This section provides general guidance and highlights key issues that may need thoughtful attention.
Special Sites Not Under Jurisdiction
Examples of sites that are not under the jurisdiction of the state, territorial, or local health department are those under the jurisdiction of the US government (e.g., military bases and federal correctional facilities), diplomatic missions, or reservations for American Indian/Alaska Native tribes. If these sites have their own healthcare systems, the health department can offer technical consultation and can share and request data from case investigations and contact tracing. At sites that do not have healthcare systems, agreements can be made between local infection control officials and the onsite authorities to delegate the public health response to the health department.
Clients Unable to Participate
There may be instances when COVID-19 clients have difficulty recalling close contacts (e.g., substance use or cognitive impairment) or they are unavailable for inquiry (e.g., died before an interview could be conducted, are intubated, unconscious, a minor, mentally incapacitated, or intellectually disabled). Social-network information, setting-based investigations, and proxy interview methods are recommended to supplement the contact list. In lieu of the ability to speak to the patient, details to inform case investigation and contact tracing may be gleaned from healthcare providers or legal proxies.
Culturally and Linguistically Diverse Minority Populations
Culturally and linguistically diverse populations are growing in the United States. These populations include racial and ethnic minorities, members of tribal nations, immigrants (i.e., those born outside the United States) and refugees. Health differences between racial and ethnic groups are often due to economic and social conditions that are more common among some racial and ethnic minorities than whites. History shows that severe illness and death rates tend to be higher for racial and ethnic minority groups during public health emergencies.
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 and economic contexts in which these communities live and work.
To help build trust, jurisdictions should try to 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, it is important to provide interpreters for individuals who have limited English proficiency and consider translating the data collection instruments. 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 minority populations experience discrimination and may be stigmatized or otherwise harmed for their participation, it is important to ensure the privacy and confidentiality of data collected and to ensure that the participant is aware of these safeguards.
Interjurisdictional Case Investigation and Contact Tracing
Patients diagnosed with COVID-19 may live in one jurisdiction and work in another, so collaboration between jurisdictions to synchronize community messaging can be helpful. Timely and confidential transfer of patient and close contact information to facilitate testing (if available), self-isolation/self-quarantine, and clearance to return to work are essential to keeping communities healthy.
Ideally, each jurisdiction will assign a person or team to send and receive reports from other jurisdictions of any patients diagnosed with COVID-19 and close contacts who reside in their jurisdiction. The jurisdiction where the patient resides is responsible for leading the investigation and notifying other health departments of any close contacts and/or congregate settings needing investigation in their area. Bi-directional confidential communication between health departments should include COVID-19 test results related to the investigation and confirmation of patients and contacts being released from self-isolation/self-quarantine.
There are nuances to each situation, and joint planning and problem-solving is recommended. A team of representatives from multiple health departments can increase the efficiency of larger investigations by planning the overall strategy together and monitoring the progress. Health department TB, HIV, and STD programs have established protocols to transfer confidential data between jurisdictions and can be a resource. Developing systems to share information about new or ongoing case investigations and contact tracing across jurisdictional boundaries is critical to ensure that appropriate COVID-19 patients and close contacts are being interviewed and monitored.
Clients with COVID-19 Traveling Within the United States or Internationally
Our nation’s population is mobile, with people traveling between states and internationally for work and leisure on a daily basis. Interjurisdictional communication is essential to the success of case investigations and contact tracing spanning multiple jurisdictions. Officials from the health department that initially encounter the patient with a positive SARS-CoV-2 laboratory result or probable diagnosis should interview the patient to gather as much identifying and locating information as possible for the patient, any close contacts visited, and events attended during the patient’s travels, as well as information about the mode of travel. These data should be shared with the jurisdictions in which the close contacts are located. If the patient is initially interviewed in a jurisdiction other than his or her residence, information should be transferred between jurisdictions for continuity of case management. If a person becomes symptomatic after they have returned home from their trip, it will be important to assess whether the flight (or other mode of transportation) was within the contact elicitation window. If so, flight information should be obtained and appropriate authorities informed, and close contacts participating in the journey notified. The jurisdiction where the patient resides is assigned responsibility for managing the overall investigation.
Case investigations and contact tracing for flights arriving in the United States or between US states, or cruise ships arriving at a US port, are coordinated by CDC. To initiate case investigation and contact tracing of an aircraft or ship, the health department managing the overall investigation should notify the CDC quarantine station with jurisdiction for their area. CDC will obtain identifying and locating information for potentially exposed passengers and provide that information to health departments with jurisdiction for where the contacts reside. These health departments then follow-up with contacts within their jurisdiction and report outcomes to the relevant CDC quarantine station. For international flights departing the United States, CDC will notify public health authorities at destinations who will be responsible for conducting the aircraft case investigation and contact tracing.