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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


March 7, 2022


TO:
California Local Health Jurisdictions

SUBJECT:
Shifting Public Health Case Investigation, Contact Tracing, and Outbreak Investigation Priorities

​​​​Note: This Guidance is no longer in effect and is for historical purposes only. 



​CDPH supports local health jurisdictions' (LHJs) that have decided to shift focus and to prioritize case investigation and contact tracing (CICT) efforts for high-risk individuals or settings, and to leverage automated notifications and public education and information for cases and exposed persons in the general population. As the SARSCoV-2 virus has evolved (the shorter incubation period, dramatically increased transmissibility, and high proportions of asymptomatic cases), its transmission dynamics has reduced the impact and feasibility of universal case investigation and contact tracing. In addition, with the increasing availability of more effective prevention strategies at this stage of the pandemic, including vaccination, masking, ventilation, testing, and treatment, prioritizing CICT to the highest risk situations and leveraging other public health tools will have a more efficient and higher impact on prevention of the most severe outcomes of COVID-19.

LHJs should consider continuing large-scale CICT activities predominantly via automated digital systems, and then allow the public health workforce to focus on case investigation and contact tracing for the highest risk populations and settings. Outbreak investigation and management is expected to remain a public health priority, with a focus on settings with individuals at high risk for severe outcomes or with the potential for explosive growth. Highest priority settings include health care and congregate residential settings with vulnerable populations. Local health jurisdictions may adapt these recommendations to local conditions, including levels of community transmission, hospitalizations, and public health staffing and resources. As with all strategies and guidance related to SARSCoV-2 virus, this approach may change in the future if the next variant has different characteristics that warrant a different public health approach to mitigate transmission.

General Guiding Principles:

Prioritize CICT and outbreak investigations in high-risk settings.

COVID-19 outbreaks in skilled nursing facilities (SNFs) and Long-term Care Facilities (LTCFs), including residential care facilities for the elderly, impact populations at the highest risk for severe outcomes. Outbreaks in congregate living settings have the potential to spread and affect persons with medical co-morbidities and limited access to health care resources, which may result in severe outcomes. CDPH recommends that LHJs prioritize the following settings, populations, and situations for CICT, outbreak investigation, health education outreach, and/or other technical assistance and resource support, as indicated by the situation or setting:

1. Cases reported as working or residing in higher-risk settings that include vulnerable populations, specifically certain congregate or health care settings:

  • In-patient & residential health care settings – e.g., acute care, skilled nursing, mental health, long-term care
  • Congregate living settings – e.g., assisted-living facilities, correctional facilities, homeless shelters and encampments, migrant farm worker housing

2. Clusters or suspected outbreaks in high-density or other required reportable settings, such as:

  • Critical infrastructure work settings – e.g., K-12 schools, childcare, food processing plants, manufacturing plants, transportation, food services, first responders
  • Health care settings – e.g., outpatient/non-residential health care settings
  • Community settings of concern for super-spreader events (e.g., with large number of people, indoor prioritized over outdoor) – e.g., mass gatherings
  • Other outbreaks with unusual clinical or epidemiological characteristics (high severity of disease in healthy, younger, or vaccinated individuals)

To address the disproportionate impact COVID-19 has on vulnerable communities, LHJs may also consider continuing to provide health education and resources via targeted outreach to cases and exposed persons in populations most likely to have resource needs. These populations might be defined according to local needs by geography (e.g., known vulnerable areas based on zip code, address), race/ethnicity, and/or age.

Leveraging Technology & Automated Outreach

LHJs are encouraged to send automated surveys and educational information to all reported cases and contacts as feasible. CDPH and LHJs will both work to improve the general public's access to clear information and resources in appropriate languages and communication methods so that individuals can keep themselves and their communities protected

from illness and the consequences of severe infection.

CalCONNECT

CalCONNECT will continue to facilitate LHJs' ability to send automated surveys and educational information to cases in English and Spanish and will prioritize translation of these tools into other languages. The survey responses will help LHJs prioritize outreach to populations at highest risk for severe outcomes and to facilitate the rapid provision of information, treatment, or other needed support. The CalCONNECT Technical Assistance and Support Coordination (TASC) team can provide LHJs assistance with adjusting workflows and optimizing use of CalCONNECT automation and tools to facilitate a smooth transition to new local CICT protocols.

CA Notify

CA Notify will continue to send alerts to notify users who are exposed to COVID- 19 and will direct them to applicable public health education and resources.

LHJs may consider further promoting the activation and use of CA Notify among their local constituents to help expand the reach and effectiveness of this digital tool.

CDPH Ongoing Support

In addition to maintaining the CalCONNECT and CA Notify systems and user support, CDPH will continue to provide resources and support to LHJs related to CICT safety-net staffing, workforce training, and outbreak investigation consultation.

State CICT Workforce.

As LHJs are aware, the State's redirected COVID-19 CICT staffing support program will end June 30, 2022, and the CDC-Foundation- supported COVID-19 Schools Case Investigation staffing program will end July 31, 2022. CDPH will continue to offer Disease Investigation Unit (DIU) teams, as available, to support LHJs that need assistance with local priority COVID-19- focused CICT (including acute outbreak management support) and are looking into extending the DIU's safety-net support to other disease conditions in the future. The DIU teams can also provide LHJs with continuity assistance during the transition of local workflows away from universal CICT protocols. CDPH is additionally currently seeking state employee volunteers to join the new California Public Health Reserve Corps (PHRC). The PHRC volunteers will be trained, organized, and prepared for emergency activation to support requests from LHJs with priority COVID-19-related case and outbreak investigation, testing and vaccination education and coordination support, and other emergency response efforts in alignment with CDPH and LHJ procedures.

Training.

The UCSF/UCLA Virtual Training Academy will continue to provide free training to help ensure a cross-trained local and state public health workforce that can shift as needed to support a variety of public health priority efforts.

Training content and skills-building that will continue to be offered include case investigation and contact tracing; health education and motivational interviewing; outbreak management; school coordination and communication support; cultural humility; and vaccination education. We are exploring the possibility of expanding course offerings to include additional relevant and needed training content.

Outbreak Consultation.

The CDPH outbreak consultation team will continue to support LHDs as needed for complex, multijurisdictional outbreaks, health care associated outbreaks, or other situations when epidemiologic or investigative staff technical assistance is requested; and can consider additional on-the- ground investigation, testing, or vaccination support, if needed.

ELC Contact Tracing Funding and Reporting

CDPH wants to inform LHJs that ELC funding requirements allow flexibility for these evolving public health activities, and jurisdictions can work with the CDPH ELC Team to revise workplans to remain consistent with the award if they choose to prioritize CICT to high-risk situations. There are numerous options for prevention efforts that can be supported by the ELC funding, such as testing, joint testing and vaccination events, enhanced detection, school supports, isolation and quarantine supports, and others. The CDPH ELC Team is available for consultation or to answer further questions about ELC reporting or funding requirements: CDPHELC@cdph.ca.gov.

CDC has also indicated that they recommend jurisdictions continue CI and CT for priority high-risk situations, congregate residential settings, and large outbreaks, and acknowledges that there are multiple metrics related to individual-level CICT in the ELC cooperative agreement. In the coming months CDC has indicated that they will aim to streamline the measures to be more aligned with shifting priorities. CDC and CDPH acknowledge that LHJs may be unable to provide data for some ELC CICT metrics at this time, and while monthly ELC data and information reporting is still required, LHJ funding will not be withheld based on the inability to provide data for all current metrics.

References & Resources

  • CDC's recommendations for Prioritizing Case Investigation and Contact Tracing for COVID-19 (Released February 28, 2022)
  • Council of State and Territorial Epidemiologists (CSTE), the Association of State and Territorial Health Officials (ASTHO), the Association of Public Health Laboratories (APHL), the National Association of County and City Health Officials (NACCHO), and the Big Cities Health Coalition (BCHC), joint-partner statement regarding a (transition) away from universal case investigation and contact tracing for individual cases of COVID-19 (Released January 24, 2022)