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EDMUND G. BROWN JR.
Governor

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


July 30, 2020


TO:
All Californians

SUBJECT:
Guidance on Isolation and Quarantine for COVID-19 Contact Tracing


​Guidance on Isolation and Quarantine for COVID-19 Contact Tracing 

July 17, 2020 


Please note: this guidance was updated on 07/30/20 to reflect recent changes to the CDC guidance on the duration of isolation.

After initial Stay At Home orders in mid-March, over the course of a few months, physical distancing and stay-at-home interventions helped flatten the curve in the State of California. As we gradually reopen sectors of our economy, and move outside of our homes and mix with others outside of our household we have noted a concerning increase in cases and hospitalizations, and the risk for exposure and infection has increased. 

An important component to containing the spread of COVID-19 is timely case identification and contact tracing. While intense work is focused on COVID-19 vaccine and effective therapeutics, we do not expect that these will be available for many months or longer. To continue to loosen restrictions, we must take a multi-pronged approach, which includes continuing to scale-up a robust contact tracing plan and effective isolation or quarantine of those that are infected and exposed to COVID-19. 

California Connected, the state’s contact tracing public awareness campaign, has been designed to raise awareness about contact tracing and our collective social responsibility to respond to this call to action. Additionally, the contact tracing program looks to build a contact tracing workforce that will augment local staffing resources. These public health workers from communities across the state will connect with individuals who test positive for COVID-19 and work with them, and people they have been in close contact with, to ensure they have access to confidential testing, as well as medical care and other services to help prevent the spread of the virus. 

This guidance provides a framework for local public health departments and the contact tracing workforce related to both the isolation and quarantine.


ISOLATION AND QUARANTINE 

Isolation: separates those infected with a contagious disease from people who are not infected. 

Quarantine: restricts the movement of persons who were exposed to a contagious disease in case they become infected. 

Isolation and quarantine are proven public health interventions fundamental to reducing COVID-19 transmission. Adequate isolation and quarantine processes must be in place to respond to the increasing number of cases we see with modification of local and statewide physical distancing and stay-at-home orders. 

Isolation and quarantine can create substantial hardships. Those under isolation or quarantine must be treated with respect, fairness and compassion; and their dignity and privacy must be protected. Federal resources made available to local public health departments should be considered to support people who are not able to isolate or quarantine in accordance with this guidance. 

All instructions provided by the local public health jurisdiction to individuals who are being asked to isolate or quarantine should be provided in their primary language and be culturally appropriate. Additionally, local public health departments should ensure that instructions for individuals with disabilities, including those with access and functional needs, are provided. 


DISCRIMINATION AND STIGMA 

California has a diverse population with no single race or ethnic group constituting a majority of the population. These populations include different racial and ethnic groups, members of tribal nations, immigrants and refugees. They may be at higher risk for COVID-19 or worse health outcomes due to a number of reasons including living conditions, work circumstances, underlying health conditions, and limited access to care. It is important that case investigations and contact tracing are conducted in a culturally appropriate manner, which includes meaningfully engaging community representatives from affected communities, collaborating with community-serving organizations, respecting the cultural practices in the community, and taking into consideration the social, economic and immigration contexts in which these communities live and work. Local public health departments should be mindful of discrimination not only based on race, but also based on disability. 

To help build trust, jurisdictions should employ public health staff who are of the same racial and ethnic background as the affected community and are fluent in their preferred language. When that is not possible, interpreters and translations must be provided for individuals who have limited English proficiency. Core demographic variables should be included in case investigation and contact tracing forms, including detailed race and ethnicity, as well as preferred language. 

Finally, given that diverse populations experience discrimination and stigma, it is important to ensure the privacy and confidentiality of data collected and to ensure that the participant is aware of these safeguards. Every person in California, regardless of immigration status, is protected from discrimination and harassment in employment, housing, business establishments, and state-funded programs because of their race, national origin, and ancestry, among other protected characteristics. 


DURATION OF ISOLATION 

The California Department of Public Health (CDPH) recommends a symptom-based strategy to determine the duration of isolation for people with COVID-19 who are symptomatic, meaning they have symptoms. Persons with COVID-19 who have symptoms and were instructed to care for themselves at home may discontinue isolation under the following conditions: 

  •  At least 10 days have passed since symptom onset; AND
  • At least 24 hours have passed since resolution of fever without the use of fever-reducing medications; AND
  • Other symptoms have improved 

The symptoms-based strategy will prevent most, but not all, instances of secondary transmission. Increasing evidence suggests people with mild to moderate COVID-19 remain infectious no longer than 10 days after symptom onset. However, a very limited number of persons with severe illness or who are severely immunocompromised may warrant extending duration of isolation for up to 20 days after symptom onset. Consider consulting with local infectious disease experts when making decisions about discontinuing isolation of persons who are likely to remain infectious longer than 10 days. 

For persons with COVID-19 who are asymptomatic, meaning that they have NOT had any symptoms, CDPH recommends that these individuals be instructed to care for themselves at home. They may discontinue isolation under the following conditions: 

  • At least 10 days have passed since the date of the first positive COVID-19 diagnostic (federally approved Emergency Use Authorized molecular assay) test. If they develop symptoms, then the strategies for discontinuing isolation for symptomatic persons (see above) should be used. 

DURATION OF QUARANTINE 

For individuals who have had close contact (less than 6 feet for at least 15 minutes) with a person who is COVID-19 positive, CDPH recommends the exposed person be quarantined and stay home for a period of 14 days from the day of exposure. Household members and intimate partners of COVID-19 positive persons should also be quarantined for this period, as well as anyone who has had unprotected contact with an infected person’s body fluids and/or secretions, such as being coughed or sneezed on, sharing utensils or saliva, or providing care without wearing appropriate protective equipment, such as a facemask and gloves. 

Health care workers and critical infrastructure workers, including first responders, should follow guidance that includes special consideration for these groups. Of note, to ensure continuity of operations of essential functions, CDPH advises that critical infrastructure workers may be permitted to continue work following possible exposure to COVID-19, provided they remain asymptomatic and additional precautions are implemented to protect them and the community. Similarly, after options to improve staffing have been exhausted to mitigate staffing shortages, asymptomatic healthcare personnel who have had an exposure to a person with COVID-19 may be allowed to continue to work with persons who have COVID-19. 


ISOLATION AND QUARANTINE AT HOME 

The majority of people with COVID-19 have mild to moderate symptoms, do not require hospitalization, and can be isolated at home. However, the ability to prevent transmission in a residential setting is an important consideration. The federal Centers for Disease Control and Prevention (CDC) has guidance for both patients and their caregivers to help protect themselves and others in their home and community. 

Considerations for the suitability of care at home include whether: 

  • The person is stable enough to be home. 
  • If needed, appropriate and competent caregivers are available at home.
  • There is a separate bedroom where the person can recover without sharing immediate space with others.
  • There is a separate bathroom or one that can be disinfected after use.
  • Resources for access to food and other necessities are available.
  • The person and other household members have access to appropriate, recommended personal protective equipment (PPE; at a minimum, gloves and facemask/cloth face covering) and can adhere to precautions recommended as part of home care or isolation (e.g., respiratory hygiene and cough etiquette, hand hygiene). 

In addition, both the person and caregiver should be educated and understand the clear indications for when they must seek clinical care. Although mild illness typically can be self-managed or managed with outpatient or telemedicine visits, illness may worsen quickly days after the initial onset of symptoms. 

Individuals in quarantine at home or in an alternate site that is shared with other people (e.g., household members) should maintain physical distance (at least 6 feet) from others at all times, self-monitor for symptoms (check temperature twice a day and watch for fever, cough, shortness of breath, or any other symptoms that can be attributed to COVID-19), and avoid contact with people at higher risk for severe illness. If symptoms develop, contacts should immediately contact their healthcare provider and/or local health department to determine where they can get testing. 

The following are general steps for people suspected or confirmed to have COVID-19 to prevent spread to others in homes and communities. There are also specific steps for Home Isolation and Home Quarantine listed below. These steps should be conveyed via simple verbal and written instructions in the person’s primary language.

  • Stay at home except to get medical care.
  • Separate yourself from other people in your home.
  • Call ahead before visiting your doctor.
  • Wear a facemask (or if unavailable, cloth face covering) over your nose and mouth when not in separate bedroom.
  • Avoid using the same bathroom as others, or if not possible, clean and disinfect it after use.
  • Cover your coughs and sneezes.
  • Wash your hands often.
  • Avoid sharing household items.
  • Clean all “high-touch” surfaces every day.
  • Monitor your symptoms.


HOME ISOLATION: Isolation of persons who are infectious or individuals who have tested positive for COVID-19 can be at home provided the following conditions are in place. 


What setup is needed: 

  • A separate bedroom. If a bedroom must be shared with someone who is sick, consider advising the following:
    • Make sure the room has good air flow by opening the window and turning on a fan to bring in and circulate fresh air if possible.
    • Maintain at least 6 feet between beds if possible.
    • Sleep head to toe.
    • Put a curtain around or place other physical divider (e.g., shower curtain, room screen divider, large cardboard poster board, quilt, or large bedspread) to separate the ill person’s bed.
  • A separate bathroom or one that can be disinfected after use.


What equipment is needed:

  • A facemask (or if unavailable, a cloth face covering) should be worn by the infected person if there are others in the household or when healthcare or home care workers enter the house.
  • Gloves for any caregivers when touching or in contact with the person’s infectious secretions.
  • Appropriate cleaning supplies for disinfecting the household.
  • A thermometer for tracking occurrence and resolution of fever. 


Access to necessary services:

  • Clinical care and clinical advice by telephone or telehealth.
  • Plan for transportation for care if needed.
  • Food, medications, laundry, and garbage removal. 


When to seek care:
  • If new symptoms develop or their symptoms worsen.
  • If the infected person is going to a medical office, emergency room, or urgent care center, the facility should be notified ahead of time that the person has COVID-19; the person should wear a facemask (or if unavailable, a cloth face covering) for the clinical visit.
  • Any one of the following emergency warning signs signal a need to call 911 and get medical attention immediately:
    • Trouble breathing.
    • Bluish lips or face.
    • Persistent pain or pressure in the chest.
    • New confusion or inability to arouse.
    • New numbness or tingling in the extremities.

Out-of-hospital monitoring by healthcare systems or public health can be considered, especially for those at higher risk. This may consist of oxygen saturation measurement or other assessments. Persons in isolation can be contacted regularly during isolation to 6 assess for clinical worsening and other needs. Frequency and mode of communication should be customized based on risk for complications and difficulty accessing care. 


HOME QUARANTINE: Quarantine of persons who have been exposed to an individual who has tested positive for COVID-19 can be provided at home if the following conditions are in place. 


What setup is needed:
  • A separate bedroom. If a bedroom must be shared with someone who was exposed, consider advising the following:

    • Make sure the room has good air flow by opening the window and turning on a fan to bring in and circulate fresh air if possible.

    • Maintain at least 6 feet between beds if possible.

    • Sleep head to toe.

    • Put a curtain around or place other physical divider (e.g., shower curtain, room screen divider, large cardboard poster board, quilt, or large bedspread) to separate the ill person’s bed.

  • A separate bathroom or one that can be disinfected after use. 


NOTE: When everyone living in a household has been exposed, there is no requirement for a separate bedroom or bathroom if all persons remain without symptoms and without a positive COVID-19 test. However, facemasks (or if unavailable, a cloth face covering) for those quarantined are needed for any possible encounter with persons entering from outside the household. 

When just one person is quarantined in a household with other household members who have not been exposed, a separate bedroom and separate bathroom (or one that can be disinfected after use) are needed. Additionally, facemasks (or if unavailable, cloth face coverings) for the quarantined individual and disinfectants to clean surfaces are needed for any possible encounter with persons entering from outside the household. 

What equipment is needed:

  • A facemask (or if unavailable, a cloth face covering) should be worn by the exposed person if there are others in the household or when healthcare or home care workers enter the house.
  • Gloves for any caregivers when touching or in contact with the exposed person’s infectious secretions.
  • Appropriate cleaning supplies for disinfecting the household.
  • A thermometer for tracking occurrence and resolution of fever. 


Access to necessary services:

  • Clinical care and clinical advice by telephone or telehealth.
  • Plan for transportation for care if needed.
  • Food, medications, laundry, and garbage removal. 


Clinical monitoring:
  • Quarantined individuals should be instructed to self-monitor for symptoms (check temperature twice a day, watch for fever, cough, shortness of breath, and other symptoms that can be attributed to COVID-19).
  • Individuals at home who are originally quarantined and then develop symptoms should be tested immediately. They should be isolated and follow the recommendations above for “Home Isolation.” If it is determined that they cannot suitably isolate at home, an alternate site of isolation should be considered. 

LEGAL AUTHORITY FOR ISOLATION AND QUARANTINE 

California local public health officers have legal authority to order isolation and quarantine. Local jurisdictions may vary in their approach and should consult with legal counsel on jurisdiction-specific laws and orders. Some have issued blanket isolation and quarantine orders for anyone diagnosed with COVID-19 or who have been a close contact to an infected person. Others have issued orders to individuals immediately whereas others seek voluntary cooperation without a legal order initially. 

ALTERNATE SITES FOR ISOLATION AND QUARANTINE 

Local public health departments should work with other local partners across all sectors to assess alternate places for isolation and quarantine for persons who are unhoused or who are unable to appropriately or safely isolate or quarantine at home. Alternate sites could include hotels, college dormitories, or other places, such as converted public spaces. Additionally, local public health jurisdictions are encouraged to partner with community organizations to leverage existing resources to provide supportive and culturally appropriate services to persons who are self-isolating and quarantining.

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