Summary

As announced on August 28, 2020, the Blueprint for a Safer Economy includes a health equity metric which will be used (along with other metrics) to determine a county's tier. The purpose of this metric is to ensure California reopens its economy safely by reducing disease transmission in all communities. This document outlines the equity metric and requirements which is effective October 6, 2020.

Blueprint for a Safer Economy – COVID-19 and Equity

It has been clearly documented that certain communities - low-income, Black, Latino, Pacific Islander, and essential workers – have been disproportionately impacted by COVID-19 in terms of higher rates of infection, hospitalizations, and deaths.  These disparities create a public health imperative to address exposure in all communities, including especially those disproportionately impacted, as a measure to protect all communities. 

The Blueprint for a Safer Economy relies on two measures – case rate[i] and test positivity[ii] – to determine when a county can move to a less restrictive tier with more sector openings and resultant increased interaction among residents.  In order to avoid a surge of infections, the level of baseline infection in a community should be progressively lower as there is more movement and mixing.  

Most counties have significant differences in test positivity among more and less advantaged neighborhoods, with these differences often also overlapping with race and likelihood of employment as essential workers. Especially as counties move into less restrictive tiers with more movement, the importance of this differential prevalence of infection grows because mixing and opportunities for transmission increase.  Therefore, it is imperative to reduce disease transmission in all communities to ensure California reopens its economy safely.

In order to advance to the next less restrictive tier, depending on its size, a county will need to meet an equity metric and/or demonstrate targeted investments to eliminate disparities in levels of transmission. 

• For a county with a population of greater than 106,000, the county must:

• Equity Metric.  Ensure that the test positivity rates in its most disadvantaged neighborhoods, referred to as the Health Equity Quartile of the Healthy Places Index* census tracts, do not significantly lag behind its overall county test positivity rate, as described in detail below.

• Targeted Investments.  Submit a plan that (1) defines its disproportionately impacted populations, (2) specifies the percent of its COVID-19 cases in these populations, and (3) shows that it plans to invest Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (Strategy 5: Use Laboratory Data to Enhance Investigation, Response, and Prevention) grant funds at least at that percentage to interrupt disease transmission in these populations. The targeted investments can include spending on augmenting testing, disease investigation, contact tracing, isolation/quarantine support, and education and outreach efforts for workers.  Effective for the October 20 tier assignment, this plan must be submitted to CDPH by October 15 before a county may progress to a less restrictive tier. The required components due by October 15 include: Planned Activity, Priority Population, Funding Amount, and Source. Due to data limitations in small populations, the equity metric described above cannot be reliably applied to smaller counties, as described below.

Learn more about the Targeted Equity Investment Plans

• For a county with a population of fewer than or equal to 106,000, the county must:

• Targeted Investments.  Submit a plan that (1) defines its disproportionately impacted populations, (2) specifies the percent of its COVID-19 cases in these populations, and (3) shows that it plans to invest Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (Strategy 5: Use Laboratory Data to Enhance Investigation, Response, and Prevention) grant funds at least at that percentage to interrupt disease transmission in these populations. The targeted investments can include spending on augmenting testing, disease investigation, contact tracing, isolation/quarantine support, and education and outreach efforts for workers.  Effective for the October 20 tier assignment, this plan must be submitted to CDPH by October 15 before a county may progress to a less restrictive tier. The required components due by October 15 include: Planned Activity, Priority Population, Funding Amount, and Source. Due to data limitations in small populations, the equity metric described above cannot be reliably applied to smaller counties, as described below.

In addition, to support a data-driven approach to protecting public health and eliminating COVID-19 disparities, the state is committed to partnering with counties to improve the collection of race and ethnicity data associated with testing and cases.  To date, approximately a third of cases and up to half of test results reported to the state so do not have required race/ethnicity data. The state will partner with counties to determine milestones in improving the collection of this data.  The state will provide county-level data on the completeness of race/ethnicity for COVID-19 tests and cases, and will continue to track and publicly post county level data on testing, case rates and deaths by race and ethnicity.  

Learn more about the Targeted Equity Investment Plans

The COVID-19 Health Equity Playbook for Communities is intended to support local communities in achieving their Health Equity Measure as part of the California's Blueprint for a Safer Economy and building an equitable recovery. Counties can use this document to inform Targeted Equity Investment Plans. This living document will continue to be updated as the pandemic progresses and as more is learned about what strategies are working on the ground.

Equity Metric

The Public Health Alliance of Southern California's California Healthy Places Index (HPI) is a composite measure of socioeconomic opportunity applied to census tracts that includes 25 individual indicators across economic, social, education, transportation, housing, environmental and neighborhood sectors. 

Each county's census tracts will be divided into quartiles based on HPI.  While the state's Health Equity Quartile HPI census tracts are home to 24% of Californians, they account for 40% of COVID-19 cases.  Consequently, the Blueprint for a Safer Economy framework includes two measures to address the public health impact of populations mixing more as counties move through tiers and more activities are allowed.

• Health Equity Quartile Test Positivity Rate Must Meet Specified Threshold for Less Restrictive Tier.  In order to move to a less restrictive tier, a county must meet the case rate and test positivity thresholds for that tier for the prior two consecutive weeks.  In addition, the county's Health Equity Quartile HPI census tracts must also meet the specified test positivity threshold, as described below, for the less restrictive tier during those same weeks. 

• For counties entering the red tier, their Health Equity Quartile HPI census tracts' test positivity must also be ≤8%.
  

• For counties entering the orange tier, their Health Equity Quartile HPI census tracts' test positivity must be within 5% of the orange tier threshold, or ≤5.2%.
  

• For counties entering the yellow tier, their Health Equity Quartile HPI census tracts must be within 10% of the yellow tier threshold, or ≤2.2%.
  

• Accelerated Progression if Health Equity Quartile Test Positivity Rate Meets Threshold for Two Tiers Less Restrictive. Attending to the Health Equity Quartile HPI test positivity rate can also accelerate a county's progression to a less restrictive tier. 

• For counties in purple or red tiers, if the county's case rate has changed no more than 5% or is declining but has not met threshold for the next less restrictive tier, the county can still progress to the next less restrictive tier if both the countywide and the county's Health Equity Quartile HPI census tracts' test positivity rate meet the below thresholds for two consecutive weeks.
  

• Purple tier: <5% for movement to red tier
  

• Red tier: <2% for movement to orange tier

• As of 04/06/21, the criteria for acceleration from Orange tier to Yellow tier has been removed since the case rate threshold for the Yellow tier has been increased from <1 to <2 cases per 100,000 people. 

• Movement due to accelerated progression does not apply when overall county metrics for progression are met.
  

Case Rate**

• For counties that accelerated from Purple to Red, or Red to Orange, case rate has increased more than 15% for the last two consecutive weeks.
  

OR

Countywide Test Positivity

• For counties that accelerated from Purple to Red, countywide test positivity has moved from Orange into Red (5%-8%) for the last two consecutive weeks.

• For counties that accelerated from Red to Orange, countywide test positivity has moved from Yellow into Orange (2.0%-4.9%) for the last two consecutive weeks.
  

Due to the limited number of census tracts, test positivity cannot be reliably calculated by quartile for smaller counties.  Therefore, at this time, counties with a total population of fewer than or equal to 106,000 are excluded from this equity metric but must meet the targeted investment requirement described above.  Twenty-three counties with a cumulative total population of fewer than 1 million (2.4% of state population) are exempted from this measure.  These counties collectively account for fewer than 1% of the state's Asian-American population, 1% of the Latino, Black and Native Hawaiian/Pacific Islander populations, 4% percent of the white population, and 6% of the Native American population. 

Technical Assistance Team

CDPH will assemble a Health Equity Technical Assistance Team that will partner with key regional collaboratives and advocacy groups to develop a menu of best practices, resources, and vendors with an equity focus to share and provide resources to counties.  In addition, CDPH will coordinate regional hubs to provide resources relevant to each area.

[i] Case Rate: Calculated as the average daily number of COVID-19+ cases (excluding certain cases) over 7 days, divided by the number of people living in the county/region/state. For purposes of the Blueprint for a Safer Economy, the adjusted case rate is used to determine tiers. The adjusted case rate is calculated as the case rate multiplied by a case rate adjustment factor that is based on the difference between the county testing volume (testing volume, tests per 100,000 per day) and the median testing volume calculated across all counties. See Blueprint for a Safer Economy for more information.

[ii] Calculated as the total number of positive polymerase chain reaction (PCR) tests for COVID-19 over a 7-day period (based on specimen collected date) divided by the total number of PCR tests conducted; this excludes tests for certain cases. This number is then multiplied by 100 to get a percentage. Due to reporting delay (which may be different between positive and negative tests), there is a 7-day lag. See Blueprint for a Safer Economy for more information.

* The Healthy Places Index is a project of the Public Health Alliance of Southern California, fiscally administered by the Public Health Institute.

** Per the March 5, 2021 update to the Blueprint Framework, the case rate criteria that must be met will be updated after the statewide vaccine equity metric goals have been met to align with the shift in case rate thresholds for each tier.