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Vaccine Equity Metric

The State has focused on saving lives and protecting its communities during the public health emergency. California implemented the Blueprint for a Safer Economy on August 30, 2020 to reduce COVID-19 in the state with criteria for loosening and tightening restrictions on activities. Every county in California is assigned to a tier based on its test positivity and adjusted case rate for tier assignment. Additionally, a health equity metric took effect on October 6, 2020.  In order to advance to the next less restrictive tier, each county must meet an equity metric or demonstrate targeted investments to eliminate disparities in levels of COVID-19 transmission, depending on its size.  The California Health Equity Metric is designed to help guide counties in their continuing efforts to reduce COVID-19 cases in all communities and requires more intensive efforts to prevent and mitigate the spread of COVID-19 among Californians who have been disproportionately impacted by this pandemic.

The pandemic in California has not affected all communities equally. Forty percent of COVID cases and deaths occur in our lowest Vaccine Equity Metric Quartile, which combines Healthy Places Index (HPI) scores at ZCTA with CDPH-derived ZCTA scores (CDZS). California believes that equitable vaccine administration is a crucial tool to safely and effectively increasing economic activity.  By proactively preventing transmission and protecting the most hard hit and vulnerable groups, we have a better chance of moving through the pandemic as a state.

A heightened ability to protect individuals in these disproportionately impacted communities not only improves health in those communities but has critical impacts on the state as a whole, including:

1. Reduced stress on the hospital system through reduced hospitalizations among populations that often have higher levels of underlying risk from chronic illnesses and/or structural factors associated with crowded housing conditions and exposures that are not easy to avoid.

2. Reduced general transmission of the virus through reduced transmission between close household or other community members in communities where we have historically seen the highest levels of test positivity and case rates compared to communities in the Vaccine Equity Quartiles.

3. Reduced likelihood of the threat of variants as variants depend on high levels of community transmission to emerge, spread, and dominate.

4. Reduced threat of vaccine escape (when a virus develops partial or full vaccine resistance). The full and timely vaccination of individuals reduces the risk of high levels of transmission commensurate with higher levels of mutation and the potential for mutations that are resistant, in whole or in part, to a given vaccine.

For all of these reasons, California's approach to modifying the Blueprint for a Safer Economy is anchored not just on the level of overall vaccinations across California but with a particular focus on vaccinating individuals living in the state's Vaccine Equity Quartile communities as a critical indicator of the ability to expedite protection and disease transmission prevention to all communities in the state.

As of March 4, 2021, the Blueprint for a Safer Economy has been updated to reflect full swing vaccination efforts in California with the goal of achieving community immunity.

Modifications to the Blueprint will primarily include two approaches: (1) shifting the tier threshold to higher case rates per 100K population per day based on meeting vaccination thresholds within Vaccine Equity Quartile communities and; (2) changing certain sector specific guidance and issuing new sector guidance to incorporate learnings from the last year about how the virus spreads.  

Statewide Vaccine Equity Metric Goal #1:

Purple (Widespread) tier will shift from greater than 7 cases per 100,000 to greater than 10 cases per 100,000; and the Red (Substantial) tier will be widened to 4-10 cases per 100,000 when:

• 2 million doses have been administered to persons living in the Vaccine Equity Quartile. (assessed statewide). 

Orange (Moderate) and Yellow (Minimal) tier ranges will remain the same. 

Statewide Vaccine Equity Metric Goal #2:

Purple (Widespread) tier threshold will remain at greater than 10 cases per 100,000, Red (Substantial) tier case rate range will narrow to 6-10 cases per 100,000; and the Orange (Moderate) tier case rate range will shift to 2-5.9 cases per 100,0000. The Yellow (Minimal) tier case rate range will shift to less than 2 cases per 100,000 when:  

• 4 million doses have been administered to persons living in the Vaccine Equity Quartile (assessed statewide). 
  

Blueprint Tier Framework Thresholds Upon Meeting Statewide Vaccine Equity Metric Goals

The day a Vaccine Equity Metric goal has been met, tier assignments will be revised to reflect the shift in Blueprint tier thresholds shifts. Updated tier assignments will be effective two days after tier assignments are announced. 

Plan for Reducing COVID-19 and Adjusting Permitted Sector Activities to Keep Californians Healthy and Safe

This guidance outlines a framework for a safe progression of opening more businesses and activities in light of the pandemic. The framework for this guidance is informed by increased knowledge of disease transmission vulnerabilities and risk factors and is driven by the following goals:

1. To progress in phases based on risk levels with appropriate time between each phase in each county so impacts of any given change can be fully evaluated.
   

2. To aggressively reduce case transmission to as low a rate as possible across the state so the potential burden of COVID-19 does not challenge our healthcare delivery system's ability to surge with space, supplies and staff; and to prevent the emergence and transmission of variants of the disease, including those resistant to vaccines.  
   

Tier Framework

This framework lays out the measures that each county must meet, based on indicators that capture disease burden, testing, and health equity. A county may be more restrictive than this framework. This framework also notes signals of concern, including impacted healthcare capacity that may lead towards a dimming intervention. This framework replaces the former County Data Monitoring metrics.  As the COVID-19 pandemic continues to be an evolving situation and new evidence and understanding emerges, the California Department of Public Health (CDPH), in collaboration with other State officials, will continue to reassess metrics and thresholds.

See chart below for the framework metrics as set according to tiers based on risk of community disease transmission. As of March 13, 2021, thresholds for the tiers will be updated in the table below once statewide vaccine equity goals are met.  Calculation of metrics is described in Appendix 1. Description of the Health Equity Metric can be found on the Health Equity Metric page.

Metrics with values greater than or less than tier cut points by 0.05 are rounded up or down using conventional rounding rules.

^Excludes state and federal inmates, ICE facility residents, State Hospital inmates and US Marshal detainees

*Population denominators from the Department of Finance: State Population Projections - Total Population by County- Table P-1 

**Case rate will be determined using cases confirmed by PCR

*** Counties are assigned a tier based on two metrics: test positivity and case rate. Large counties with populations greater than approximately 106,000 must also meet the health equity metric described on the Health Equity Metric page in order to advance to a less restrictive tier.

The case rate is adjusted based on testing volume per 100,000 population as described below.  Due to variability in data, this adjustment does not apply to small counties (defined as those with a population less than 106,000 residents).

As counties focus on increased testing in their health equity quartiles and to support school openings, they are likely to experience an increased number of cases. We want to avoid disincentivizing increased testing, provided that test positivity is low and there is sufficient capacity for contact tracing and isolation. We are therefore increasing the adjustment for higher volume testing. 

California COVID-19 Case Rate Adjustment Factor

• Counties with fewer than 106,000 residents, will be exempted from case rate adjustments, and counties with test positivity <3.5% will be exempted from adjustment for testing rates lower than the state median.
  

Moving through the Tiers

Rules of the framework:

1. CDPH will assess indicators weekly on Mondays and release updated tier assignments on Tuesdays.
   

2. A county must remain in a tier for a minimum of three weeks before being able to advance to a less restrictive tier.
   

3. A county can only move forward one tier at a time, even if metrics qualify for a more advanced tier.
   

4. The health equity metric is applied to jurisdictions with populations greater than 106,000. Rules of the health equity metric are described on the Health Equity Metric page.

5. City local health jurisdiction (LHJ) data will be included in overall metrics, and city LHJs will be assigned the same tier as the surrounding county
   

6. An LHJ may continue to implement or maintain more restrictive public health measures if the local health officer determines that health conditions in that jurisdiction warrant such measures.
   

7. Tier status goes into effect the Wednesday following each weekly tier assignment announcement on Tuesdays.
   

8. Once statewide vaccine equity goals are met, determination of the number of weeks a county has accumulated towards movement to a more or less restrictive tier follows the framework that is in place at the time of tier assessment. For example, if a county had a case rate of 8 per 100,000 and test positivity < 8% for 2 weeks prior to the time when the Goal 1 thresholds are met, the county will be eligible to move to the Red Tier.
   

To advance:

1. A county must have been in the current tier for a minimum of three weeks.
   

2. A county must meet criteria for movement to the next less restrictive for the prior two consecutive weeks in order to progress to the next tier; which can be achieved by either or combination of criteria described below:

1. Meeting the Adjusted Case Rate, Test Positivity, and Health Equity metric criteria for a less restrictive tier. For small counties with a population less than 106,000, Adjusted Case Rate and Test Positivity will be used for the default assessment. If a small county does not meet the adjusted case rate to earn a week towards a less restrictive tier (but does meet the test positivity criteria), CDPH will review absolute new case counts, and whether vaccine administration coverage in the county within or equal to 5% (absolute value) of the statewide average.  More information can be found under the Small County Framework section. 
   

2. Meeting the criteria for movement to the next less restrictive tier through health equity accelerated progression.
   

To move back:

1. During the weekly assessment, if a county's adjusted case rate and test positivity have fallen within a more restrictive tier for two consecutive weekly periods, the state will review the most recent 10 days of data, including hospitalization data, and if CDPH determines there are objective signs of stability or improvement the county may remain in the tier. If the county’s most recent 10 days data does not show objective signs of stability or improvement the county must revert to the more restrictive tier. For subsequent weekly assessments, the above rules apply.
   

2. At any time, state and county public health officials may work together to determine targeted interventions or county wide modifications necessary to address impacted hospital capacity and drivers of disease transmission, as needed, including movement across more than one tier. Key considerations will also include the rate of increase in new cases and/or test positivity, more recent data as noted above, vaccination rates, public health capacity, and other epidemiological factors.
   

3. Counties with a population less than 106,000 will have a small county case assessment criteria applied to it to ensure movement to a more restrictive tier is appropriate. More information can be found under the Small County Framework section. 

4. Counties will have three days, beginning the Wednesday after tier assignments are announced on Tuesdays, to implement any sector changes or closures unless extreme circumstances merit immediate action.
   

Risk Criteria

Activities and sectors will begin to open at a specific tier based on risk-based criteria (PDF), as outlined below.  Lower risk activities or sectors are permitted sooner and higher risk activities or sectors are not permitted until later phases.  Many activities or sectors may increase the level of operations and capacity as a county reduces its level of transmission.

Criteria used to determine low/medium/high risk sectors

• Ability to accommodate face covering wearing at all times (e.g. eating and drinking would require removal of face covering)

• Ability to physically distance between individuals from different households

• Ability to limit the number of people per square foot

• Ability to limit duration of exposure

• Ability to limit amount of mixing of people from differing households and communities

• Ability to limit amount of physical interactions of visitors/patrons

• Ability to optimize ventilation (e.g. indoor vs outdoor, air exchange and filtration)

• Ability to limit activities that are known to cause increased spread (e.g. singing, shouting, heavy breathing; loud environs will cause people to raise voice)
  

Schools

Schools may reopen for in-person instruction based on equivalent criteria to the K-12 School Guidance.  Schools in counties within the Purple Tier are not permitted to reopen for in-person instruction, with exceptions outlined in the K-12 School Guidance. See the guidance and the K-12 Schools FAQ for additional information on school re-opening eligibility criteria under the Blueprint.  

As stated in the K-12 School Guidance, schools are not required to close if a county no longer meets relevant school re-opening criteria (e.g., goes from Red Tier to Purple Tier or has adjusted county case rates ≥25/100,000 population) but may consider increasing testing per the CDPH supported testing framework.  

County Tier Adjudication Process

For more information, visit our County Tier Adjudication Request page. 

APPENDIX 1: Calculation of metrics

 Data Source: CalREDIE