Investigating a COVID-19 Case

COVID-19 Case Investigation Workflow

Step 1: Case identification & prioritization

COVID-19 case investigations are typically initiated when a health department receives a positive SARS-CoV-2 test result report from a laboratory or a patient’s confirmed or probable diagnosis of COVID-19 from a healthcare provider.

Ideally, jurisdictions will have ample testing available and the public health infrastructure to allow laboratory confirmation of all COVID-19 cases within the community and the capacity to investigate all symptomatic and asymptomatic patients with a confirmed diagnosis of COVID-19.

For guidance on the appropriate use of testing, see Overview of Testing for SARS-COVID-19.

Once a COVID-19 laboratory or provider report is received, this information will be entered into the health department surveillance system. With expanded laboratory testing in both public and private sectors, it is important to establish electronic laboratory reporting systems to enhance the timeliness of data to inform public health action.

The health department should use a triage system to use any information known about a patient diagnosed with COVID-19, prior to case interview, to delegate the investigation to either a case investigator or special infection control team (specific settings where a special team is needed are included in Outbreak Investigations).

Health departments can communicate with healthcare providers by phone when a positive laboratory test is reported to obtain information necessary for triaging.  Conversely, health departments could request that providers phone-in case information on the same day that a provider receives a positive SARS-CoV-2 test result in a Priority 1 or Priority 2 patient (see Box 1).

In addition to identifying potential outbreaks, information to assist in case prioritization includes a patient’s COVID-19 symptoms, underlying health conditions, locating information (residence type/location/contact information), workplace role and location, confirmation that patient was notified of test result, and initiation of self-isolation.

Triage staff should have rapid turn-around times with provider queries (within 24 hours). Triage staff should then prioritize cases for investigation to either a case investigator or special infection control team based on known information. These strategies are only feasible with adequate staff to provide triage support and sufficient patient information available to allow for prioritizing.

For areas that have limited public health resources to investigate all cases, the case investigation hierarchy (Box 1) and case investigation and contact tracing prioritization recommendations can be used to help guide prioritization when information is known about the case. The hierarchy is based on the assumption that clients with a confirmed or probable diagnosis of COVID-19 in Priority 1 are likely to have exposed a larger number of people and/or are likely to have close contacts who could potentially expose many people, those at higher risk for severe disease, or critical infrastructure workers. Priority 2 includes clients who may be at higher risk for severe disease and will need prompt risk assessment and linkage to any needed medical and support services. Clients should be prioritized based on the highest priority category they fall into.

When prioritizing clients with a positive SARS-CoV-2 test result or a probable diagnosis of COVID-19 to investigate, jurisdictions should be guided by the local characteristics of disease transmission, demographics, and public health and healthcare system capacity. Decisions should be supported by local guidance and circumstances.

Step 2: Rapid notification of results or diagnosis

• Some clients will have been notified of their positive SARS-CoV-2 test result or probable case diagnosis by their healthcare provider and already received instructions for self-isolation.
• When communication with the client about their positive SARS-CoV-2 test result or probable diagnosis is unclear or has not taken place, the health department should notify the client as soon as possible (within 24 hours of reporting to the health department).
• A client with a probable COVID-19 diagnosis should self-isolate and be linked to testing (if recommended by healthcare providers or state or local public health authorities).
• If there is a need for testing and the case investigator plans to collect the specimen in person, case investigators need to have had appropriate training on infection prevention and control practices. They must also obtain any necessary personal protective equipment (PPE) prior to conducting in-person activities.
• The first connection can be made through different channels such as phone, text, email or in-person (if appropriate) in the primary language of the individual. This process can be manual, automated, or semi-automated based on jurisdictional capacity. Protocol should clearly outline the primary and secondary means of reaching a client and address confidentiality at the start of communication.
• Special considerations should be given to ensure culturally and linguistically appropriate communication.
• Protocols should be in place to provide services to people who are deaf or who have hearing loss.
• Depending on the source of the case report, information for locating a client may be insufficient. Tips on additional resources that may be used to obtain missing locating information can be found in Appendix B. Every effort should be made to reach the client remotely before attempting in-person communication.

Step 3: Case interview

• Every effort should be made to interview the client by telephone or video conference instead of in-person. For in-person interviews, guidance on recommended infection prevention and control practices at a home or non-home residential setting can be found on CDC’s Evaluating PUIs Residential page.
• Clients in special populations and/or congregate settings may require additional considerations and should be triaged and assigned to a special infection control team, if available. See Outbreak Investigations for additional information.
• Appendix C includes critical data elements that can be incorporated into a jurisdiction’s paper form or electronic system used to elicit detailed information about a client’s close contacts and activity history, including any household contacts during self-isolation.
• Key Information to Collect During a Case Interview provides a roadmap for the case interview and identifies critical information to be collected during each part of an interview.
• Talking with the Patient – A Case Investigator’s Guide to COVID-19 focuses on communication strategies for case interviews and provides suggested language for each topic area covered in an interview.

Step 3a: Monitoring and isolation instructions

• Clients with probable or confirmed COVID-19 should be advised to self-isolate immediately, if they are not doing so already. Self-isolation is recommended for people with probable or confirmed COVID-19 who have mild illness and are able to recover at home.
• It should be made clear to the client whether the isolation instructions are voluntary or mandatory, as determined by state or local public health authorities.
• Advise clients to cancel or postpone plans that involve social gatherings, vacations or other planned travel until cleared for these activities by public health authorities.
  • Local and state health departments may request federal public health travel restrictions, which prevent listed travelers from boarding commercial airplanes and trigger public health notification if they enter the United States by land or sea, to support state- or local-mandated isolation for infected individuals. Support with federal public health travel restrictions may be requested by public health partners by contacting the CDC quarantine station with jurisdiction for the area.
• If needed, jurisdictions should refer clients for social support services (for example, food, childcare, housing, and other services) to help encourage clients to stay at home and comply with isolation.
• If clients refuse to comply voluntarily with self-isolation instructions, jurisdictions should consider what options (e.g., legal order for isolation) are available to them under relevant state or local legal authority.
• The client should be informed of COVID-19 symptoms to monitor for and be instructed to get medical attention immediately if he/she experiences any emergency warning signs, such as trouble breathing. Clients with no primary healthcare provider will need linkage to telemedicine or phone consultation.
• The client should also be informed of ways to prevent infection among those living in their household.
• Additional isolation guidance should be reviewed with the client and instructional materials provided. Sample materials can be found on the CDC website:
  • 10 things you can do to manage your COVID-19 symptoms at home [449 KB, 1 Page]
  • What to Do If You Are Sick
  • When You Can be Around Others After You Had or Likely Had COVID-19
• All instructions should be provided in a client’s primary language.

Step 3b: Assessing self-isolation support needs

Emphasis should be placed on helping clients identify any need for social support during self-isolation.

Isolation of clients with a diagnosis of COVID-19 prevents transmission to others and is critical to the success of any case investigation and contact tracing efforts. For most clients diagnosed with COVID-19 (i.e., those in an outpatient setting who are medically stable or discharged home following diagnosis at hospital), self-isolation can take place at home. If possible, clients should be asked to voluntarily stay home, monitor themselves for symptoms, and maintain social distance from others. The timeframe for self-isolation varies by case but, in general, people should isolate until the risk of secondary transmission is considered low. See Box 3 for specific instructions. Adherence to self-isolation instructions mainly depends on the clients’ needs and individual living situations, as well as on the support provided by the case investigation and contact tracing team.

Self-isolation requires that clients remain separate from others in the home, staying in a specific room away from other people and pets, and ideally with access to a separate bathroom. First and foremost, a case investigator should assess a patient’s ability to self-isolate in a safe environment that provides access to a private room and bathroom, as well as access to adequate food and water, among other considerations. For a portion of the U.S. population, self-isolation at home will be a challenge. It may be particularly difficult for some of the most vulnerable populations. Considerations must also be made for clients who express fear of abuse or violence if they must self-isolate at home. Additionally, some clients (e.g., single parents, nursing mothers, parents with children and toddlers, and other primary caregivers) may face other challenges, such as childcare or dependent adult care, that may affect the ability to self-isolate. Social services, housing and other supportive services will be needed for those who are unable to separate themselves from others in their current living situation. See Support Services for further considerations.

Clients will also need to be supported with health coaching to ensure daily monitoring of temperature and COVID-19 symptoms and have access to clinical services for medical concerns. Coordination of access to telehealth services, which may include remote access to non-clinical services, may be needed for clients without virtual access to a primary care provider. Reminding clients about the emergency warning signs and contact information for healthcare providers is imperative to ensure early medical management in the event that they develop new symptoms, or their symptoms worsen.

All clients with a confirmed or probable diagnosis of COVID-19 who are entering self-isolation in a non-healthcare setting ideally would be provided a COVID-19 kit with the following resources:*

• Washable cloth face covering
• Gloves
• Digital thermometer
• Alcohol-based hand sanitizer with at least 60% alcohol, soap, EPA-registered household disinfectant
• COVID-19 health education materials (translated into the appropriate language)
• Instructions for cleaning and disinfecting your home for those sharing space with others
• A hotline/warmline to address any support needs during the self-isolation period, including medical, mental, and behavioral support

*The composition of the COVID-19 kit will depend on the jurisdiction’s resources.

Step 3c: Eliciting contacts

• Contact elicitation is a voluntary and critical part of the case interview.
• The case investigator can use information from any reports received by the health department, along with the patient’s symptom history gathered earlier in the case interview, to determine the contact elicitation window (the timeframe when the patient was infectious and not under isolation). See Box 2 below for additional guidance on determining the contact elicitation window.
• A close contact is defined as someone who was less than 6 feet away from an infected person for a cumulative total of 15 minutes or more over a 24-hour period.
• It will be important that the case investigator clearly explain why close contacts are being elicited and assure the patient that their identity will not be disclosed to any close contacts that they identify.
• The trust and rapport built earlier in the case interview, combined with open-ended and probing questions, will help facilitate the contact elicitation portion of the interview.
• Information to be gathered for each close contact can be found in the Contact Elicitation Investigation data elements table in Appendix C and includes the contact’s name and locating information, the setting of the exposure, contact’s work setting and occupation, and any underlying health conditions or other risk factors the contact may have (if known by the patient).
• In communities near international land borders, specific interview questions should be asked to identify relevant contacts across the border.
• The case investigator should also confirm the best way to reach the patient for any follow-up discussion.
• Proxy interviews are essential when the patient cannot be interviewed (e.g., patient is deceased, intubated, unconscious, a minor, cognitively impaired). Key proxy interviewees are those likely to know the patient’s practices, habits, and behaviors. However, because proxy interviews jeopardize patient confidentiality, jurisdictions should establish clear guidelines for these interviews that recognize the challenge of maintaining confidentiality.

Step 4: Case follow-up & medical monitoring

• The initial case interview covers a great deal of material, which can be overwhelming for a client.
• In some instances, the case investigator may need to follow up with the client to clarify details from the
  conversation including:

• • Onset of symptoms, particularly the nonspecific symptoms (e.g., fatigue, muscle pain);
  • Further exploration of occupation and interactions in the workplace or last day at work;
  • Transportation to and from work, social and recreational activities;
  • Additional locating information for close contacts or additional contacts from their self-isolation period;
  • Home, family, and other factors that could affect their compliance with self-isolation.

• Ideally, all clients diagnosed with COVID-19 will be monitored using real-time communication methods (e.g., telephone call, video conferencing) to share daily reports on their temperature and COVID-19 symptoms throughout the length of their self-isolation.
• Prioritizing which clients to monitor closely and which may be able to adequately self-monitor should be determined in the context of existing resources. In some instances, clients with underlying health conditions and other special circumstances (such as pregnancy) may present complex medical challenges. While these may not require hospitalization, these clients may need in-home medical monitoring by a healthcare provider until their COVID-19 symptoms resolve.
• If a jurisdiction’s resources do not allow for active daily monitoring, clients will be asked to self-monitor and communicate remotely (e.g., email, recorded video, telephone message, text, monitoring apps) to notify public health authorities of their health status and promptly communicate any new symptoms or symptoms of increasing severity.
• For those individuals self-monitoring and sharing reports remotely, reports must be received by the agreed upon time each day, and protocol must address follow-up actions for clients who do not report out.

Step 5: Additional case follow-up

• Additional follow-up may be needed for clients with COVID-19 who are transitioning from one facility to another—for example, from a hospital to a long-term care facility or to home isolation. Care coordination plans should be put in place to maintain proper infection control and isolation procedures.
• Additional coordination will also be necessary to support clients with COVID-19 who are discharged from a correctional facility (e.g., prisons, jails, youth detention centers). These individuals will be transitioning to self-isolation in their home communities and will need assessment for social supports to ensure adequate housing, food, and medical care throughout the remainder of their self-isolation.
• Transitional case management plans are incredibly important to ensure continuity of care for clients with COVID-19 and protect the community from further transmission.

Step 6: Discontinuation of isolation

Duration of isolation depends on many factors, including symptom status, illness severity and setting (for example, correctional facilities, shelters, or healthcare facilities). Case investigators should refer to current CDC guidance on isolation guidance COVID-19 Quarantine and Isolation when providing recommendations to people with COVID-19.