Interim Guidance for Case Investigation and Contact Tracing in Institutions of Higher Education (IHEs)

Overview

To promote safe and healthy learning environments in Institutions of Higher Education (IHEs), IHE administrators can work together with health departments to reduce the risk of coronavirus disease 2019 (COVID-19). IHE administrators play an important role by taking steps to slow the spread of disease to prevent outbreaks, and protect students, staff, and faculty. Regardless of the level of community transmission, IHEs should be prepared for COVID-19 outbreaks in their communities that may introduce infection to the IHE, identification of cases among students, staff, and faculty, and potential exposure(s) to COVID-19 that may occur at IHE facilities or events.

Interim Guidance for Administrators of U.S. Institutions of Higher Education provides guidance to assist IHE administrators in planning a comprehensive response. Many IHEs are adopting approaches to reduce the risk of SARS-CoV-2, the virus that causes COVID-19, transmission on campus. These approaches include increased social distancing in classrooms and dining halls, requirements for face masks, reducing density of on-campus housing, and various testing strategies. However, off-campus community settings including apartments, bars and restaurants, and community spaces related to campus (e.g., communities of faith, Greek organizations, athletic events, other mass gatherings) can also pose a risk for SARS-CoV-2 transmission. These off-campus settings should also be considered in case investigation and contract tracing efforts.

Case investigation and contact tracing are essential interventions pdf icon[9.9 MB, 20 Pages]external icon in a successful, multipronged response to COVID-19, and should be implemented along with other mitigation strategies. As students move into communities near IHEs, and IHEs resume in-person learning, case investigation and contact tracing with students, faculty and staff associated with the campus should be anticipated as a crucial strategy to reduce further transmission once a case is identified. Centers for Disease Control and Prevention (CDC) encourages collaboration between IHEs and state, tribal, local, and territorial (STLT) health departments when investigating cases and exposures to infectious diseases, including SARS-CoV-2, the virus that causes COVID-19. Prompt and coordinated actions, including case investigation and contact tracing, inform decision-making about strengthening, focusing, and relaxing mitigation strategies. This document aims to highlight potential collaboration between health officials and IHE administrators to facilitate effective case investigation and contact tracing.

Background

COVID-19 is a nationally notifiable disease. When diagnosed or identified through laboratory or clinical criteria, COVID-19 cases are required to be reported, by health care providers and laboratories, to state, tribal, local, and territorial (STLT) health departments. When laboratories send positive test results for SARS-CoV-2 to health departments, many of these results are received via electronic laboratory report. Testing locations, such as pharmacies and community testing sites, are also required to report positive test results to the health department for follow-up. Healthcare providers from a variety of clinical settings, including school-based clinics and community-based settings, also complete case reports on symptomatic patients diagnosed with COVID-19.  Health departments have primary responsibility for case investigation and contact tracing. Case investigation and contact tracing are core disease control measures that have been employed by STLT health department personnel for decades, and an important part of the COVID-19 response.

Case investigation is the process of working with a person (patient) who has been diagnosed with COVID-19 to discuss their test result or diagnosis, assess their symptom history and health status, and provide instructions and support for self-isolation and symptom monitoring. This interaction is the first step to review the activity history of the person diagnosed with COVID-19, while infectious, and identify people (contacts) who may have been exposed to COVID-19.

Contact tracing is the process of notifying people (contacts) of their potential exposure to SARS-CoV-2, the virus that causes COVID-19, provide information about the virus, and discuss their symptom history and other relevant health information. In addition, instructions for self-quarantine and monitoring for symptoms, and support and referrals to testing, clinical services, and other essential support services are provided, as indicated.

The case investigation and contact tracing processes help to prevent further transmission of disease by separating people who have (or may have) an infectious disease from people who do not. Prompt identification, voluntary self-quarantine, and monitoring of those contacts exposed to SARS-CoV-2, can effectively break the chain of transmission and prevent further spread of the virus in a community.

Classification of an individual as a close contact is based on many factors and should be assessed on a case-by-case basis. In the context of COVID-19, the definition of a close contact is someone who was within 6 feet for a total of 15 minutes for more of a person diagnosed with COVID-19. ​More information to inform the determination of exposure risk  can be found on CDC’s Public Health Guidance for Community-Related Exposure webpage. The page notes that: 1) data to inform the definition of close contact are limited. Factors to consider when defining a close contact include proximity, the duration of exposure (e.g., longer exposure time likely increases exposure risk), and whether the exposure was from a person with symptoms (e.g., coughing likely increases exposure risk). Furthermore, while research indicates masks may help keep those who are infected from spreading the infection, there is less information regarding how much protection masks offer a contact exposed to a symptomatic or asymptomatic patient. Therefore, the determination of close contact should be made irrespective of whether the person with COVID-19 or the contact was wearing a mask. 2) Data are insufficient to precisely define the duration of time that constitutes a prolonged exposure. Recommendations vary on the length of time of exposure, but within 6 feet for a total of 15 minutes or more can be used as an operational definition. Brief interactions are less likely to result in transmission; however, symptoms and the type of interaction (e.g., whether the infected person coughed directly into the face of the exposed individual) remain important. Assessment of exposure, beyond close contacts, is a recommended strategy in some IHE settings to control transmission of SARS-CoV-2.

SARS-CoV-2 (the virus that causes COVID-19) can cause symptomatic illness and asymptomatic infection among young and healthy populations. The IHE setting may be a potential source of COVID-19 outbreaks due to the number of individuals intermingling in close proximity for extended periods of time. IHE settings contain a mixed population of students, staff, and faculty, ranging from young to older adults, who can be highly interconnected in multiple, close-contact networks such as classrooms, libraries, theaters, gymnasiums, social meal events (e.g., brown bag lunch lectures, grazing tables at IHE events, study and snacking sessions, dining facilities), sports teams, clubs, dormitories, on-campus work environments, transportation, and fraternities/sororities. These close settings, as well as close contact activities such as certain sports, may cause the IHE population to be at increased risk of transmission of the virus. In addition, many campuses host child-care centers, operate retail centers or have venues open to the general population. COVID-19 outbreaks have been reported from IHEs that extended beyond students, to include household and community contacts.¹ Additionally, modeling studies have estimated that new cases of COVID-19 increase more quickly within a residential IHE setting than in the general population.² Close-contact residential settings (on-campus and off-campus), large group classes in closed indoor settings, and frequent small-group interactions, have been modeled to demonstrate that multiple, short chains of infection can increase the likelihood of virus spread. ³ As a result of this close-contact network, it is important to use case investigation and contact tracing to rapidly identify persons who test positive for SARS-CoV-2, those who have been exposed to the virus, and those who may be at risk for possible exposure. This identification process is necessary to mitigate transmission and prevent SARS-CoV-2 outbreaks.

Health departments are responsible for leading case investigations, contact tracing, and outbreak investigations. Case investigation and contact tracing in response to COVID-19 transcends standard practice. Throughout the country, health departments are scaling up case investigation and contact tracing programs by using different staffing models and technology supports. Given the large number of COVID-19 cases reported to health departments, coupled with how easily and quickly SARS-CoV-2 is spreading, health department resources can be overwhelmed. Multisector partnerships can be an asset to expand the reach and timeliness of case investigation and contact tracing, thus facilitating prompt isolation and quarantine of cases and contacts. Partnerships between health departments and IHEs are encouraged because they may help limit the spread of COVID-19, in these settings and local communities.

Federal, state, and local legal considerations

All COVID-19 preparedness and response activities should be implemented in a manner that is consistent with jurisdictional public health recommendations and should align with existing federal, state, tribal, local, and territory workplace laws, as well as federal privacy laws such as the Family Educational Rights and Privacy Act (FERPA)external icon.

CDC encourages collaboration between the IHEs and health department when an IHE employee or student case is identified and during investigation of IHE-related exposures to COVID-19. All case investigation and contact tracing support activities conducted by the IHE should be undertaken in coordination and agreement with the health department.

Allowable contact tracing activities among minors may vary greatly by jurisdiction, based on state, tribal, local, and territorial law. Some jurisdictions allow for individuals as young as 12 to answer medical and public health-related questions, while others require permission by the parent, caregiver, or guardian for all minors. IHEs should consult with public health officials and legal counsel to determine how best to conduct case investigations and contact tracing involving minors, as well as permissions necessary. This is particularly important with implementation of innovative models, such as proximity apps, which identify individuals who may have been exposed to COVID-19 by using their electronic devices to record time spent in proximity to a case. According to state, tribal, local, and territory legal parameters, some IHEs and health departments may need to obtain consent from parents, caregivers, or guardians for activities conducted with some or all minors, and students with disabilities.

Confidentiality is a cornerstone of health department case investigation and contact tracing. Minimum professional standards for any agency handling confidential information should include providing employees with appropriate information and/or training regarding confidential guidelines and legal regulations. All personnel involved in case investigation and contact tracing activities with access to such information should sign a confidentiality statement acknowledging the legal requirements not to disclose COVID-19 information. Efforts to locate and communicate with clients and close contacts must be carried out in a manner that preserves the confidentiality and privacy of all involved. This includes not revealing the name of the client to a close contact unless permission has been given (preferably in writing), and not giving confidential information to third parties (e.g., roommates, neighbors, family members). Note that all activities and information collected by an IHE should be limited to the IHE setting and be consistent with applicable federal, state, tribal, local, and territorial privacy, health/medical, and workplace laws and regulations (e.g., U.S. Equal Employment Opportunity Commission [EEOC]external icon, Americans with Disabilities Act [ADA]external icon, and Section 504 of the Rehabilitation Act [Section 504]external icon). Violation of privacy and confidentiality can result in breaking federal or state laws intended to protect the public, and also erode trust that the health department and the IHE have built with the student, staff, and faculty. Additional resources to become familiar with include the HHS Office for Civil Rights (OCR) HIPAAexternal icon, HHS COVID-19 Bulletins, and CDC’s compilation of training plans on requirements for the protection of health information.

IHEs are encouraged to consult with their human resources, legal, medical, and occupational safety and health guidance policies and other resources to help them develop and implement their COVID-19 preparedness, response, and control plan.

Roles and responsibilities

IHE involvement with the official health department case investigation or contact tracing process may vary. It will depend on the authorities, responsibilities, and capacities of their health departments; federal, state, tribal, local, and territorial laws and regulations; and capacity of the IHE to participate in these activities.

When health department personnel investigate a case, if they learn that a person was physically present at an IHE where close contact with others (staff, faculty, students, or community members) may have occurred, the health department may contact the IHE staff, faculty, students, and others to let them know of potential exposures. In some instances, this may involve obtaining consent from parents, caregivers or guardians to contact all or some minors.

Health department collaboration with the IHE will vary, depending upon the situation. The following three scenarios outline possible health department actions when an IHE case is identified:

• Ask the IHE for help in understanding the risk for transmission of the virus in the IHE community and help to identify exposures and contacts in the IHE setting. This may include health department-initiated interviews, site visits, and reviews of IHE records to identify close contacts who may have been exposed to the virus to better understand the risk for transmission. Please note that an “agreement” with the health department does not facilitate disclosure of PII from education records without falling under the FERPA health or safety emergency exception.
• Ask the IHE to identify contacts among the immediate community of students, staff and faculty affected by the case. While this is not typical, some health departments have or may initiate agreements with IHE occupational health, medical programs, or trained occupational safety and health personnel who are able to formally and confidentially carry out some aspects of contact tracing in the IHE setting. In such situations, to protect privacy, health departments should take responsibility for case investigation and contact tracing outside of the IHE setting. If IHEs are interested in this type of agreement, they should contact their health department in advance to discuss the possibility and details of this option. Please note that an “agreement” with the health department does not facilitate disclosure of PII from education records without falling under the FERPA health or safety emergency exception.
• Conduct contact tracing without directly engaging the IHE. The health department may decide they do not need assistance or information from the IHE. They may refrain from direct involvement because they may not have the resources to follow up with the IHE. They also may not be permitted to involve an IHE because state, tribal, local, or territorial privacy laws may limit third-party involvement in contact tracing without the case patient’s consent. To the extent possible, health departments should notify IHEs that contact tracing is in progress, even if not able to provide any additional information.

IHE administrators can play an important role in establishing preventive measures to limit the spread of COVID-19 in the IHE setting and provide partnership and support in case investigation and contact tracing when a case is identified.

Assisting the health department with contact tracing

State, tribal, local, and territorial health departments have the legal authority to complete contact tracing.  IHE activities should supplement the health department activities to ensure all exposed individuals are documented in a secure manner and receive proper follow-up. Where possible, IHEs and health departments should establish policies and procedures prior to the identification of a case within the facility. IHEs that have the interest, expertise and resources to take a proactive role in case investigation and contact tracing in the IHE setting, should take the following steps in planning for implementation of IHE-based programs to support case investigation and contact tracing for COVID-19:

• Define roles, responsibilities, communication, reporting and data requirements with health departments and initiate formal agreements, as appropriate. There are many different kinds of IHEs (e.g., large universities with on-campus residential and healthcare facilities, small schools with a commuter population), and many different structures for engagement of staff/faculty (e.g., adjunct faculty, contract staff), students (e.g., internships, externships, student teaching, clinical rotations), and the community (e.g., IHE concert venues, retail shopping, research-parks). Depending on the structure of the IHE and its presence within the community, the level of community interaction will vary. Typically, the scope of case investigation and contact tracing for the IHE is limited to outreach to their students, staff, and faculty. It is essential that IHEs and health departments partner to ensure contact tracing among community members, and that work closely with city/county officials to jointly craft communication regarding potential exposure sites within the community.
• Become familiar with Health and Safety Codes regarding case investigation and contact tracing, ADA, Section 504, Occupational Health, FERPA and other relevant laws, regulations and guidance. Consult occupational health programs to determine policies and practices related to IHE staff and faculty.
• Identify appropriate IHE personnel to provide leadership, oversight and quality assurance of case investigation and contact tracing activities.
• Identify appropriate personnel to conduct case investigation and contact tracing activities. Typically, health departments partner with occupational health, medical programs, or trained occupational safety and health staff who can formally and confidentially carry out some aspects of contact tracing. IHEs should ensure compliance with federal, state, tribal, local, and territorial OSHA and privacy laws in the selection of staff and implementation of case investigation and contact tracing activities with students, staff, and faculty.
• Provide knowledge and skill-based training for personnel conducting case investigation and contact tracing. CDC’s website has resources for training. IHEs should ensure that trainings and resources are coordinated with local health departments to maintain a cohesive program within the jurisdiction.
• Define roles and responsibilities for IHE occupational health clinics/programs and student health centers, making distinctions between the role as a health care provider with responsibilities for case reporting, and the role as advisor(s) in case investigation, contact tracing and outbreak response when COVID-19 is identified in the IHE setting. IHEs should ensure compliance with federal, state, tribal, local, and territorial privacy and occupational health laws in determining the specific responsibilities of IHE clinic and student health center staff with students, staff, and faculty, during COVID-19 case investigation, contact tracing and outbreak response.

• Ensure confidentiality, privacy and data security training and signed confidentiality agreements for all personnel conducting case investigation and contact tracing. Awareness of federal, state, tribal, local, and territorial laws regarding patient privacy and confidentially should be a priority. For additional information about confidentiality, please see CDC guidance on Confidentiality and Consent.
• Develop policies and procedures for case investigation and contact tracing among students, staff, and faculty. IHE administrators and public health officials should work together to determine what information is needed in order to properly notify potentially exposed students, staff, or faculty, who is most appropriate to deliver that information, and how that information can be delivered in a secure manner. IHEs should review existing Interim Guidance on Developing a COVID-19 Case Investigation Contact Tracing Plan, Case Investigation and Contact Tracing in Non-healthcare Workplaces: Information for Employers and other Contact Tracing Resources to inform the development of policies and procedures.
• Review, with state, tribal, local, or territorial public health officials, required data elements for a case investigation and identify the best methods of gathering necessary information. IHE administrative data management systems may vary greatly in design and accessibility. Information relevant to a case investigation and contact tracing can be provided by the health department. Specific pieces of personal information including phone number, demographics, and class schedule will greatly increase the speed with which health officials can complete the exposure notification process. Ensuring privacy and confidentiality about persons diagnosed with and potentially exposed to COVID-19 is critical in maintaining trust with students, faculty, and staff. Secure methods (i.e., secure email, reporting portals, secure FTPs, etc.) of transferring contact information to health departments will prevent unauthorized release of private information.
• Health department staff may provide training or language to properly discuss cases and exposures without revealing identifiable information. IHEs should identify personnel necessary to gather and transmit the information and be prepared to answer, at minimum, the following questions:
  • How can you quickly identify everyone in a classroom or shared space at a specific time? How is this information retrieved from the IHE data system? Do contacts have to be identified one at a time or can you access information on group exposure (e.g., all students in one classroom)?
  • How quickly can you determine if there are shared dining or meals? How will this information be gathered?
  • How are extracurricular activities documented and recorded?
  • How will household contacts be identified and who will conduct notification of exposure and related referrals in different settings (e.g., housemates at current residence, including student housing or community housing; family members, including children who may attend other schools, childcare programs or other early care settings, and other relatives)?
• Technology can support case investigation, symptom monitoring and contact tracing but cannot take the place of the staff who interview, counsel, and provide support for those impacted by COVID-19. There are two key types of technology that can contribute to the contact tracing process: case management tools—which augment information collected from surveillance systems, enhance data capture, and provide workforce management tools (such as automated SMS symptom monitoring of cases and contacts); and proximity tracing and exposure notification tools—voluntary opt-in tools to augment traditional contact tracing using Bluetooth or GPS. Digital tools to support contact tracing should be reviewed for compliance with federal, state, tribal, local, and territorial laws and regulations, considered, developed and implemented in coordination with the public health officials, with the inclusion of robust evaluation plans. For more information, reference CDC’s Guidelines for the Implementation and Use of Digital Tools to Augment Traditional Contact Tracingpdf icon.

IHEs can be an excellent resource

IHEs with relevant expertise can be an excellent resource to state, tribal, local, and territorial health departments as they scale up case investigation and contact tracing in response to COVID-19.

• Enhancing case investigation and contact tracing skill sets. IHE faculty expertise in public health programs, epidemiology, and outbreak response may be beneficial in the development of distance-based training programs. Additional expertise in the development of interactive skill-building training modules that support cultural competency, patient or client resiliency, and encourage health seeking behaviors, may be beneficial in enhancing the communication skills of case investigators and contact tracers.
• Evaluation of case investigation and contact tracing programs. IHE faculty with expertise in program evaluation can be an incredibly valuable resource in the COVID-19 response. Partnership in the assessment of case investigation and contact tracing processes and outcomes, continuous quality improvement, and identification of promising practices are essential in implementation of an effective program.
• Provision of technical assistance to enhance case investigation and contact tracing outcomes. Some IHEs have expertise in community engagement, development of communities of practice, or a keen understanding of the cultural factors faced by tribal nations, refugees, immigrants, migrants, and other vulnerable populations such communities with lower incomes. As health departments take steps toward building case investigation and contact tracing programs with more culturally competent services, technical assistance from subject matter experts can help to refine program messaging and tools. IHE personnel may also partner with health departments to act as facilitators and bridge dialogue with affected communities.
• Provision of staffing for health department case investigation and contact tracing programs. Some IHEs have developed formal agreements with state, tribal, local, and territorial health departments to provide staffing for the scale up of case investigation and contact tracing. Laws and regulations that determine allowances and restrictions with implementation of case investigation and contact tracing vary by jurisdiction. Therefore, roles and responsibilities of the IHE in case investigation and contact tracing should be discussed and determined in conjunction with state, tribal, local, or territorial health department staff prior to initiation of activities. These agreements can take several forms including:
  • IHEs accepting responsibility for administration and implementation of case investigation and contact tracing of probable and confirmed COVID-19 cases among students, staff, and faculty;
  • IHE conducting case-specific community contact tracing activities related to cases which are identified through IHE students, staff, and faculty;
  • IHE conducting work on behalf of the health department, with more broad responsibility for assistance with administration and implementation of community-wide contact tracing;
  • IHE creating opportunities (e.g., volunteer workforce) and policies (e.g., academic credits for activity hours conducted) to encourage students, staff, and faculty with relevant expertise (e.g., epidemiology, public health, community health, nursing students, medical students) to support health department case investigation or contact tracing programs;
  • Individual students, staff, or faculty who are interested in gaining experience in the COVID-19 response may work shifts with a health department case investigation or contact tracing program.

CDC encourages partnerships between IHEs and health departments to enhance scale-up of case investigation and contact tracing infrastructure. IHE students, staff, and faculty can be an asset to IHE-based case investigation and contact tracing. Students in public health programs may be considered for recruitment as they will have basic knowledge of epidemiological principles and may also have experience working with state, tribal, local, or territorial health departments. Students from organizations representing minority or ethnic groups, student populations, and other populations with disproportionate case rates, or hard to reach communities with lower incomes, could be assets in enhancing the cultural competency of case investigation and contact tracing staff. Student organization leadership who are trusted campus leaders and understand the importance and confidentiality of the contact tracing process, may also be an effective workforce. Regardless of the structure, collaborative planning, clear identification of roles and responsibilities, comprehensive training and ongoing quality assurance is essential for the success of case investigation and contact tracing.

References

1. Lewis M, Sanchez R, Auerbach S, et al (2020). MMWR Morb Mortal Wkly Rep 2020;69:830-835. DOI: http://dx.doi.org/10.15585/mmwr.mm6926e1external icon.

2. Gressman P and Peck J (2020). Simulating COVID-19 in a University Environment Retrieved from: https://arxiv.org/pdf/2006.03175.pdf pdf icon[PDF – 30 Pages]external icon

3. Weeden K and Cornwell B (2020). The Small World Network of College Classes: Implications for Epidemic Spread on a University Campus. Retrieved from: https://biology.usu.edu/covid19/weedencornwell_small_world_campus.pdf pdf icon[27 Pages, 2.3 MB]external icon