriptions generated electronically by a prescriber’s password-protected electronic medical record (EMR) and sent directly to a pharmacy’s fax number.
    • Prescriptions generated electronically, printed, and faxed to a pharmacy from the prescriber’s/clinic’s fax machine, in accordance with the NLPB Standards of Practice-Facsimile Transmission of Prescriptions and Personal Health Information.
    • Prescriptions generated electronically, printed, hand-signed by the prescriber, and given to the patient to bring to their pharmacy.

    Under ideal conditions, the prescription should be sent directly from the prescriber to the pharmacy to help ensure that a duplicate is not in circulation.

    We understand that, during the pandemic, many physicians are not practicing in their offices or clinics and may not have access to their EMRs and fax machines. During this time, pharmacy professionals may have to deviate from our usual guidance; however, they are still expected to validate prescriptions and ensure authenticity to the best of their ability.

    Provision of services to personal care homes (PCHs)

    During the pandemic, there may be times when PCHs are advised to limit all non-essential visitations. In these circumstances, pharmacy professionals should exercise reduced physical contact service to PCHs to the greatest extent possible. Consider the following:

    • Make arrangements for PCH staff to receive medication deliveries at the door. Use professional judgement with respect to obtaining confirmation of delivery signatures, as limiting contact through exchange of paper may be warranted.
    • As a reminder, if a medication order changes before the next cycle, PCH staff are not permitted under their own standards to re-label medications. During times of restricted access, it may also not be appropriate for pharmacy staff to enter the home to do this. Depending on the service agreements in place, the medication that requires relabelling may be returned to the pharmacy by the home or picked up by a pharmacy staff member and a new label affixed. A label can be provided to PCH staff to apply to the Medication Administration Record.
    • Medication storage and medication safety audits may be delayed to a more appropriate time unless there are particular safety concerns that need to be addressed.
    • Annual medication reviews for residents may be performed off-site, if possible. Reviews may need to be postponed if PCH staff, pharmacists, and other health providers have limited availability to assess and implement recommendations, unless there are specific concerns that need to be addressed.

    If it is determined a pharmacy professional must enter the PCH to provide essential services, appropriate infection prevention and control measures must be taken in accordance with public health recommendations.

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