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Community Non-Residential Settings

B73 COVID-19 - Procedural Guidance for DPH Staff



COMMUNITY NON-RESIDENTIAL SETTING TYPES

  • Education settings: Include TK-12 schools, early care and childhood centers, institutes of higher education, and programs serving school-aged children (including day care, camps, and youth sports programs). Educational settings where no students are present (such as District Offices) will be reported as Education Outbreaks and should follow Reporting Procedures for Education Settings, but the Outbreak Investigation team may choose to follow General Investigation Guidelines for Workplace Settings.
  • Workplace settings: Include, but not limited to: manufacturing, storage, transport, distribution, offices, retail, construction, media, fitness/gyms, restaurants, ticketed and non-ticketed transit, civic organizations, law enforcement, places of worship, government, auto, hotels, banks, and veterinary offices.
  • Some worksites and educational settings have associated residential congregate facilities where employees and/or students reside. See specific outbreak definitions and control measures for these settings below.

DEFINITIONS

Case:

In the sections below, “cases” refer to individuals with a positive viral test (i.e., a PCR or antigen test, including self-administered and self-read tests) for COVID-19. For outbreak investigations, individuals who tested positive for COVID-19 with an over-the-counter rapid antigen test, without CLIA oversight, are included in the outbreak case counts.

Case exposure window:

For the purposes of epi-linking and determining the outbreak surveillance period, cases should be considered infectious beginning 2 days before symptom onset or positive test date (if asymptomatic) until they meet criteria to return to the site, provided they follow all public health instructions including consistently wear a well-fitting mask around others. See the COVID-19 Core/Background for clinical details regarding communicability and potential period of infectiousness.

Epidemiological links:

Epidemiological links among cases exist when the cases are present in the same setting during the same time period during at least one case’s exposure window. Epidemiologically linked cases include persons with identifiable connections to each other, such as sharing a physical space (e.g., same physical work area, same shift/department, same floor/unit) within likely timing of exposure and without other more likely sources of exposure. Epidemiological links indicate a higher likelihood of transmission of disease between cases in that setting rather than sporadic transmission from the broader community.

Outbreak Definitions:

Under Title 17, Section 2500, California Code of Regulations, all suspected outbreaks are reportable.

Community Non-residential Outbreak:
  • At least 3 cases with symptomatic or asymptomatic COVID-19 infection within a 7-day period who are epidemiologically linked, do not share a household*, and are not close contacts of each other outside of the outbreak site (except when transportation is provided by the employer or site).
  • For workplace settings with more than 100 employees on-site, an outbreak is also defined as 5% of the facility census are cases (symptomatic or asymptomatic) within a 7-day period even in the absence of identifiable epidemiological links. This second definition does NOT apply to educational settings.

*Housing and transportation provided by the employer or school are considered extensions of the facility. Because of this, multiple cases in these settings are evaluated as individual cases and may be counted towards an outbreak.

Outbreak-associated cases are:
  1. The index case in the outbreak.
  2. Cases who are epidemiologically linked to other outbreak-associated case(s) during the case exposure window.
Non-outbreak-associated cases are:
  1. Cases that may have acquired or transmitted SARS-CoV-2 infection at the facility but are not epidemiologically linked to any outbreak-associated cases.
  2. Cases that are epidemiologically linked to an outbreak-associated case(s) but whose exposure was more likely to have occurred off site. This includes cases who share a household or carpool in private vehicles with outbreak-associated cases, where transmission was more likely to have occurred outside of the facility.
Outbreak Surveillance Period:
  1. The  onset date of an outbreak is defined as the earliest date any outbreak-associated case was present at the facility during the case’s exposure window (the index case)
    1. Sporadic case(s) 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 7 days of each other.
    2. If earlier cases are found, investigation of prior cases should continue until a first index case can be determined, and the outbreak onset date should be updated to reflect the new findings.
  2. The last day of surveillance is the 7th day after the last date an exposure occurred from an outbreak-associated case. If exposure status is unknown, use last outbreak-associated case’s symptom onset date or specimen collection date (whichever is earlier). See Outbreak Closure Criteria for additional details.

For additional information regarding the incubation, transmission, infectiousness, and diagnostic procedures, see the COVID-19 Core Information/Background chapter.

Epidemiologic Data for Outbreaks & Reporting Procedures

  1. Instruct outbreak site liaison to report all outbreak-associated cases via SPOT and ensure cases have been reported.
    1. Non-outbreak-associated cases do not need to be reported. They may be reported via SPOT but can be unlinked from the Exposure Event after the Outbreak Investigation team confirms that there are no epi-links between the case and the outbreak-associated case(s). (See Definitions for descriptions of outbreak-associated and non-outbreak-associated cases).
  2. Monitor for new cases until there are no new outbreak-associated cases for at least 7 days from the latest (most recent) day any outbreak-associated case was present at the facility during the case's exposure window. (See Outbreak Closure Criteria).
  3. Obtain site floor plan, if appropriate. (Optional)
  4. Create an epi-curve using the symptom onset date, if available, or the first positive specimen collection date (whichever date is earlier) for outbreak-associated cases. Only include individuals that meet the case definition. (Optional)
  5. Complete required documentation in IRIS and CalCONNECT as outlined in protocols from Nursing Administration and Community Field Services (see Additional Guidance and Resources for links to Nursing Administration protocols).
  6. The facility must notify the Outbreak Investigation team of a COVID-19-related death or hospitalization of case(s) among outbreak-associated cases.

GENERAL INVESTIGATION GUIDELINES

EDUCATION SETTING OUTBREAK INVESTIGATIONS can be conducted over the phone. The frequency of follow-up with the facility for outbreak updates will be at least weekly, but more frequently as needed and determined by Outbreak Investigation team.
WORKSITE OUTBREAK INVESTIGATIONS 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, Outbreak Investigation team can re-classify without the need for ACDC notification or approval.

  • Enhanced Investigation refers to traditional prospective investigation, with regular follow-up with the employer, until outbreak resolution is achieved.
  • Employer Guidance refers to a response involving initial follow-up by the Outbreak Investigation team 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 required.

Education and Worksite Settings

  1. Consultation with Environmental Health ( EHSurvey@ph.lacounty.gov) may be recommended in certain situations to provide additional guidance on prevention and mitigation. These situations may include but are not limited to when there are concerns regarding ventilation or facility non-compliance. Joint site visits to the facility/site by the Outbreak Investigation team and EH may also be required.
  2. Inform the facility/site that they will be included on a public outbreak notification list posted on the LAC Public Health website until criteria for closing the outbreak(s) have been met.
  3. Immediately notify ACDC and EH if Outbreak Investigation team 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.
  4. Notify ACDC within 24 hours of identification of any of the 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
  5. During the investigation, if Outbreak Investigation team determines that the outbreak does not meet outbreak criteria, please consult with ACDC. ACDC will review findings and make a final determination on whether outbreak should be closed as false.
  6. Communications to ACDC regarding outbreaks can be directed to  CommunityOutbreak@ph.lacounty.gov.

GENERAL CONTROL RECOMMENDATIONS FOR OUTBREAKS

  1. Individuals at schools and worksites can generally follow general community COVID-19 guidelines. Reinforce COVID-19 Instructions for Cases and Close Contacts. See Control of Cases & Contacts.
  2. Evaluate if and where additional measures to prevent transmission may need to be implemented by the facility/site. This may include: remote working; reducing density of people indoors; implementing separate shifts and/or break times; moving indoor activities outdoor; and improving ventilation indoors (see CDPH and CDC recommendations).
  3. Emphasize good hand hygiene and respiratory etiquette (cover cough and sneezes, dispose of tissues properly).
  4. 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
  5. Ensure that individuals with COVID-19 symptoms get tested as soon as possible.
    1. Symptomatic individuals who test negative with an over-the-counter (OTC) COVID-19 rapid antigen test, or a self-test, should consider retesting 2 days later and should stay home until symptoms are improving and they have been afebrile for 24 hours.
  6. Do not require a healthcare provider’s note for cases or individuals with symptoms of COVID-19 to return to the facility/site.
  7. Post signage to reinforce COVID-19 prevention and control measures, like wearing masks, frequent hand washing, covering your cough, and testing if you have symptoms.
  8. Minimize, where possible, the sharing of objects such as cups, food, and drink.
  9. Identify strategies to improve ventilation to reduce the spread of COVID-19. (See Best Practices to Prevent COVID-19 – Guidance for Businesses and Employers.)
  10. Provide thorough cleaning and disinfection of spaces that the case(s) occupied, in addition to equipment, the work/education environment, and frequently touched surfaces and objects following possible COVID-19 exposure. (See CDC's When and How to Clean and Disinfect a Facility).
    1. Use cleaning chemicals with EPA-registered disinfectant labels with claims against emerging pathogens see EPA’s About List N: Disinfectants for Coronavirus (COVID-19)
  11. If appropriate, post the Public Health COVID-19 Exposure Notice at all public entrances to the facility/site and issue additional public notifications regarding possible exposures, as required by the Outbreak Investigation team. Examples of a public notification include, but are not limited to, press releases, social media postings, and/or other communications for the public, clients, students, and/or their legal guardians.
    1. Outbreak counts and locations are publicly posted without personal identifiers on Public Health’s website.
  12. Post notices alerting persons to COVID-19 exposure in shared spaces. Shared spaces include, but are not limited to, bathrooms, breakrooms, conference rooms and kitchens. (See Exposure Notification Poster.)
  13. Implement strategies to protect individuals who are at higher risk for adverse health complications. This may include strategies such as telecommuting, staggering shifts, and cross training staff in worksites. For educational settings, this may include increasing ventilation to the extent possible, increasing physical spacing between desks, masking, and moving activities outdoors.
  14. Promote vaccination. Assess need for referrals to vaccination sites or the mobile vaccine team.
  15. In very rare circumstances, closure of the facility may be warranted to control the spread of COVID-19.

CONTROL OF CASES AND CONTACTS

Note: The facility should be instructed to enforce the following actions for cases and close contacts


Cases

  1. Identify all persons with COVID-19 and instruct them to follow Instructions for COVID-19 Cases and Close Contacts. Emphasize importance of early detection of cases and following all isolation instructions. Reinforce recommendations and requirements for COVID-19 testing, masking, and exposure notifications. Instructions can be made stricter at the discretion of the outbreak team.
    1. For worksite settings (including staff members at education settings), refer to Responding to COVID-19 in the Workplace and Cal/OSHA COVID-19 Prevention Non-Emergency COVID-19 Regulation FAQs.
    2. For educational settings, refer to the COVID-19 Prevention and Response Guidelines for Education Settings.
  2. Determine when the case was first symptomatic and when they were tested.
  3. Determine which days or shifts the case was on site during the case’s exposure window.
  4. Determine the last date of exposure at the facility. This is the most recent date a case was on site at the facility during the case's exposure window.
    1. For asymptomatic positive cases wearing a mask or those returning to site masked with improved symptoms, assume they do not cause continuing exposure.
  5. Instruct employee case(s) to notify all other employers of their illness to initiate contact investigations or other necessary infection control measures.
  6. Instruct the employer or site coordinator to notify the Outbreak Investigation team immediately if any close contacts of the outbreak-associated cases test positive for COVID-19.
  7. If an ill person has severe symptoms, call 9-1-1. Notify EMS and the receiving healthcare facility of possible exposures.

Close Contacts

  1. Initiate contact investigation around each case to identify all close contacts associated with the site, as defined by the COVID-19 Instructions for Cases and Close Contacts.
  2. Notify all persons who are close contacts that they had an exposure while maintaining the cases’ privacy. Instruct them to follow the instructions for close contacts. For close contacts who cannot be identified or contacted, a notification poster can also be used (See Exposure Notification Poster).
  3. Instruct close contacts to follow instructions for close contacts.
    1. For worksites (including staff members at education settings), refer to Responding to COVID-19 in the Workplace and Cal/OSHA COVID-19 Prevention Non-Emergency COVID-19 Regulation FAQs.
    2. For educational settings, refer to the COVID-19 Prevention and Response Guidelines for Education Settings.
  4. If close contacts have or develop symptoms, they should stay home and get tested as soon as possible.
    1. Symptomatic close contacts who test negative with an over-the-counter (OTC) COVID-19 rapid antigen test, or a self-test, should consider retesting 1-2 days later and should stay home until symptoms are improving and they have been afebrile for 24 hours.
  5. If testing identifies additional cases among close contacts or at the site, a new contact investigation is initiated around the new case(s) to identify and test their close contacts. This protocol is repeated for each identified case at the facility/site.
  6. Do not require a healthcare provider’s note for close contacts to return to the facility/site.

Residential Settings

In addition to the measures outlined above, the following actions should be implemented for residential congregate settings associated with these sectors where employees and students may reside.

  1. For cases, designate a separate area for the placement of residents who have confirmed COVID-19 to isolate from others. This ideally includes a separate room and dedicated restroom that is not shared by residents who are not cases.
  2. Any breach in isolation of COVID-19 case would constitute an ongoing exposure at facility and monitoring period will need to be extended.
  3. If residents that are close contacts develop symptoms of COVID-19, they should isolate and test for COVID-19 as soon as possible.
  4. Continue to monitor all residents that are close contacts for fever and symptoms of COVID-19 for 7 days after last date of exposure at facility/site.
  5. Post notices alerting persons to COVID-19 exposure in shared spaces in residential settings. Shared spaces include, but are not limited to, bathrooms, common areas, and kitchens. (See Exposure Notification Poster.)

CRITERIA FOR CLOSING FACILITIES

  1. In most cases, a temporary closure is neither necessary nor appropriate. Facilities should only 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 and adverse health outcomes.
    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.

OUTBREAK CLOSURE CRITERIA

  1. The outbreak may be considered resolved based on the following conditions:
    1. No outbreak-associated cases have occurred within the outbreak surveillance period; and
    2. The location appears to have effectively implemented all necessary COVID-19 control and preventive measures and observed violations have been abated.
  2. Certain outbreaks with different transmission dynamics or compliance issues may require more restrictive criteria, upon discretion of the DPH OB physician lead.
  3. Employers may be subject to additional regulations per CALOSHA.
Outbreak Surveillance Period
Outbreak surveillance period

ADDITIONAL GUIDANCE AND RESOURCES

General

Case Reporting Tools

CalCONNECT New User Access

Line List Templates (for internal use only, not to be shared with outbreak site liaison)

SPOT Quick Guides for outbreak site liaisons



Public Health has made reasonable efforts to provide accurate translation. However, no computerized translation is perfect and is not intended to replace traditional translation methods. If questions arise concerning the accuracy of the information, please refer to the English edition of the website, which is the official version.

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