​Background

On March 4, 2020 Governor Newsom proclaimed a State of Emergency as a result of the threat of COVID-19, and on March 12, 2020, through Executive Order N-25-20, he directed all residents to heed any orders and guidance of state and local public health officials.  Subsequently, on March 19, 2020, Governor Newsom issued Executive Order N-33-20 directing all residents to heed the State Public Health Officer's Stay-at-Home order which requires all residents to stay at home except for work in critical infrastructure sectors or otherwise to facilitate authorized necessary activities.  On April 14th, the State presented the Pandemic Roadmap, a four-stage plan for modifying the Stay-at-Home order, and, on May 4th, announced that entry into Stage 2 of the plan would be imminent.

Given the size and diversity of California, it is not surprising that the impact of COVID-19 has differed across the state.  While some counties are still in the initial stabilization phase (Stage 1) of the pandemic response, there are a number of less affected counties.  Provided these counties are able to demonstrate an ability to protect the public and essential workers, they may be in a position to adopt aspects of Stage 2 of California's roadmap at a faster pace than the state as a whole.  As directed by the Governor in Executive Order N-60-20, this guidance provides information on the criteria and procedures that counties will need to meet in order to move more quickly than other parts of the state through Stage 2 of modifying the Stay-at-Home order. It is recommended that counties consult with cities and other stakeholders as they consider moving through Stage 2.

Local Variance

A county that has met certain criteria in containing COVID-19 may consider increasing the pace at which they advance through Stage 2, but not into Stage 3, of California's roadmap to modify the Stay-at-Home order.  Counties are encouraged to first review this document in full to consider if a variance from the state's roadmap is appropriate for the county's specific circumstances.  If a county decides to pursue a variance, the local public health officer must:

1.    Notify the California Department of Public Health (CDPH) and engage in a phone consultation regarding the county's intent to seek a variance. 

2.    Certify through submission of a written attestation to CDPH that the county has met the readiness criteria (outlined below) designed to mitigate the spread of COVID-19.  Attestations should be submitted by the local public health officer, and accompanied by a letter of support from the County Board of Supervisors, as well as a letter of support from the local hospitals or health care systems.  In the event that the county does not have a hospital or health care system within its jurisdiction, a letter of support from the relevant regional health system(s) is also acceptable. The full submission must be signed by the local public health officer.

Please use the CDPH COVID-19 Variance Attestation Form (PDF). All county attestations, and submitted plans for moving through Stage 2 as outlined below, will be posted publicly on CDPH's website.  

While not required, CDPH recommends as a best practice the development of a county COVID-19 containment plan by the local public health officer in conjunction with the hospitals and health systems in the jurisdiction, as well as input from a broad range of county stakeholders, including the County Board of Supervisors. 

In addition to pre-submission phone consultations, CDPH is available to provide technical assistance to counties as they develop their attestations and COVID-19 containment plans.  Please email Jake Hanson to set up a time with our technical assistance team.

Readiness for Variance

The county's documentation of its readiness to increase the pace through Stage 2 must clearly indicate its preparedness according to the criteria below.  This will ensure that individuals who are at heightened risk, including for example the elderly and those residing in long-term care and locally controlled custody facilities, continue to be protected as a county progresses through California's roadmap to modify the Stay-at-Home order, and that risk is minimized for the population at large.

As part of the attestation, counties must provide specifics regarding their movement through Stage 2 (e.g., which sectors, in what sequence, at what pace), as well as clearly indicate how their plans differ from the state's order.

It is critical that any county that submits an attestation continue to collect and monitor data to demonstrate that the variances are not having a negative impact on individuals or healthcare systems.  Counties must also attest that they have identified triggers and have a clear plan and approach if conditions worsen for modifying the pace of advancing through stage 2, including reinstituting restrictions, in advance of any state action. Counties must also submit their plan for how they anticipate moving through Stage 2 (e.g., which sectors will be opened, order of opening etc.).

Readiness Criteria

To establish readiness for an increased pace through Stage 2 of California's roadmap to modify the Stay-at-Home order, a county must attest to the following readiness criteria and provide the requested information as outlined below:

• Epidemiologic stability of COVID-19.  A determination must be made by the county that the prevalence of COVID-19 cases is low enough to be swiftly contained by an epidemiological response.  Given the anticipated increase in cases as a result of modifications, this is a foundational parameter that must be met to safely increase the county's progression through Stage 2.  The county must attest to:

• No more than 1 COVID-19 case per 10,000 in the past 14 days prior to attestation submission date.

• No COVID-19 death in the past 14 days prior to attestation submission date.
  

• Protection of Stage 1 essential workers.  A determination must be made by the county that there is clear guidance and the necessary resources to ensure the safety of Stage 1 essential critical infrastructure workers.  The county must attest to:

• Guidance for employers and essential critical infrastructure workplaces on how to structure the physical environment to protect essential workers.  Please provide copies of the guidance(s).

• Availability of supplies (disinfectant, essential protective gear) to protect essential workers.  Please describe how this availability is assessed.
  

• Testing capacity.  A determination must be made by the county that there is testing capacity to detect active infection that meets the state's most current testing criteria (available on CDPH website).  The county must attest to:

• Minimum daily testing volume to test 1.5 per 1,000 residents, which can be met through a combination of testing of symptomatic individuals and targeted surveillance.  Please provide the plan and the county's average daily testing volume for the past week.  If the county does not believe a testing volume of 1.5 per 1,000 residents is merited, please provide justification for this. 

• Testing availability for at least 75% of residents, as measured by a specimen collection site (including established health care providers) within 30 minutes driving time in urban areas, and 60 minutes in rural areas.  Please provide a listing of all specimen collection sites in the county, whether there are any geographic areas that do not meet the criteria, and plans for filling these gaps.  If the county depends on sites in adjacent counties, please list these sites as well.
  

• Containment capacity.  A determination must be made by the county that it has adequate infrastructure, processes, and workforce to reliably detect and safely isolate new cases, as well as follow up with individuals who have been in contact with positive cases.  The county must attest to:

• Sufficient contact tracing.  For counties that have no cases, there should be at least 15 staff per 100,000 county population trained and available for contact tracing; for counties with small populations, there must be at least one staff person trained and available.  Please describe the county's contact tracing plan, including workforce capacity, and why it is sufficient to meet anticipated surge.

• Availability of temporary housing units to shelter at least 15% of county residents experiencing homelessness in case of an outbreak among this population requiring isolation and quarantine of affected individuals.  Please describe the county's plans to support individuals, including those experiencing homelessness, who are not able to properly isolate in a home setting by providing them with temporary housing (including access to a private bathroom), for the duration of the necessary isolation or quarantine period.

• Hospital capacity.  A determination must be made by the county that hospital capacity, including ICU beds and ventilators, and adequate PPE is available to handle standard health care capacity, current COVID-19 cases, as well as a potential surge due to COVID-19.  If the county does not have a hospital within its jurisdiction, the county will need to address how regional hospital and health care systems may be impacted by this request and demonstrate that adequate hospital capacity exists in those systems.  The county must attest to:

• County (or regional) hospital capacity to accommodate a minimum surge of 35% due to COVID-19 cases in addition to providing usual care for non-COVID-19 patients.  Please describe how this surge would be accomplished, including surge census by hospital, addressing both physical and workforce capacity.

• County (or regional) hospital facilities have a robust plan to protect the hospital workforce, both clinical and nonclinical, with PPE.  Please describe the process by which this is assessed. 

• Vulnerable populations.  A determination must be made by the county that the proposed variance maintains protections for vulnerable populations, particularly those in long-term care settings.  The county must attest to:

• Skilled nursing facilities (SNF) have >14 day supply of PPE on hand for staff, with established process for ongoing procurement from non-state supply chains.  Please list the names and contacts of all SNFs in the county along with a description of the system the county has to track PPE availability across SNFs. 

• Sectors and timelines. Please provide details on the county's plan to move through Stage 2.  This should include which sectors and spaces will be opened, in what sequence, on what timeline.  Please specifically indicate where the plan differs from the state's order.  Please note that this variance should not include sectors that are part of Stage 3.

• Triggers for adjusting modifications.  Please share the county metrics that would serve as triggers for either slowing the pace through Stage 2 or tightening modifications, including the frequency of measurement and the specific actions triggered by metric changes.  Please include your plan for how the county will inform the state of emerging concerns and how it will implement early containment measures. 

• Your plan for moving through Stage 2. Please provide details on your plan for county to move through opening sectors and spaces that are part of the State's plan for Stage 2. A reminder, that this variance only covers those areas that are part of Stage 2, up to, but not including Stage 3. For additional details on sectors and spaces included in Stage 2, please see roadmap counties. 
  

COVID-19 Containment Plan

While not mandatory, CDPH strongly recommends that counties requesting a variance to increase the pace through Stage 2 create a county COVID-19 containment plan as noted above.  While not exhaustive, the following areas and questions are important to address in any containment plan.

Testing

• Is there a plan to increase testing to the recommended daily capacity of 2 per 1000 residents?

• Is the average percentage of positive tests over the past 7 days <7% and stable or declining?

• Have specimen collection locations been identified that ensure access for all residents?

• Have contracts/relationships been established with specimen processing labs?

• Is there a plan for community surveillance? 

Contact Tracing

• How many staff are currently trained and available to do contact tracing?

• Are these staff reflective of community racial, ethnic and linguistic diversity?

• Is there a plan to expand contact tracing staff to the recommended levels to accommodate a three-fold increase in COVID-19 cases, presuming that each case has ten close contacts?

• Is there a plan for supportive isolation for low income individuals who may not have a safe way to isolate or who may have significant economic challenges as a result of isolation? 

Protecting the Vulnerable

• How many congregate care facilities, of what types, are in the county?

• How many correctional facilities, of what size, are in the county?

• How many homelessness shelters are in the county and what is their capacity?

• What is the COVID-19 case rate at each of these facilities?

• Do facilities have the ability to safely isolate COVID-19 positive individuals?

• Do facilities have the ability to safety quarantine individuals who have been exposed?

• Is there sufficient testing capacity to conduct a thorough outbreak investigation at each of these facilities? 

• Do long-term care facilities have sufficient PPE for staff, and do these facilities have access to suppliers for ongoing PPE needs?

• Do these facilities (particularly skilled nursing facilities) have access to staffing agencies if and when staff shortages related to COVID-19 occur?

Acute Care Surge

• Is there daily tracking of hospital capacity including COVID-19 cases, hospital census, ICU census, ventilator availability, staffing and surge capacity?

• Are hospitals relying on county MHOAC for PPE, or are supply chains sufficient?

• Are hospitals testing all patients prior to admission to the hospital?

• Do hospitals have a plan for tracking and addressing occupational exposure?
  
  

Essential Workers

• How many essential workplaces are in the county?

• What guidance have you provided to your essential workplaces to ensure employees and customers are safe in accordance with state/county guidance for modifications?

• Do essential workplaces have access to key supplies like hand sanitizer, disinfectant and cleaning supplies, as well as relevant protective equipment?

• Is there a testing plan for essential workers who are sick or symptomatic?
  
  Is there a plan for supportive quarantine/isolation for essential workers?

Special Considerations

• Are there industries in the county that deserve special consideration in terms of mitigating the risk of COVID-19 transmission, e.g. agriculture or manufacturing?

• Are there industries in the county that make it more feasible for the county to increase the pace through stage 2, e.g. technology companies or other companies that have a high percentage of workers who can telework?

Community Engagement

• Has the county engage with its cities?

• Which key county stakeholders should be a part of formulating and implementing the proposed variance plan?

• Have virtual community forums been held to solicit input into the variance plan?

• Is community engagement reflective of the racial, ethnic, and linguistic diversity of the community?
  
  

Relationship to Surrounding Counties

• Are surrounding counties experiencing increasing, decreasing or stable case rates?

• Are surrounding counties also planning to increase the pace through Stage 2 of California's roadmap to modify the Stay-at-Home order, and if so, on what timeline?  How are you coordinating with these counties?

• How will increased regional and state travel impact the county's ability to test, isolate, and contact trace?