Non-Residential Settings

1. Communications to ACDC regarding outbreaks in non-residential settings can be directed to:
   1. FoodSafety@ph.lacounty.gov for restaurants, grocery stores, food processing/manufacturing, or food warehouses; and
   2. ACDCVector@ph.lacounty.gov for most other worksites.
   3. CovidCorrections@ph.lacounty.gov for law enforcement/court facilities
   4. Additional ACDC outbreak teams for special settings (e.g., Hospital Outbreak Bioterrorism Response team for places of worship, gyms, mass transit and ticketed and non-ticketed events).
2. For the purpose of investigation, a case refers to an individual who is reported by the employer as having a test result positive for SARS-CoV-2/COVID-19, unless otherwise specified. Employer-reported cases generally do not need to be verified with laboratory test results or linkages in IRIS. Though PCR tests are preferred when identifying new cases, “at-home” tests will be accepted unless there is additional information that indicates the result is not valid (e.g., a negative follow-up PCR test in an asymptomatic person). Antibody tests (i.e., IgG- or IgM-positive) are not accepted as cases.
3. As deemed necessary by outbreak team leaders, conduct immediate interview of cases to obtain information regarding job duties, shifts and areas worked, contacts, dates of attendance, and other critical information.
4. Outbreaks will be classified by ACDC for Enhanced Investigation or Employer Guidance. If an outbreak that ACDC opened as Employer Guidance later meets Enhanced Investigation criteria, OMB investigators can re-classify without the need for ACDC notification or approval
   1. Enhanced investigation refers to traditional prospective investigation, with regular follow-up with the employer, until outbreak resolution is achieved.
   2. Employer Guidance refers to a response involving initial follow-up by the investigator to assess the situation and provide education and recommendations to the employer. The worksite is advised to call back if additional cases occur. No prospective follow-up is conducted.
5. For Enhanced Investigation outbreaks, the frequency of follow-up with the employer for outbreak updates, including requesting updated line lists, should be at least weekly (but may be more frequent initially), as needed by the Outbreak Management Branch (OMB) MD. For Employer Guidance outbreaks, investigators will follow-up with employer upon opening the outbreak, prior to closing, and when additional cases are reported by the employer during the surveillance period or as needed by Outbreak Management Branch (OMB).
6. ACDC will immediately notify EH upon opening an outbreak. For Enhanced Investigations, site visits will be conducted by OMB and/or EH. Site visits are not required for Employer Guidance outbreaks.
   1. Upon notification of an Enhanced Investigation outbreak, OMB will contact EH immediately to coordinate a site visit.
   2. Communications to EH can be directed (EHSurvey@ph.lacounty.gov) and must include the following information at minimum:
      • IRIS Outbreak #
      • Facility's name and address
      • Name of facility's point of contact
      • Phone number of point of contact
      • Email of point of contact
      • Description of each OB zone
      • Number of cases in each OB zone
      • Number of employees in each OB zone
      • Total number of cases (entire facility)
      • Total number of onsite employees (entire facility)
      • Summary of known information
      • OMB Outbreak Investigator (OI) & MD
      • Specific request(s) of EH
7. Inform the facility, or site, that they will be included on a public outbreak notification list posted on the LAC Public Health website until the facility meets criteria for closing outbreaks (see Closing Outbreaks).
8. Outbreaks identified as high priority must be immediately reported to ACDC and the Division of Environmental Health. See High Priority Outbreaks section for definition and additional response.
9.  Outbreaks with 20 or more employee cases in the defined outbreak area within a 30-day period are “major outbreaks” until there are fewer than 3 cases detected in the defined outbreak area. Employees associated with major outbreaks may be subject to more frequent testing (see Testing Considerations).
10. Immediately notify ACDC and EH if OMB has determined a need for a DPH-ordered closure due to circumstances that prevent the facility to safely operate as noted in Criteria for Closing Facilities.
11. Notify ACDC within 24 hours of identification of any of following:
1. Concerning issues of non-compliance
2. Significant increase in case counts
3. Voluntary facility closures that are planned to last longer than 48 hours
12. If during the course of investigation, OMB determines that the outbreak does not meet outbreak criteria, please consult with ACDC, so that ACDC may review findings and make a final determination on whether outbreak should be closed as false.

Additional guidance and resources:

• COVID-19 Outbreak Notification Letter (intranet access required)
• COVID-19 Informative Letter - signed by Dr. Balter, Director, LAC DPH Communicable Disease Control and Prevention
• COVID-19 Template for Notification to Visitors and Employees
• Responding to COVID-19 in the Workplace
• Best Practices for Preventing COVID-19 - Guidance for Businesses and Employers
• Los Angeles County Code Title 11 - Health and Safety
• California Department of Fair Employment and Housing - Employment Information on COVID-19
• Cal/OSHA COVID-19 Guidance and Resources
• U.S. Equal Employment Opportunity Commission

COVID-19 Core Information:

For up-to-date information on symptoms, transmission, period of infectiousness, contacts, and fully vaccinated persons please refer to the B73 COVID-19 Home Page.

1. DPH testing recommendations should be communicated to the facility administrator/manager or site coordinator.
2. Testing is recommended for all individuals, regardless of vaccination status, in the defined outbreak area (see Determining OB-Associated Cases and OB Zones) in all non-residential congregate settings. At home tests may be both self-administered and self-read if verification of results, such as time and date stamped photograph of the result or an OTC test that uses digital reporting with time and date stamped results, is provided. See Testing Considerations.
3. Enforce masking while indoors among all individuals on site (including clients, customers, and vendors), regardless of vaccination status. All persons must wear masks outdoors if social distancing cannot be maintained. Encourage all employees to use a well-fitting medical grade mask (surgical or respirator) to reduce transmission risk during an outbreak.
4. Evaluate if and where physical distancing measures need to be implemented by the employer to enable employees and other individuals to the extent possible, maintain 6 feet physical distance from others including when eating or drinking.
5. Emphasize respiratory etiquette and good hand hygiene (cover cough and sneezes, dispose of tissues properly).
6. Signage should be posted at the site to reinforce wearing face masks, frequent hand washing, covering your cough, and maintaining social distancing.
7. Sick persons (including clients, customers and vendors) with any illness, even with mild symptoms, should be restricted from entering the facility/site. They should be instructed to stay home and self-isolate and get tested for COVID-19.
8. Screen all employees for symptoms, either at home or in-person, and if feasible also clients, customers and vendors. Consider checking for fever by measuring body temperature.
9. Emphasize importance of early detection of cases and removing them from contact with others.
10. Ensure adequate and easily accessible supplies for good hygiene, including:
1. Tissues and trash receptacles
2. No touch hand sanitizer dispenser near customer entrances, if feasible
3. Handwashing stations
4. Soap
5. Paper towels
6. Alcohol‐based hand sanitizer
11. Provide employees, and, if possible, clients, customers and vendors, with accurate and updated Public Health information and materials about novel coronavirus.
12. Minimize, where possible, close contact and the sharing of objects such as cups, food, and drink (see Sector Specific Best Practices for specific guidance in each setting).
13. Provide thorough cleaning and disinfection of equipment and the work environment of the employee case(s) along with frequently touched surfaces and objects such as doorknobs/push bars, elevator buttons, restroom doors, etc. Use cleaning chemicals with EPA-registered disinfectant labels with claims against emerging viral pathogens (see www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2). Temporary closure is not essential as long as environmental cleaning can be appropriately conducted.
14. Clean touchable, shared equipment between shifts or between users, whichever is more frequent, including, but not limited to, working surfaces, tools, handles and latches, and controls on stationary and mobile equipment.
15. Notify all employees of COVID-19 outbreak at site while maintaining patient privacy and reinforce prevention measures across the facility/site. A template letter for employers to draft notification on company letterhead is available if needed. If necessary, investigators can request employers to submit a draft template in legible font (size 14 or larger) to DPH for approval prior to distributing or posting. See Template for Notification to Visitors and Employees in Additional Guidance and Resources.
16. Post a notification letter of outbreak at the entrance of the facility/site and community area (see COVID-19 Template for Notification to Visitors and Employees in Additional Guidance and Resources).
17. Issue a public notification regarding on-site exposures if unidentifiable employees, attendees, clients, or customers may have been close contacts. Examples of a public notification include, but are not limited to, issuing a press release, using social media, and/or including information in communications released to the public and/or customer list.
18. Assess if there are shared spaces that are used by persons at nearby sites, including but not limited to employees of other businesses or residents living in a multiuse building. Shared spaces include, but are not limited to bathrooms, breakrooms, conference rooms and kitchens. Instruct management at the outbreak location that notices should be posted alerting persons to COVID-19 exposure in these shared spaces. See Exposure Notification Poster.
19. Implement strategies to protect employees who are at higher risk for adverse health complications. This may include strategies such as telecommuting, staggering shifts, and cross training staff.
20. Instruct site to maintain daily visitor log, if feasible, with date and time of visit.
21. Assess need for referrals to vaccination sites or the mobile vaccine unit.

HIGH PRIORITY OUTBREAKS

1. A worksite outbreak is classified as high-priority if, during the outbreak investigation, a facility is associated with:
   1. An unusually high number of cases than expected based on community transmission occurring in the defined outbreak area of a facility within a 14-day period. Refer to current case criteria for entry to LAC DPH COVID-19 high-priority investigations summary log.
   2. Worksite closures, either voluntary or ordered by LAC DPH, for any reason
   3. Identification of a noteworthy COVID-19 variant from one or more outbreak-associated cases
   4. Special circumstances (i.e., a sensitive environment or population, significant political or media attention, notable fatalities or other complications, etc.)
2. Other considerations that may qualify a worksite outbreak as high-priority include:
   1. The majority of employees at the facility are not represented by a union, are low-wage workers, or are working in a high-risk setting (e.g., employees are in close contact with others indoors, require frequent contact with others in daily work tasks). These settings often include those in the manufacturing and warehousing sectors.
   2. Labor partners, or other external groups, have elevated their concerns to elected officials or to DPH.
   3. Significant media interest.
   4. OMB or ACDC determines that the outbreak should be included on the list.
3. OMB to complete a high priority log report to submit to the Policy Group by the evening prior to the next log report update. Written reports will include the latest information about the latest data from the facility (e.g., case count, number of deaths, number of workers tested), a plan for ensuring the worksite comes into compliance, and a description of any enforcement actions that should be taken.

1. Instruct employees with COVID-19 to self-isolate at home, regardless of vaccination status, previous infection, or symptom status.
   1. Cases should not return to the worksite until they have completed their isolation period. Day 0 of the isolation period is the first day symptoms developed. For asymptomatic cases, the specimen collection date is Day 0. See Home Isolation Instructions.
   2. A negative COVID-19 test can be required for a case to return to work. See Responding to COVID-19 in the Workplace.
2. Identify any ill employees and immediately exclude them from working in-person at the worksite. Instruct them to not return to work until they have tested or seen a provider and have met return-to-work criteria described in Responding to COVID-19 in the Workplace.
3. Employer, or site coordinator, should advise all symptomatic employees get tested as soon as possible, regardless of vaccination status or previous infection. They can be referred to their primary care provider or 2-1-1 to access county or city testing resources.
   1. Clinically suspected cases and close contacts with symptoms that test negative or indeterminate/inconclusive for SARS-CoV-2, regardless of vaccination status, should not return to work until they have met return-to-work criteria described in Responding to COVID-19 in the Workplace.
   2. It is strongly recommended that those with indeterminate or inconclusive SARS-CoV-2 results have repeat testing.
   3. If the employee tests negative for COVID-19, or is diagnosed with another illness, they may not return to work until they have been fever-free without the help of fever-reducing medicines for at least 24 hours.
4. If the employee came to the site while ill, they should be separated from others with door closed, masked, and directed to go home right away.
5. Determine when the employee was first symptomatic and when they were tested.
6. Determine which days or shifts the case was on site.
7. If ill person has severe symptoms, call 9-1-1. Notify EMS and the receiving healthcare facility of possible exposures.
8. Consider alternative work options like teleworking if employee is well enough to do so.
9. Instruct employee case to notify all other employers of their illness in order to initiate contact investigations or other necessary infection control measures.
10. Document clinically suspected and test-positive cases on the Case Line List or Other Employees tab in the COVID-19 Line List for Non-Residential Congregate Settings (see Forms). See Determining Outbreak-Associated Cases and Outbreak Zone section for instructions.
11. Instruct the employer to notify the Outbreak Investigator assigned to the facility immediately if any additional employees or contacts, if known, test positive for COVID-19.

Contacts of Cases

1. Employers should initiate contact investigation around each case to identify all close contacts associated with the site (including employee or client/customer/vendor) during the infectious period of the case(s).
   1. In instances where there is a known COVID-19 case in a client, customer or vendor, the employer or site coordinator should initiate investigation to identify employees close contacts at site.
2. Employers should instruct asymptomatic contacts to follow requirements described in Responding to COVID-19 in the Workplace.*
   1. If direct communication with close contacts is possible, a template letter for notification and instructions for reporting symptoms or positive test results back to facility or site coordinator can be provided as a guide for messaging.
   2. If close contacts cannot be individually contacted or none could be identified, a template letter for general notification and instructions for self-monitoring can be provided as a guide for messaging to employees.
3. If close contacts have or develop symptoms, then they should not return to work until they have met return-to-work criteria described in Responding to COVID-19 in the Workplace.*
4. Employee close contacts in all industries, including those employed in critical infrastructure such as food services, transportation, government services, law enforcement, and other sectors, must adhere to the same return-to-work criteria.
5. Clients, customers and vendors (i.e., non-staff): Contact any clients, customers and vendors that may have been close contacts to an employee case, if feasible.
   1. Advise close contacts of testing and masking requirements and to monitor their health (see Home Quarantine Guidance). Clients, customers, and vendors should call their primary care provider or 2-1-1 to discuss testing options.
   2. A template letter can be provided as a guide for messaging.
   3. If close contacts cannot be identified or contacted, a notification poster can also be posted (see Exposure Notification Poster.)
6. Document the close contacts on the Contact Outbreak Line List in the COVID-19 Line List for Non-Residential Congregate Settings (see Forms), regardless of prior testing or vaccination status, and submit it to DPH Nursing Informatics Line List DPH-NIU-LineList@ph.lacounty.gov as soon as possible in order for contacts to be followed up by Case/Contact Interview Branch (CCIB) in a timely manner.
7. Employer should instruct employee close contacts who had exposure to a site-associated COVID-19 case to get tested in accordance with current DPH guidelines.
   1. If testing identifies additional cases, a new contact investigation is initiated around the new case to identify and test their close contacts. This protocol is repeated for each identified case at the workplace.
8. Do not require a healthcare provider's note for employees to return to work.

Note: CDC does not recommend testing, symptom monitoring, or special management for people exposed to asymptomatic people with potential exposures to SARS-CoV-2 (i.e., "contacts of contacts"), these people are not considered exposed to SARS-CoV-2.

*Although Table 2. Requirements for Employees that are Close Contacts refers to non-outbreak settings, guidance can be followed in the same manner.

1. If the boundaries of an outbreak can be characterized in smaller, more specific area(s) of a facility rather than the entire worksite, an outbreak zone (OB zone) can be used to monitor the outbreak. Cases associated with the OB zone are followed as outbreak-associated cases and outbreaks can be closed when there are no new cases associated with the OB zone by the end of the surveillance period, even if there are new cases outside of the OB zone.
   1. The OB zone is interpreted similar to "exposed group" referenced in some workplace response guidances.
   2. ACDC will define the OB zone, if applicable to the setting, when the outbreak is opened.
   3. OMB can redefine the OB zone as needed upon further investigation.
   4. Additionally, OMB can expand the outbreak during the course of the investigation to include new OB zone(s) if a new epi-linked cluster of 3 or more cases within a 14-day period occurs outside of the previously identified OB zone.
2. The start of an active outbreak is defined as the earliest date any case among the first epi-linked cluster was present at the facility while infectious. Sporadic case/cases occurring prior to the identified epi-linked cluster can be considered part of the outbreak if there is an identifiable epi-link between the sporadic case to a case in the cluster or a subsequent outbreak-associated case and the epi-linked cases are within 14 days of each other.
3. All cases associated with the defined outbreak area (the facility or OB zone) occurring with a symptom onset or positive test after the first case, regardless of whether they are epi-linked, should be counted as part of the outbreak until the end of the surveillance period. The surveillance period ends 14 days from the latest day any case associated with the defined outbreak area was on-site while infectious (i.e., last exposure in a facility).
4. The cases that determine the start of an outbreak and the end of the surveillance period may not necessarily be the first and last case of the outbreak, respectively, as they may have not been on-site at the facility at the earliest and latest dates, respectively.

Cases to Exclude from Further Investigation:

1. Some cases can be excluded from the outbreak and do not need further investigation. Document these cases in the Other Employees line list in the COVID-19 Line List for Non-Residential Congregate Settings (see Forms). These are cases that cannot be associated with the facility during their exposure period in which they could acquire SARS-CoV-2 infection nor the infectious period in which they could transmit it to another employee. The following cases can be excluded:
   1. Cases whose primary work location is within the defined outbreak area but have episode date before OB start date (i.e., a previous case in the outbreak location one month earlier). Episode date is the date of symptom onset or positive specimen collection date – whichever is earlier.
   2. Cases who previously tested positive in the past 90 days.
   3. Cases that were not on-site at any time during their exposure period. The exposure period begins 14 days prior to the episode date.
   4. Cases with household or carpool exposure to a COVID-positive individual, if the employer can provide detailed information, including exact dates, that meets all below criteria:
      1. Episode date occurred after the episode date of the household member or carpool passenger, but within the case’s exposure period, AND
      2. Contact occurred while the household member or carpool passenger was infectious, AND
      3. The case was not present on-site during their infectious period. The infectious period begins two days prior to episode date. For example, case was working from home as part of a hybrid schedule when they became ill.

Cases to Include in the Outbreak

1. Outbreak-associated (OB-associated) cases are those that can be counted as part of the outbreak. Document these cases on the Case Line List in the COVID-19 Line List for Non-Residential Congregate Settings (see Forms) by noting “Yes” in the column titled “Outbreak-Associated”. These cases can be associated with the defined outbreak area (the OB zone or the entire facility, whichever is applicable) either during their exposure period or the infectious period. OB-associated cases are defined as:
   1. Cases whose primary work location is within the defined outbreak area (the facility or the OB zone) with an episode date after the OB start date, OR
   2. Cases whose primary work location is outside of the defined OB area, but are epi-linked to the outbreak at any time within their exposure period or infectious period.
   3. Special Considerations:
      • Cases who carpool together in private vehicles or are from same household and have an episode date within a 14-day period:
        1. If cases have the same episode date, designate those that work primarily within the defined outbreak area as OB-associated (e.g., employees testing positive during mass testing) and those that primarily worked outside of the defined outbreak area as not OB-associated.
        2. If cases have different episode dates, the case with the earliest episode date should be designated as OB-associated if they work primarily within the defined outbreak area. Subsequent cases who primarily work within the defined outbreak area can also be designated as OB-associated if they were present on-site during infectious period given the risk of subsequent worksite transmission to others. All other cases can be designated as not OB-associated including subsequent cases that were not present on-site during their infectious period.
      • Cases that result from secondary transmission from an OB-associated case and use shared housing facilities (e.g., migrant labor camps, man camps) or shared transportation services, provided by the employer, should be designated OB-associated.

Cases that are Not Outbreak Associated

1. Cases not OB-associated should not be counted as part of the outbreak. They may still have acquired or transmitted SARS-CoV-2 infection at the facility and should remain on the Case Line List for continued evaluation. Document these cases on the Case Line List in the COVID-19 Line List for Non-Residential Congregate Settings (see Forms) by noting “No” in the column titled “Outbreak-Associated”. Cases that are not outbreak-associated cases are:
   1. Cases whose primary work location is outside of the defined outbreak area and are not epi-linked to the outbreak.
   2. Cases with household or carpool exposure as described above in Special Considerations.

1. DPH recommendations for testing should be communicated to the facility administrator/manager or site coordinator (see Responding to COVID-19 in the Workplace).
2. Employers may request that employees report their test results (see California Department of Fair Employment and Housing and www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws). Employers must maintain confidentiality in compliance with privacy laws.
3. Employees may be required to provide proof of testing to employers (see Responding to COVID-19 in the Workplace).
4. Site-wide testing may be considered in if outbreak is extensive or close contacts are not identifiable).
5. Upon identification of a major outbreak, all employees in the OB zone must test as soon as possible. Instruct employers to refer to Cal OSHA guidance as additional testing may be required (see Cal/OSHA COVID-19 Guidance and Resources).
6. Document test results of employees who are not cases or contacts, including employees in the exposed group or participating in site-wide testing, in the Other Employees list in the COVID-19 Line List for Non-Residential Congregate Settings (see Forms).
7. Document pertinent COVID-19 testing practices and testing history that the facility has performed in IRIS including:
   1. Whether targeted testing was conducted
   2. Whether wider testing (e.g., mass testing) of the exposed group or facility was conducted
   3. Dates of targeted or mass testing
   4. Number of employees tested
   5. Test results

1. If OMB determines an ordered closure is needed because certain circumstances prevent the facility from operating safely, immediately notify EH and ACDC and initiate the closure protocol. Facilities may be ordered to close temporarily under the following circumstances:
   1. Magnitude of outbreak and/or lack of disease-control measures that significantly increase the risk of continued disease transmission.
   2. New case(s) identified above baseline, despite implementation of outbreak-control measures.
   3. Inability of facility to implement outbreak-control measures recommended by DPH.
   4. Absence of clear, timely updates or communication from the facility to DPH
2. If EH or ACDC have reason to believe that a facility that is experiencing an outbreak should be closed, OMB will immediately be notified and OMB will initiate closure protocol.
3. In most cases, a temporary closure is not essential if environmental cleaning and other standard infection control measures, including deep-cleaning of COVID-19 case’s work and shared spaces, can be appropriately conducted without closure. Notify ACDC immediately if the facility plans to close longer than 48 hours— either voluntarily or by recommendation, such as for extensive environmental cleaning.