CDC Activities and Initiatives Supporting the 

COVID-19 Response and the President’s Plan 

for Opening America Up Again

May 2020

iii

Contents

Overview of CDC’s Surveillance and Control Goals and Activities 1

Appendix A: Surveillance for COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Appendix B: Healthcare System Surveillance 13

Appendix C: Guidance on Infection Control and Contact Tracing 16

Appendix D: Guidance on Test Usage (Asymptomatic Populations and Serology) 21

Appendix E: Assessing Surveillance and Hospital Gating Indicators 24

Appendix F: Setting Specific Guidance 38

1

This document briefly summarizes CDC’s initiatives, activities, and tools in support of the Whole-of-Government 

response to COVID-19.

Overview of CDC’s Surveillance and Control Goals and Activities

The principal objectives of COVID-19 surveillance are to monitor the spread and intensity of the pandemic, 

to enable contact tracing to slow transmission, and to identify disease clusters requiring special intervention.

Secondary objectives include understanding the severity and spectrum of disease, identifying risk factors for and 

methods of preventing infection, and producing data essential for forecasting. In addition to tracking the disease 

itself, monitoring of healthcare capacity and essential supplies through the National Healthcare Safety Network 

(NHSN) is critical to ensure adequacy of care.

Because no single system can capture all parameters of the pandemic, CDC has implemented multiple, 

complementary surveillance systems (Appendix A). Key systems are case-based reporting through the National 

Notifiable Diseases Surveillance System (NNDSS), laboratory-based surveillance, syndromic-surveillance data 

reported through the National Syndromic Surveillance Program (NSSP), and data on healthcare system capacity 

reported through the NHSN (Appendix B). Additional systems, such as COVID-Net, provide rich, publicly available 

information for meeting secondary objectives. CDC continues to explore emerging and experimental surveillance 

platforms with a critical eye toward proven utility.

Control of the epidemic requires action at the individual, community, and population levels. CDC has provided 

state, tribal, local, and territorial health departments with extensive detailed guidance on contact tracing, 

infection control, and a wide range of other prevention and control topics. Recent models suggest that asymptomatic and pre-symptomatic transmission and delays in case recognition can greatly reduce the effectiveness 

of contact tracing. To enhance the speed and thus effectiveness of contact tracing, CDC is exploring technologic 

methods for instantaneous voluntary notification of contacts of confirmed cases.

At the community level, recent events have shown the devastating effects that outbreaks can have among 

vulnerable populations, especially those in congregate settings such as nursing homes, prisons, and homeless 

shelters. Similarly, outbreaks in food production plants and other critical industries are crippling communities 

financially and threatening national food security. Rapid identification and response to these events is a CDC 

priority that can mitigate the immediate impact and provide critical insights needed to prevent future outbreaks 

in similar settings. CDC has developed extensive tools to assist states, counties, facilities, and industries in 

responding to and preventing these events (Appendix C).

Laboratory testing of asymptomatic individuals is an evolving consideration as more is learned about the role of 

asymptomatic and subclinical infections in transmission SARS-COV-2. Emerging evidence suggests that asymptomatic infections may play an important role in the epidemiology of the disease. However, it is important to 

define the circumstances where testing asymptomatic persons is likely to be helpful in controlling the COVID-19 

pandemic. Interim guidance about laboratory test usage for asymptomatic populations and for serologic testing 

and serologic surveillance is provided in Appendix D.

Surveillance and hospitalization indicators can aid public health and government officials in their decisions when 

to reopen communities. The disease occurrence and hospital gating indicators in the Opening Up America Again 

guideline provide states and communities insight into the trajectory of the COVID-19 pandemic in their jurisdiction. These indicators are part of the broad assessment jurisdictions should undertake when deciding when 

and how to adjust community mitigation strategies for COVID-19 (Appendix E).
2

As businesses and other organizations gradually open after the COVID-19-related slowdown, they will need to 

consider a variety of measures for keeping people safe. These considerations include practices for scaling up 

operations, safety actions (e.g., cleaning and disinfection, social distancing), monitoring possible reemergence 

of illness, and maintaining health operations. Interim guidance for helping establishments with these steps is 

provided in Appendix F.

Widespread community mitigation combined with ongoing containment activities represents both an effective 

intervention for limiting the spread of COVID-19 and a serious threat to the economic well-being of the country 

and the world.
3

CRITICAL INITIATIVES AND ACTIVITIES

A. Expanding Testing and Advising Testing Practices

Extensive, rapid, and widely available COVID-19 testing is essential. CDC is working within the “All-of-Government 

and All-of-America Approach” to increase testing capacity and availability to improve case detection and contact 

tracing though all phases of the US plan to Opening Up America Again. As the supply and nature of tests expand, 

testing criteria have been broadened to include a wider range of people and situations.

Prioritizing Patients for Testing: Current recommendations for testing: https://www.cdc.gov/coronavirus/2019-

nCoV/hcp/clinical-criteria.html

Focusing Testing Efforts: CDC is working across the US government to support diverse efforts to increase testing in 

multiple settings to support diagnosis, surveillance, and outbreak control: 

• Testing for Diagnosis and Clinical Management: CDC is working with federal government partners to 

support hospitals, healthcare systems, clinics, and public health departments to ensure the capability to 

diagnose COVID-19 infections with a turnaround time needed for appropriate clinical care and public health 

decision-making. CDC is:

» Working with federal government partners to provide a wide range of technical assistance resources to 

each state to help them develop a state-specific testing plan that meets their unique needs.

» Equipping state public health laboratories with sufficient quantities of devices, reagents, and testing 

supplies in the International Reagent Resource (IRR).

» Working with the White House Coronavirus Task Force to enhance the national supply of reagents and 

testing supplies so that the commercial market is able to supply state efforts. This supply should be sufficient to achieve a rate of less than 10% positive tests for COVID-19 among symptomatic, asymptomatic, 

and pre-symptomatic individuals.

• Testing for Surveillance and Outbreak Control: Identify newly emergent cases or clusters of COVID-19 

among symptomatic and asymptomatic individuals who are prioritized by public health officials and clinicians, and improve reporting of COVID-19 cases to public health systems. CDC is:

» Utilizing established, nationwide surveillance systems to identify any areas of potential COVID-19 

outbreaks, including use of CDC’s Influenza-Like Illness Network and the National Syndromic Surveillance 

Program.

» Enabling public health systems at state, local, territorial, and tribal levels to develop a robust system to 

identify COVID-19 infections, particularly among vulnerable populations such as residents of nursing 

homes, people of racial and ethnic minority groups (e.g., African Americans, American Indians, Alaska 

Natives) at higher risk of disease, and those in areas of high social vulnerability, closed settings, and 

congregate housing.

» Supporting existing case-based surveillance efforts for identifying infections through routine testing of 

persons in clinical encounters.

» Enhancing case investigation and contact tracing efforts through increased public health staff and rapid 

testing capability.

» Working with point-of-care diagnostic test manufacturers and state health departments to improve 

reporting of results from rapid, point-of-care devices 

» Evaluating various serologic assays for use in surveillance and for potential use for returning to work.
4

Defining Usage: CDC is working with state, local, and other partners to define the circumstances where testing of 

asymptomatic persons is likely to be helpful in controlling the pandemic, as well as the best application of surveillance serologic testing.

• Emerging evidence suggests that asymptomatic infections play an important role in the epidemiology of 

SAR-CoV-2 infections. Testing for asymptomatic infection should focus (1) on persons with an increased 

likelihood of infection and (2) on settings with particularly vulnerable populations.

• CDC is working to identify indications for serologic testing. Broadly, the purpose of serologic test falls into 

two categories: serologic surveillance of populations and serologic testing of individuals to determine if they 

have had a prior infection. This current CDC COVID-19 test is not currently designed for individual use (i.e., to 

test people who want to know if they have been previously infected with SARS-CoV-2). Serologic surveillance 

has the potential to provide important insights into the transmission dynamics of disease, as well as a more 

complete picture of total burden of COVID-19 infections in a community or among first responders and frontline health providers. More information is needed to determine how the results of serologic testing correlate 

with possible immunity.

• See Appendix D and https://www.cdc.gov/coronavirus/2019-ncov/lab/serology-testing.html for additional 

details on testing strategies, testing of asymptomatic infections, and serologic testing.

Augmenting Existing Infrastructure and Technology to Improve Data Flow and Reporting:

CDC is supporting the improvement of current data infrastructure, and the development and integration of 

digital/technology solutions to augment state and community-wide sites to ensure timely and transparent 

communication to all citizens inclusive of daily new cases, hospitalizations, use of intensive care units (ICU), and 

mortality by county and or zip code. To ensure geographic relevant information is continuously available to state 

and local governments and the public in those communities, this should also include laboratory and potential 

immunization data systems. Activities include:

• Working with state and local officials and web development groups to develop and support interactive 

web-based platforms that allow open and transparent data visibility to all communities, such as the Florida 

Public Health COVID-19 website.

• Working with manufacturers for point-of-care diagnostic tests, commercial laboratories, state and local health 

departments, testing locations (providers, hospitals, pharmacies), and public health partners (Association of 

Public Health Laboratories [APHL], Council of state and Territorial Epidemiologists [CSTE]) to improve data 

quality, integration, and electronic reporting.

• Developing, integrating, and testing the ability for laboratories to securely share data with digital platforms 

selected by public health, including platforms that may be used for testing, or to support state and local 

contract tracing.

• Exploring digital solutions to share laboratory results with patients directly and sharing tested best practices 

with state and local partners. This could also extend to immunization record access.

• Developing recommendations for minimum requirements of platforms to integrate, store, and manage 

personal laboratory information on digital platforms (what states should consider before investing or having 

additional standards for platforms handling these data).
5

B. Phased Plan and Indicators for Reopening America

The plan for reopening America outlines a three-phased approach for reducing community mitigation measures 

while protecting vulnerable populations. The phased approach can be implemented statewide or community-bycommunity at governors’ discretion. The guidelines propose the use of six “gating” indicators to assess when to 

move through from one mitigation phase to another.

Table 1. Gating Criteria and Phase-specific Thresholds

Gating Criteria Threshold for entering

Phase 1

Threshold for entering

Phase 2

Threshold for entering

Phase 3

Decreases in newly 

identified COVID-19 cases 

Downward trajectory (or 

near-zero incidence) of 

documented cases over a 

14-day period

Downward trajectory (or 

near-zero incidence) of 

documented cases for at 

least 14 days after entering 

Phase 1

Downward trajectory (or 

near-zero incidence) of 

documented cases for at 

least 14 days after entering 

Phase 2

Decreases in emergency 

department (ED) and/or 

outpatient visits for COVIDlike illness (CLI)

Downward trajectory (or 

near-zero incidence) of CLI 

syndromic cases reported 

over a 14-day period 

Downward trajectory (or 

near-zero incidence) of CLI 

syndromic cases reported 

for at least 14 days after 

entering Phase 1

Downward trajectory (or 

near-zero incidence) of CLI 

syndromic cases reported 

for at least an additional 14 

days after entering Phase 2

Decreases in ED and/

or outpatient visits for 

influenza-like illness (ILI)

Downward trajectory (or 

near-zero incidence) of 

ILI reported over a 14-day 

period 

Downward trajectory (or 

near-zero incidence) of ILI 

reported for at least 14 days 

after entering Phase 1

Downward trajectory (or 

near-zero incidence) of 

ILI reported for at least an 

additional 14 days after 

entering Phase 2

Decreases in percentage of 

SARS-CoV-2 tests positive 

Downward trajectory (or 

near-zero percent positive) 

of positive tests as a 

percentage of total tests 

over a 14-day period (flat or 

increasing volume of tests)

Downward trajectory (or 

near-zero percent positive) 

of positive tests as a 

percentage of total tests for 

14 days after entering Phase 

1 (flat or increasing volume 

of tests)

Downward trajectory (or 

near-zero percent positive) 

of positive tests as a 

percentage of total tests for 

at least 14 days after entering 

Phase 2 (flat or increasing 

volume of tests)

Treat all patients without 

crisis care

Jurisdiction inpatient & 

ICU beds <80% full Staff 

shortage in last week = no 

PPE supplies adequate for 

>4 days

Jurisdiction inpatient & 

ICU beds <75% full Staff 

shortage in last week = no 

PPE supplies adequate for 

>4 days

Jurisdiction inpatient & 

ICU beds <70% full Staff 

shortage in last week = no 

PPE supplies adequate for 

>15 days

Robust testing program Test availability such that 

percentage of positive tests 

is ≤20% for 14 days Median 

time from test order to result 

is ≤4 days 

Test availability such that 

percentage of positive tests 

is ≤15% for 14 days Median 

time from test order to result 

is ≤3 days 

Test availability such that 

the percentage of positive 

tests is ≤10% for 14 days 

Median time from test order 

to result is ≤2 days 
6

Decisions to move between phases should also consider the public health capacity of the jurisdiction based on 

the criteria listed below. Other epidemiologic data sources available locally can be used to corroborate trends 

seen in core epidemiologic gating criteria. Special consideration should be given to infections identified in 

populations and settings such as healthcare personnel, patients in healthcare facilities (e.g., nursing homes, 

dialysis centers, long-term care facilities), and residents of congregate living settings (e.g., prisons, youth homes, 

shelters), underserved populations, and people of racial and ethnic minority groups (e.g., African Americans, 

American Indians, Alaska Natives) at higher risk of disease. Incidence and trajectory (increasing versus decreasing) 

of COVID-19 illnesses in the surrounding region should also be considered.

Table 2. Assessing Capacity for Case Identification, Follow Up, and Containment

Category Considerations for Assessing Capacity for Case Identification, Follow Up, and Containment

SARS-CoV-2 

testing in 

jurisdiction

Testing is available as indicated for clinical, public health, and infection prevention needs.

Identification of 

new COVID-19 

cases

All new COVID-19 cases in the jurisdiction can be rapidly identified through active surveillance, 

including proactive monitoring for asymptomatic cases through surveillance monitoring.

Interviewing new 

COVID-19 cases 

Initial interviews can be conducted for nearly all new COVID-19 cases within one day of health 

department notification.

Contact tracing Follow up (isolation, self-monitoring, and rapid testing of selected contacts) can be initiated for 

nearly all identified contacts of newly identified cases.

Incidence relative 

to local public 

health resources

Public health capacity is sufficient to fully perform contact tracing and investigate outbreaks based 

on local incidence and resources available.

While some communities will progress sequentially through the reopening phases, there is the possibility of 

recrudescence in some areas. Given the potential for a rebound in the number of cases or level of community 

transmission, a low threshold for reinstating more stringent mitigation standards will be essential. The decision 

to reinstate community mitigation strategies will undoubtedly be very difficult and will require careful thought to 

define an evidence-based monitoring strategy and specific guidance for these decisions.

Technical Support for States

As part of the “Whole-of-Government” public health effort, CDC is providing states and other jurisdictions with 

technical assistance regarding testing, surveillance data collection and reporting, contact tracing, infection 

control, and outbreak investigation. Implementation of these activities is supported by the Paycheck Protection 

Program and Health Care Enhancement Act, which includes $11 billion to be awarded, within 30 days, directly 

to states, localities, territories, tribes, tribal organizations, urban Indian health organizations, or health service 

providers to tribes to develop, purchase, administer, process, and analyze COVID-19 tests, conduct surveillance, 

trace contacts, and related activities. Listed below are additional strategies CDC is using to strengthen the 

capacity of state, tribal, local, and territorial (STLT) health departments to fight against COVID-19. This technical 

assistance is essential to ready the nation to re-open and minimize future COVID-19 outbreaks in jurisdictions 

across the country.
7

Contact Tracing

Contact tracing, a core disease control measure used by local and state health department personnel for decades, 

is a key strategy for preventing further spread of infectious diseases, including COVID-19. Contact tracing is part 

of the process of supporting affected individuals and warning contacts of exposure in order to stop chains of 

transmission. CDC is ramping up America's capacity to perform contact tracing. As part of this effort, CDC has 

developed multiple training tools for communities to train the newest frontline workers in public health. CDC will 

train newly identified contact tracers on how to quickly locate and talk with the affected individuals, assist with 

isolation issues, and work with affected individuals to identify people with whom the affected individuals have 

been in close contact. Identification of contacts will allow further outreach by public health to identify individuals 

who need to self-isolate.

Table 3. CDC Priorities and Strategies to Support STLT Health Departments

Priorities Strategies

Contact tracing guidance and training 

https://www.cdc.gov/coronavirus/

2019-ncov/php/contact-tracing/index.html

Provide CDC guidance on case investigation and contact tracing to STLT 

health departments

Address key issues such as staffing and roles, when to initiate an 

investigation, steps to the investigation, confidentiality and consent, 

self-isolation, quarantine, and necessary support services (housing, food, 

medicine); data management; digital contact tracing tools and technology; 

and evaluation and monitoring

• Work with states to develop a comprehensive proactive plan for the 

identification of asymptomatic case in areas of high vulnerability and/

or high rates of co-morbidities

Deploy COVID-19 Response Corps

https://www.cdc.gov/coronavirus/

2019-ncov/php/open-america/responsecorps.html

Use a multi-pronged approach to enhance and complement the efforts 

of STLT health department staff through innovative hiring mechanisms 

designed to address the surge staffing needs of STLT health departments.

Provide access to a variety of mechanism to complement local efforts to 

increase capacity.

• Realign existing CDC field staff

• Deploy CDC teams to address outbreaks in special settings

• Partner with CDC Foundation and other organizations to place surge 

staff for STLT health departments across the nation

• Partner with other federal agencies (e.g., AmeriCorps) to offer staffing 

options with states

• Facilitate access to a variety of contact tracing and case investigation 

training products and tools for a diverse and evolving public health 

workforce

Continued on the next page 
8

Priorities Strategies

Innovative technologies Support implementation of innovative methods and technologies at the 

STLT levels to help inform and guide the national response.

• Develop guidance for assisting states and locals in evaluating tools, 

refining guidance, and identifying gaps in contact tracing workflow

• Leverage partnerships to facilitate information sharing among our state 

and local partners regarding digital contact tracing tools

• Share the landscape of digital tools, including those for contact tracing, 

case management, workforce management, and proximity tracking

Conclusion

As part of the Whole-of-Government Response, CDC has developed and is continually evaluating and improving 

the comprehensive surveillance program to generate essential data for tracking the pandemic and guiding the 

overall response to COVID-19. In addition, CDC is working with federal, state, and local partners to improve testing 

and to advise and support communities during the phased reopening of America.
9

Appendix A: Surveillance for COVID-19

The goals of US surveillance are to produce timely and accurate information at national, state, local and 

community levels to inform decisions on public measures for implementing and adjusting disease reduction strategies, to guide clinical decisions, to educate the public and key stakeholders, and to provide data for estimating 

and forecasting disease burden.

Surveillance Objectives 

• To identify both symptomatic and asymptomatic/presymptomatic cases and track contacts to slow transmission of COVID-19 in the United States

• To monitor spread and intensity of COVID-19 disease in the United States 

• To understand disease severity and spectrum of illness

• To understand risk factors for severe disease and transmission

• To monitor for virus changes

• To estimate disease burden

• To produce data for forecasting spread and impact

• To identify when thresholds have been met to adjust community mitigation measures 

Approach

Using multiple surveillance systems and epidemiology networks, CDC in collaboration with state, local, and 

academic partners, monitors the progression and impact of COVID-19 spread in the United States. The combination of data from the different systems is used to generate an ongoing picture of virus spread and produce data 

to address the key questions for directing and refining the US response. Surveillance data are used for:

• Situational awareness—Timely monitoring of the spread and intensity of COVID-19 disease in the United 

States. Surveillance systems allow for efficient targeting of public health measures, developing timely 

communications, and preparing health systems for increasing numbers of ill people. Data from these systems 

will be updated daily or weekly to create an ongoing, accurate understanding of impacted regions, affected 

populations, trends over time, and viral characteristics.

• Understanding impact and forecasting disease spread—All surveillance systems will be employed to produce 

data to understand overall impact and epidemic characteristics to inform future use of public health and 

medical resources.

• Characterizing COVID-19 infection across a spectrum of conditions include: 

» asymptomatic infections

» symptomatic infection

» medically attended outpatient and ambulatory visits

» hospitalizations

» deaths 
10

Operational Plan

The plan is operationalized according to the following components:

• Increase laboratory testing and reporting to detect cases quickly and 

reliably for timely public health action

• Use robust syndromic surveillance, proactive monitoring for 

asymptomatic cases in settings with people at risk for infection 

or with known vulnerabilities 

• Use laboratory reporting systems to monitor local disease 

trends to identify if thresholds (gates) have been met

• Corroborate trends and risk assessment with high-quality 

data from sentinel surveillance and systems

• Monitor disease and outbreaks in healthcare, 

institutional, workplace and group settings

• Use data for estimation of disease burden over time and to aid disease and transmission forecasts

Federal, State, and Local roles

The surveillance strategies rely on collaboration at federal, state, and local levels. The federal government will 

work with the states to establish the data platforms used by states and local jurisdictions to monitor transmission, 

public health, and health system capacity and provide technical assistance and coordination of information 

sharing and decision making across jurisdictions. These data platforms will be public facing to maximize transparency and maximize information to communities at the most granular level. Using the federal data systems, 

states can share data and information and communicate with residents’ decisions under consideration and 

clear guidance on adhering to mitigation levels. In addition to implementing federal programs, states can also 

coordinate resource allocation within their regions and across communities and monitor indicators closely to 

make decisive adjustments to mitigation measures. Finally, local governments are responsible for feeding data 

and information into state and federal data systems and adjoining communities.

Components of the US COVID-19 surveillance plan

The surveillance program is built on a combination of existing influenza and viral respiratory diseases surveillance 

systems, syndromic surveillance systems, case reporting systems, proactive monitoring for asymptomatic cases 

in areas of demonstrated vulnerabilities, commercial laboratory reporting, ongoing research platforms employed 

for the COVID-19 response, and new systems. The systems are summarized in Table 4 and a more fully described 

in Appendix A.

DIED

HOSPITALIZED

MEDICALLY ATTENDED

SYMPTOMATIC

INFECTED ASYMPTOMATIC
11

Table 4. Surveillance Systems Used by Objective.

Surveillance data for decision-making uses multiple systems and epidemiology networks. These approaches use laboratory 

submitted specimens, electronically transmitted data, and other sources to generate an ongoing picture of disease spread, 

intensity, and severity, and produce data to address the key questions for directing and refining the US response.

Goal addressed Outcome Platform

Trends in disease spread 

and intensity

No. of cases, by location, trends, 

demographics, underlying diseases, 

outcomes

COVID-19 case-based surveillance

No. of lab-positives; % positive, by age 

groups, location, over time

Public Health Laboratories (PHLs)

National Respiratory and Enteric Virus 

Surveillance System (NREVSS)

Commercial labs

Outpatient, syndromic—%ILI, trends in 

ILI by region, age group, concordance and 

discordance between surveillance data

ILInet

National Syndromic Surveillance Program 

(NSSP)

Outpatient—laboratory-confirmed, 

% positive, by location, by age group

Laboratory-confirmed outpatient (OP) 

surveillance

US Flu Vaccine Effectiveness (VE) network 

(acute respiratory illness)

Severity/clinical spectrum Hospitalizations rates, by age group, 

underlying condition

FluSurvnet—all ages

Hospitalizations New Vaccine Surveillance Network (NVSN)—

pediatrics

Viral changes Virus characterization, sequence changes PHLs and CDC/DVD

SPHERES

Risk factors for severe 

disease

Risk of severe disease given underlying 

illness, age

COVID-19 case-based surveillance

US Flu VE network

FluSurvnet—all ages

NVSN—pediatrics

Hospitalized Adult Influenza Vaccine 

Effectiveness Network (HAIVEN)

Influenza ICU Vaccine Effectiveness Study 

Pediatric Intensive Care Influenza Network 

(PICFLU)

Disease burden Overall number of persons affected by 

severity and age

All systems, plus additional special research 

studies

Serologic surveys

Pandemic severity Pandemic Influenza Severity Assessment 

(PISA)

Modeling based on epidemiological inputs

Continued on the next page 
12

Goal addressed Outcome Platform

Forecasting and modeling 

spread and impact

When will it peak, how many disease 

outcomes, how will it spread

Modelling work with broad coalition of 

modelers led by CDC, using data above

Transmissibility Attack rates and risk factors for transmission Field studies

Flu Transmission Evaluation Study

(FLuTES)

Household Influenza Vaccine Effectiveness 

Study (HIVES) 

Risk Factors for Severe 

disease

Risk of severe disease given underlying 

illness, age

Pandemic cohorts (community, households, 

healthcare workers, pregnant woman, longterm care facilities)

Disease Burden Overall number of persons affected by 

severity and age

All systems, plus additional special research 

studies

Serologic surveys

Pandemic Severity PISA Modeling based on Epi inputs

Forecasting and modeling 

spread and impact

When will it peak, how many disease 

outcomes, how will it spread

Modelling work with broad coalition of 

modelers led by CDC, using data above

Transmissibility Attack rates and risk factors for transmission Field studies

FLuTES

HIVE

Pandemic cohorts (community, households, 

HCWs, pregnant woman, LTCFs)
13

Appendix B: Healthcare System Surveillance

Rationale and Objective

Measuring and reporting the impact of COVID-19 on the capacity of the US healthcare system—including both 

acute-care hospitals and long-term care facilities—is an essential public health function in the pandemic response 

and in plans for Opening Up America Again. To make critical decisions, all levels of government, including federal, 

regional, state, local, tribal, and territorial, and the healthcare system need detailed and timely information about 

the availability and shortages of key resources, including hospital beds, intensive care unit (ICU) beds, ventilators, 

personal protective equipment, and healthcare personnel shortages. Reporting needs to be comprehensive across 

all states.

Regional variations in disease burden place a premium on supporting a surveillance system that can provide 

standardized data that are timely, easy to interpret, and readily accessible for multiple end users at all geographic 

levels. Among the main objectives for a national healthcare surveillance system in the current crisis are providing 

timely and readily available metrics with which to monitor the pandemic’s trajectory and progress toward Opening 

Up America Again. The key surveillance metrics available from NHSN are reported counts and a panel of additional 

summary statistics on hospitalized COVID-19 patients, hospital bed capacity, intensive care unit bed capacity, 

ventilatory capacity, supplies of personal protective equipment, and staffing shortages. These metrics, produced 

daily, serve as indicators that can drive decisions and actions at the national, state, county, tribal, territorial, and 

healthcare facility levels but needs to be expanded to be inclusive of all hospitals.

Key System

Implementation of several key surveillance metrics for monitoring the impact of the pandemic on the healthcare 

system are available through the existing Centers for Disease Control and Prevention’s (CDC) National Healthcare 

Safety Network (NHSN). NHSN’s role as a shared platform for healthcare-associated condition surveillance provides 

a powerful and unique foundation for COVID-19 surveillance.

CDC is already efficiently leveraging NHSN—which was launched in 2005 and now is the nation’s most widely 

used healthcare-associated condition tracking system—to support the nation’s COVID-19 response. NHSN 

provides a well-established technical infrastructure, readily extensible platform, and a strong set of partnerships 

with healthcare facilities, state and local health departments, the Centers for Medicare and Medicaid Services 

(CMS), and electronic health record system (EHRs) companies, and other healthcare information technology 

suppliers. This system will need to continue improving to ensure 100% reporting of all cases and outcomes.

The US healthcare system relies on NHSN to track healthcare-associated conditions, improve patient safety, fulfill 

mandatory federal and state reporting requirements, and ultimately eliminate healthcare-associated conditions.

NHSN serves as the operating system for hospital-associated infection reporting through legislation established 

by 36 states, Washington, D.C., and Philadelphia, PA. NHSN will need to be expanded to all states and all hospitals 

to provide a comprehensive analysis of COVID-19. CMS uses NHSN reporting to enable healthcare facilities to fulfill 

CMS requirements for submitting healthcare outcome data that are used in CMS’s public reporting and incentive 

payment programs. Currently, over 25,000 healthcare facilities, including almost every hospital in the nation, 

more than 7,500 dialysis facilities, and over 3,000 nursing homes participate in NHSN. To be effective, this system 

must be nationwide and be comprehensive in reporting. Personnel in these facilities have extensive experience 

submitting data to NHSN, adhering to the system’s surveillance protocols, and using their own data and national 

benchmarks provided by NHSN for local prevention and control purposes. NHSN’s collaborations with EHR 

companies, infection surveillance system providers, and the Health Level Seven (HL7) data standards organizations 

enable healthcare facilities to submit data electronically to NHSN by using HL7 data exchange specifications.
14

On March 27, 2020, CDC launched the NHSN COVID-19 Patient Impact and Hospital Capacity Module 

(https://www.cdc.gov/nhsn/covid19/report-patient-impact.html), and as of April 24, 2020, over 56% of acute 

care hospitals and over 53% of critical access hospitals have reported COVID-19 surveillance metrics. This level 

of participation needs to continue to improve until reporting is at the 95–100% range. Additionally, as of April 

28, 2020, all ~15,000 nursing homes will be required to report COVID-19 cases and deaths, as well as staffing 

and personal protective equipment supply metrics, to NHSN (https://www.cdc.gov/nhsn/ltc/covid19/index.

html) per a new CMS Interim Final Rule. The adaptation of NHSN to the immediate needs of the emergency 

response is a clear example of how CDC is retooling, modernizing, and updating its existing national surveillance capabilities to confront the pandemic.

During the COVID-19 pandemic, data on key metrics are submitted daily to NHSN, where the data are analyzed 

daily and presented out to the key components at all levels of the public health response. NHSN COVID-19 data 

are an integrally important asset in the US government response. The NHSN data are provisioned for use in secure 

access systems maintained by the White House Coronavirus Task Force, the National Response Coordination 

Center (NRCC), CDC, FEMA, ASPR, and CMS. In addition, all state health departments, several local health departments, and many HHS ASPR and FEMA Regional Offices receive data from NHSN and rely upon it for regional and 

state emergency response decisions.

NHSN uses COVID-19 data to develop and report national and state-wide estimates that serve as indicators of 

stress on the healthcare system. Figures below show examples of national trend-data as well as an example of a 

state trend.
15
16

Appendix C: Guidance on Infection Control and Contact Tracing

General CDC Guidance Hub https://www.cdc.gov/coronavirus/2019-ncov/communication/guidance-list.

html?Sort=Date%3A%3Adesc

Infection Prevention Control

• What CDC is doing for infection control

» https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html

• Standard CDC guidance on infection control in healthcare settings

» Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed 

Coronavirus Disease 2019 (COVID-19) in Healthcare Settings: https://www.cdc.gov/coronavirus/2019-ncov/

hcp/infection-control-recommendations.html

• Best practices currently in use by states and private sector

• Link to virtual training

» Training for Healthcare Professionals (including clinical care and infection control, PPE, nonpharmaceutical 

interventions, emergency preparedness and response, and additional topics): https://www.cdc.gov/

coronavirus/2019-ncov/hcp/training.html

» Preparing Nursing Homes and Assisted Living Facilities for COVID-19 (CDC webinar): https://www.youtube.

com/watch?v=p1FiVFx5O78

• Focus areas/congregate settings: 

» Long-term care facilities

› Preparing for COVID-19: Long-term Care Facilities, Nursing Homes: https://www.cdc.gov/coronavirus/

2019-ncov/hcp/long-term-care.html

» Assisted living facilities

› https://www.cdc.gov/coronavirus/2019-ncov/hcp/assisted-living.html

» Dialysis facilities

› https://www.cdc.gov/coronavirus/2019-ncov/hcp/dialysis.html

» Dental facilities

› https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html

» Ambulatory care facilities

› https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html

» Pharmacies

› https://www.cdc.gov/coronavirus/2019-ncov/healthcare-resources/pharmacies.html

» Emergency Medical Services (EMS)

› https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html

» Food processing facilities

› Meat and Poultry Processing Workers and Employers: Interim Guidance from CDC and the Occupational 

Safety and Health Administration (OSHA)

› https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/meat-poultry-processingworkers-employers.html
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» Correctional facilities

› Resources for Correctional and Detention Facilities: https://www.cdc.gov/coronavirus/2019-ncov/

community/correction-detention/guidance-correctional-detention.html.

» Businesses

› Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 

(COVID-19): https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html

› Prepare your Small Business and Employees for the Effects of COVID-19: https://www.cdc.gov/

coronavirus/2019-ncov/community/guidance-small-business.html

• Other IPC tools/Resources:

» IPC FAQs: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html

» Using PPE, including donning & doffing resources: https://www.cdc.gov/coronavirus/2019-ncov/hcp/

using-ppe.html

» Healthcare preparedness tools: https://www.cdc.gov/coronavirus/2019-ncov/hcp/preparedness-checklists.

html

» Strategies to mitigate staffing shortages: https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigatingstaff-shortages.html

» Key strategies to prepare LTCFs: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-carestrategies.html

› LTCF Letter to residents, family members and visitors: https://www.cdc.gov/coronavirus/2019-ncov/

downloads/healthcare-facilities/Long-Term-Care-letter.pdf

» Cleaning and disinfecting school and community facilities: https://www.cdc.gov/coronavirus/2019-ncov/

community/disinfecting-building-facility.html

• Cleaning and disinfecting non-emergency transport vehicles: https://www.cdc.gov/coronavirus/2019-

ncov/community/organizations/disinfecting-transport-vehicles.html

• External partners tools/resources

» Centers for Medicare & Medicaid—COVID partner toolkit—https://www.cms.gov/outreach-education/

partner-resources/coronavirus-covid-19-partner-toolkit

» American College of Emergency Physicians—Field guide—https://www.acep.org/corona/covid-19-fieldguide/cover-page/

» American Academy of Pediatrics—Guidance for Telehealth Payer Policy in Response to Covid-19 

https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/aap-guidance-telehealthpayer-policy-in-response-to-covid-19/

» Society for Critical Care Medicine—COVID-19 Resource Center—Includes literature and training 

https://www.sccm.org/COVID19RapidResources/Home

» Society for Healthcare Epidemiology of America

› COVID-19 Resource Page: http://shea-online.org/index.php/practice-resources/priority-topics/emergingpathogens/novel-coronavirus-2019-2019-ncov-resources

› Hospital epidemiology training—https://learningce.shea-online.org/content/sheacdc-outbreakresponse-training-program-ortp#group-tabs-node-course-default1/index.php

› Rapid Response Program podcast and webinar series https://learningce.shea-online.org/content/novelcoronavirus-covid-19
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» Association for Professionals in Infection Control and Epidemiology

› COVID-19 Page: https://apic.org/covid19/

› LTC text chapters: https://apic.org/resources/apic-text/apic-text-chapter-collection-long-term-care/

» American Medical Association, Resource Center for Physicians—https://www.ama-assn.org/deliveringcare/public-health/covid-19-2019-novel-coronavirus-resource-center-physicians

» American Nurses Association Resource Center—https://www.nursingworld.org/practice-policy/

work-environment/health-safety/disaster-preparedness/coronavirus/?utm_campaign=261605+COVID19+MKT&utm_source=hero&utm_medium=digitalad&utm_content=covidresourcepage

» American Dental Association—COVID-19 Center—https://success.ada.org/en/practice-management/

patients/infectious-diseases-2019-novel-coronavirus?utm_source=cpsorg&utm_medium=covidnav&utm_content=nav-covid-19-center&utm_campaign=covid-19

» Argentum (senior living)—Toolkit—https://www.argentum.org/coronavirustoolkit/

• Critical infrastructure workers 

» Implementing Safety Practices for Critical Infrastructure Workers Who May Have Had Exposure to a Person 

with Suspected or Confirmed COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/community/criticalworkers/implementing-safety-practices.html

» Transportation and Delivery Workers: 

› https://www.cdc.gov/coronavirus/2019-ncov/community/transportation/index.html

» Airport, Airline Workers

› What Airline Customer Service Representatives and Gate Agents Need to Know about COVID-19: 

https://www.cdc.gov/coronavirus/2019-ncov/community/airport-customer-factsheet.html

› What Airport Baggage and Cargo Handlers Need to Know about COVID-19: https://www.cdc.gov/

coronavirus/2019-ncov/community/organizations/airport-baggage-cargo-handlers.html

› What Airport Custodial Staff Need to Know about COVID-19: https://www.cdc.gov/coronavirus/2019-

ncov/community/organizations/airport-custodial-staff.html

› What Airport Passenger Assistance Workers Need to Know about COVID-19: https://www.cdc.gov/

coronavirus/2019-ncov/community/organizations/airport-passenger-assistance-workers.html

› What Aircraft Maintenance Workers Need to Know about COVID-19: https://www.cdc.gov/

coronavirus/2019-ncov/community/organizations/aircraft-maintenance-workers.html

» Other transit workers:

› What Bus Transit Operators Need to Know About COVID-19: https://www.cdc.gov/coronavirus/2019-

ncov/community/organizations/bus-transit-operator.html

› What Rail Transit Operators Need to Know About COVID-19: https://www.cdc.gov/coronavirus/2019-

ncov/community/organizations/rail-transit-operator.html

› What Transit Maintenance Workers Need to Know About COVID-19: https://www.cdc.gov/

coronavirus/2019-ncov/community/organizations/transit-maintenance-worker.html

› What Transit Station Workers Need to Know About COVID-19: https://www.cdc.gov/coronavirus/2019-

ncov/community/organizations/transit-station-workers.html

» Occupational Safety and Health Administration resources

› Control and Prevention: https://www.osha.gov/SLTC/covid-19/controlprevention.html

» Guidance on Preparing Workplaces for COVID-19: https://www.osha.gov/Publications/OSHA3990.pdf
19

• Return to work 

» Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim 

Guidance): https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html

• PPE reuse guidance

» Strategies to Optimize the Supply of PPE and Equipment (including eye protection, isolation 

gowns, facemasks, N95 respirators, elastomeric respirators, and ventilators): https://www.cdc.gov/

coronavirus/2019-ncov/hcp/ppe-strategy/index.html

» Decontamination and Reuse of Filtering Facepiece Respirators: https://www.cdc.gov/coronavirus/2019-

ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

» Personal Protective Equipment (PPE) Burn Rate Calculator: https://www.cdc.gov/coronavirus/2019-ncov/

hcp/ppe-strategy/burn-calculator.html

• Sustainable Isolation

» Interim Infection Control Guidance for Public Health Personnel Evaluating Persons Under Investigation 

(PUIs) and Asymptomatic Close Contacts of Confirmed Cases at Their Home or Non-Home Residential 

Settings at https://www.cdc.gov/coronavirus/2019-ncov/php/guidance-evaluating-pui.html

» Public Health Guidance for Potential COVID-19 Exposure Associated with International Travel or Cruise 

Travel at https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html

» Public Health Recommendations for Community-Related Exposure at https://www.cdc.gov/

coronavirus/2019-ncov/php/public-health-recommendations.html

» Links to programs to support people in isolation: https://www.cdc.gov/coronavirus/2019-ncov/daily-lifecoping/index.html

» Links to housing support for people without safe places for isolation: https://www.cdc.gov/

coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html

» Links to federal programs- unemployment etc.

» www.coronavirus.gov

» https://www.coronavirus.gov/smallbusiness/

» https://www.irs.gov/coronavirus-tax-relief-and-economic-impact-payments

» https://www.usa.gov/unemployment

• Call center for clinical inquiries 24/7 (770-488-7100)

» https://www.cdc.gov/cdc-info/ask-cdc.html

• Others

» NIH COVID-19 Treatment Guidelines: https://www.covid19treatmentguidelines.nih.gov/overview/

» Therapeutic options: https://www.cdc.gov/coronavirus/2019-ncov/hcp/therapeutic-options.html

» Infectious Diseases Society of America Guidelines: https://www.idsociety.org/practice-guideline/covid-19-

guideline-treatment-and-management/

» Information for Pediatric Healthcare Providers: https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatrichcp.html

» Considerations for Inpatient Obstetric Healthcare Settings: https://www.cdc.gov/coronavirus/2019-ncov/

hcp/inpatient-obstetric-healthcare-guidance.html

» Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus 

Disease 2019 (COVID-19): https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html
20

Contact Tracing

• Contact Tracing Overview: https://www.cdc.gov/coronavirus/2019-ncov/php/open-america/contacttracing.html

• Principles of Contact Tracing: Part of a Multipronged Approach to Fight the COVID-19 Pandemic: 

https://www.cdc.gov/coronavirus/2019-ncov/php/principles-contact-tracing.html (also see PDF booklet: 

https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/principles-contact-tracing-booklet.pdf)

• Sample Contact Tracing Training Plan: https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/

contact-tracing-training-plan.pdf

• Digital Contract Tracing Tools for COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/downloads/

digital-contact-tracing.pdf

• Preliminary Criteria for the Evaluation of Digital Contact Tracing Tools for COVID-19: https://www.cdc.gov/

coronavirus/2019-ncov/downloads/php/prelim-eval-criteria-digital-contact-tracing.pdf

• External partners tools/resources

» Association of State and Territorial Health Officials: Making Contact: A Training for COVID-19 Contact 

Tracers Introductory Online Course: https://learn.astho.org/p/ContactTracer

» Johns Hopkins Bloomberg School of Public Health Center for Health Security: Review of Mobile Application Technology to Enhance Contact Tracing Capacity for COVID-19 https://www.centerforhealthsecurity.

org/resources/COVID-19/COVID-19-fact-sheets/200408-contact-tracing-factsheet.pdf

» National Association of County & City Health Officials: Building COVID-19 Contact Tracing Capacity in 

Health Departments to Support Reopening American Society Safely: https://www.naccho.org/uploads/

full-width-images/Contact-Tracing-Statement-4-16-2020.pdf
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Appendix D: Guidance on Test Usage (Asymptomatic Populations and Serology)

Information on testing prioritization can be found here: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/

clinical-criteria.html

Testing asymptomatic populations

Testing of asymptomatic individuals is a growing consideration as the role of asymptomatic and subclinical 

infections in transmission becomes more apparent. Emerging evidence suggests that asymptomatic infections 

may play an important role in the epidemiology of the disease. Nevertheless, it is important to define the 

circumstances where testing asymptomatic persons is likely to be helpful in controlling the COVID-19 pandemic.

Effective testing programs will focus on (1) persons with an increased likelihood of infection and (2) settings with 

particularly vulnerable populations, including but not limited to the following:

• Contacts of known (symptomatic or asymptomatic) cases. This may include testing of contacts going back one 

to two weeks before the onset of symptoms, particularly contacts who work with vulnerable populations.

• Residents and staff of long-term care facilities. Periodic testing and sentinel surveillance in these settings 

may serve to detect outbreaks early in this setting, where devastating outbreaks are known to occur and to 

be associated with high rates of asymptomatic infection. CDC is updating guidance for surveillance in these 

settings https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html.

• Other healthcare facility workers and first responders. Healthcare facilities may consider testing staff periodically, starting with staff in high traffic, high risk areas such as emergency departments.

Serologic testing

Serologic testing currently has little role in the diagnosis of acute disease but is already playing an important role 

in the response to the pandemic. The uses of serologic testing fall into two broad categories: serologic surveillance of populations and serologic testing of individuals for proof-of-prior infection.

Serologic surveillance

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/serology-surveillance/index.html

Serologic surveillance has the potential to provide a more complete picture of how much infection has occurred 

already in the United States. Case-based surveillance for anything with a wide spectrum of severity will always 

miss many cases, and its increasingly clear that a substantial proportion of SARS-CoV-2 infections are asymptomatic. To the degree that SARS-CoV-2 infection results in measurable antibodies, serologic testing will pick up 

any infection.

The purposes of serologic surveillance are the following:

• To provide a more complete estimate of the incidence of infection.

• To determine the proportion of the population that was previously infected.

• To better understand transmission.

• To evaluate the impact of community mitigation measures.

CDC has published its COVID-19 Serology Surveillance Strategy at https://www.cdc.gov/coronavirus/2019-ncov/

covid-data/serology-surveillance/index.html
22

External serosurveys

• CDC will support state, tribal, local, and territorial health authorities to plan and implement serosurveys in 

their populations with known prior exposure. Serial antibody tests, initial and confirmatory, will be used in all 

field studies to ensure enhanced positive predictive values.

Serologic testing of individuals for proof-of-prior infection (immunity)

https://www.cdc.gov/coronavirus/2019-ncov/testing/serology-overview.html

While the lay public often mistakenly refers to this as “serologic surveillance”, it is fundamentally different and is 

at its core a clinical activity designed to guide decisions about specific individuals by determining whether or not 

they are already immune to the infection. Serologic testing may play a role in a back-to-work strategy provided 

it can be shown that serologic testing can reliably infer immunity. This immunity may not need to be absolute: 

protection against severe infection may be enough even if immunity against reinfection isn’t reliable or durable.

While there appears to be considerable public optimism that serologic testing will allow return to work without 

the need for PPE or other precautions, there are many unknowns at this early date that limit implementation of 

serology for this purpose:

• The correlates of immunity to SARS-CoV-2 are not known and there are few or no data to confirm that 

antibodies detected in serologic tests correlate with such immunity. Studies in the US military during 

the 1970s showed that reinfection with endemic coronaviruses occurred in the presence of low levels of 

antibodies. Nonetheless, most experts feel immunity from infection is likely at least in the short term.

• The performance characteristics of serologic assays are not yet known, although there is much work ongoing 

to define those characteristics. Typically, a well-performing single step serologic assay may be expected to 

have a specificity of 95% (sensitivity is a secondary concern here, although also important), which is likely 

not enough for this purpose, given the potential consequences of COVID-19. Combining two different tests 

will be critical for improving performance and should be part of any strategy to utilize serologic testing for 

“immunity” determinations.

• The current seroprevalence is likely to be highly variable. In New York City, for example, with one of the 

highest incidence rates in the country, a recent survey among customers of retail outlets found a seroprevalence of 22%. Preliminary data at CDC from remainder clinical specimens in the New York City area found 

about half that rate; in Western Washington, the preliminary rate was closer to 5%. This has two implications:

• At best, the use of serologic testing for a back-to-work strategy would likely benefit fewer than 10% of the 

population currently.

• In the setting of a relatively low seroprevalence, any serologic test would have to have excellent performance 

characteristics. If a test with 95% specificity were used in a population with a true seroprevalence of 5%, 

almost half all “positives” would be false-positive and not immune and therefore must include 2 serial tests to 

confirm all positive results.

• There is a need for high-level consensus on the role of serologic testing in a back-to-work policy. The stakes 

are high for such a policy, so that in addition to the scientific data, there is also a need to have political 

consensus on this issue. Consensus is also needed on a plan for how to provide documentation of that 

immunity, be it through federal- or state-based immunity registries, digital proof-of-immunity, or physical 

documentation such as “immunity certificates”.
23

Despite these limitations, continued interest in the use of serologic testing in a back-to-work policy is likely.

In the meantime, CDC is doing the following:

• Working with NIH/NCI, FDA, and ASPR on evaluating the first panel of 25 serologic assays. More testing will 

quickly follow these tests.

• Designing studies to track healthcare workers long term to monitor for evidence of reinfection.

• Tracking seroprevalence nationally, as described above.
24

Appendix E: Assessing Surveillance and Hospital Gating Indicators

This document is for use by public health and government officials to aid their decisions when to reopen communities. It describes four indicators specific to disease occurrence and hospital readiness, which form part of the 

“gating criteria” described in the Opening Up America Again guidelines.

Background and Summary

On April 16, 2020, the White House released the Opening Up America Again guideline (https://www.whitehouse.

gov/openingamerica/), which outlines a three-phased approach to relaxing community mitigation measures 

currently in place to limit transmission of the SARS-CoV-2 virus. The purpose of the guideline is to outline a path to 

re-opening the economy while mitigating the risk of resurgence in COVID-19 illnesses and protecting vulnerable 

populations. The phased approach can be implemented on a statewide basis or community-by-community 

at governors' discretion. The guideline proposes the use of three categories of “gating” indicators (based on 

symptoms, based on cases, and for hospitals) to assess when to move through three community mitigation 

phases (Phase One, Phase Two, and Phase Three). Two gating indicators are in each category and include:

• Indicators based on symptoms:

1. Downward trajectory of influenza-like illnesses (ILI syndrome) reported within a 14-day period 

AND

2. Downward trajectory of COVID-like syndromic cases (i.e., COVID-like illness or CLI syndrome) reported 

within a 14-day period

• Indicators based on cases:

3. Downward trajectory of documented COVID-19 cases within a 14-day period

OR

4. Downward trajectory of positive tests as a percent of total tests within a 14-day period (concurrent with 

a flat or increasing volume of tests)

• Indicators for hospital readiness:

5. Capacity to treat all patients without utilization of crisis care standards

AND

6. Robust testing program in place for at-risk healthcare workers, including antibody testing 

The Table at the end of the section summarizes all six indicators and the measures to support planning for 

transitioning through community mitigation phases. Indicators 1 through 4 rely on public health surveillance 

data to determine the trajectory of COVID-19 transmission within a jurisdiction. This document describes 

the measurement and interpretation of these four disease occurrence gating indicators. This document also 

highlights other disease occurrence measures that may be important for state or local jurisdictions to use when 

adjusting the intensity of community mitigation measures. Indicators 5 and 6 utilize hospital readiness measures 

to inform decision-making processes about readiness to move through mitigation phases. In addition to these 

indicators, CDC and CMS work collaboratively to provide guidance for reopening America. Further information 

on reopening of clinical facilities is available at https://www.cms.gov/files/document/covid-flexibility-reopenessential-non-covid-services.pdf.
25

Disease Occurrence Gating Indicators

The following subsections provide further detail for each of the disease occurrence gating indicators outlined 

in the Opening Up America Again guideline, including a description and rationale, potential data sources, how 

to assess decreases (and moving through the three mitigation phases), how to assess increases (i.e., “rebound”), 

and interpreting each measure’s strengths and limitations. Numerous data sources and surveillance systems 

exist at the local, state, and federal levels that can be used to measure and evaluate these indicators. Local and 

state officials should use the best data available, regardless of source, when assessing the trajectory of COVID-19 

illnesses. Variability will exist from jurisdiction to jurisdiction in the quality, completeness, and timeliness of these 

data sources, and sufficient data may not be available for all jurisdictions to evaluate all four of the disease occurrence gating criteria. In situations where all the gating indicators cannot be assessed, additional data sources 

available locally may assist in determining the trajectory of COVID-19 activity in the jurisdiction.

Downward trajectory of ILI reported within a 14-day period 

• Description/Rationale: ILI is a syndromic surveillance categorization applied to emergency department 

(ED) and outpatient visit symptom and diagnostic code data. This measure is intended to identify areas that 

are experiencing sustained decreases in outpatient clinic or ED visits in people with ILI. ILI is defined as fever 

with cough and/or a sore throat. COVID-19 may present with symptoms similar to ILI, so the U.S. Outpatient 

Influenza-like Illness Surveillance Network (ILINet) and the National Syndromic Surveillance Program (NSSP) 

can be used to track COVID-19 trends, especially when paired with SARS-CoV-2 and other respiratory 

pathogen testing data.

• Data Sources: Outpatient care facilities and hospital EDs selected by state and/or local health departments for 

participation in the Outpatient Influenza-Like Illness Network (ILINet) report to CDC either directly or through 

their health department via a web-based reporting system. In addition, electronic data, including data from 

CDC’s NSSP can be uploaded to ILINet. These data are stored in a shared database for use by CDC and state/

local public health officials. States and jurisdictions may collect syndromic surveillance data on ILI locally that 

is not submitted to ILINet but could be used in interpreting the ILI gating indicator. ILINet data is available 

publicly at the state-level at https://www.cdc.gov/flu/weekly/fluviewinteractive.htm.

• Assessing Decreases:

» To pass the criteria of a 14-day downward trajectory in ILI syndromic cases, a locality must either have 

experienced 14 days of decreasing cases or 14 days of minimal ILI activity. To determine a downward 

trajectory, the visits data are assessed using a smoothed curve to account for periodic fluctuations in ILI. To 

calculate this curve, CDC applies a cubic spline, or “smoothed curve”, a statistical method that smooths out 

day-to-day variability in the data. The slope of this curve is used to assess declining incidence. Localities 

must have 14 days of consecutive downward slope, allowing for 2–3-day grace periods of increasing ILI 

to allow for irregularities. It is recommended that localities assess both the total counts of ILI visits and ILI 

visits as a percentage of total ED visits. Statistical coding used by CDC (using the R package) can be shared 

with state and local jurisdictions upon request.

» Normal variation in ILI ED and outpatient visits can affect the assessment of daily trends, especially in 

smaller geographies with low daily visits and by variations in healthcare seeking behavior associated with 

the day of the week, holidays, and current social distancing measures.

» ILI activity levels are traditionally calculated for jurisdictions based on the percent of outpatient visits due 

to ILI in a jurisdiction compared with the average percent of ILI visits that occur during weeks with little or 

no influenza virus circulation in that jurisdiction (i.e., non-influenza weeks), adjusted for the sites contributing data for the week. ILI activity values within two standard deviations of the non-influenza week mean 

are classified as a minimal level of ILI.
26

» Given potential changes in healthcare seeking behaviors resulting from community mitigation measures 

that can significantly affect the denominator of ILI proportions, jurisdictions should analyze within-jurisdiction ILI trends using both the number (count) and proportion of visits to account for this potential bias.

• Mitigation Phase Transitions: All the gating indicators as well as other information available locally should 

be used by jurisdictions when choosing to move through the community mitigation phases. Below is a 

framework for specifically evaluating whether the ILI gating indicator is met with respect to these phase 

transitions.

» Transition into Phase One: achieve 14 consecutive days (or two weeks) of downward trajectory or 

maintaining minimal ILI activity level.

» Transition into Phase Two: achieve an additional 14 consecutive days (or two weeks) of improvement 

(downward trajectory or minimal ILI activity level) without experiencing a rebound (defined below).

» Transition into Phase Three: achieve another 14 consecutive days (or two weeks) of improvement 

(downward trajectory or minimal ILI activity level) without experiencing a rebound (defined below).

• Identifying Rebound: 

» An increase in ILI visits or an increase in ILI activity levels over 5 consecutive days may indicate a potential 

rebound in COVID-19 activity.

• Interpretation/Limitations: 

» ILI is a nonspecific syndromic measure and can be influenced by the circulation of numerous respiratory 

pathogens and should be interpreted in the context of virologic and other surveillance data. For example, 

ILI is expected to fluctuate in the fall and winter due to circulation of seasonal influenza.

» The purpose of ILI surveillance is to detect changes in outpatient visits for febrile respiratory illness. The 

percent of patient visits for ILI can be affected by changes in health care seeking behavior, so jurisdictions 

should look at numbers (counts) of ILI visits in addition to proportions.

» ILI frequency and activity levels within a jurisdiction are influenced by the mix of primary care practice 

types submitting data. These changes make direct comparisons of ILI from one jurisdiction to another 

invalid. Calculation of ILI activity levels allows for more appropriate comparison of ILI between jurisdictions.

Downward trajectory of COVID-like illness (CLI) reported within a 14-day period 

• Description/Rationale: CLI is a syndromic surveillance categorization applied to ED visit symptom and 

diagnostic code data. This measure is intended to identify areas that are experiencing sustained decreases in 

ED visits consistent with the presenting symptoms of COVID-19 illness (fever and either cough, shortness of 

breath, or difficulty breathing) or with a coronavirus diagnostic code that fits CDC interim coding guidelines, 

and without a diagnostic code for influenza (https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-CodingGudance-Interim-Advice-coronavirus-feb-20-2020.pdf). CLI can be used to track COVID-19 trends, especially 

when paired with SARS-CoV-2 and other respiratory pathogen testing data.

• Data Sources: Hospitals report ED visits in near real-time to state and/or local health departments and to 

NSSP. These data are stored within the BioSense Platform where they can be analyzed and exchanged by 

public health officials. States and jurisdictions may collect syndromic surveillance data on CLI locally that is 

not submitted to NSSP but could be useful for interpreting the CLI gating indicator.

• Assessing Decreases: 

» To pass the criteria of a 14-day downward trajectory in CLI syndromic cases, a locality must either 

have experienced 14 days of decreasing cases or exhibit near pre-pandemic levels of CLI. To determine 

a downward trajectory, the visits data are assessed using a smoothed curve to account for periodic 
27

fluctuations in CLI. To calculate this curve, CDC applies the cubic spline as with ILI and described above.

The slope of this curve is used to assess declining incidence. Localities must have 14 days of consecutive 

downward slope, allowing for 2–3-day grace periods of increasing CLI to allow for irregularities. It is 

recommended that localities assess both the total counts of CLI visits and CLI visits as a percentage of 

total ED visits. Statistical coding used by CDC (using the R package) can be shared with state and local 

jurisdictions upon request.

» Normal variation in CLI ED visits affects the assessment of daily trends, especially in smaller geographies 

with low daily visits and by variations in healthcare seeking behavior associated with the day of the week, 

holidays, and current social distancing measures.

• Mitigation Phase Transitions: All the gating indicators as well as other information available locally should 

be used by jurisdictions when choosing to move through the community mitigation phases. Below is a 

framework for specifically evaluating whether the CLI gating indicator is met with respect to these phase 

transitions.

» Transition into Phase One: achieve 14 consecutive days of improvement (downward trajectory or near 

pre-pandemic CLI ED visits).

» Transition into Phase Two: achieve an additional 14 consecutive days of improvement (downward trajectory 

or near pre-pandemic CLI ED visits) without experiencing a rebound (defined below).

» Transition into Phase Three: achieve another 14 consecutive days of improvement (downward trajectory or 

near pre- pandemic CLI ED visits) without experiencing a rebound (defined below).

• Identifying Rebound: Two primary methods can be used to help assess for a rebound in CLI ED visits.

» Within NSSP, daily statistical anomaly detection methods are automatically applied to time series trends, 

and anomalous increases are flagged for further epidemiologic investigation. Multiple consecutive days 

of anomalies may be an indicator of increases in COVID-19 activity and could be used to focus additional 

testing of patients.

» Regression methods (e.g., binomial regression) can be used to classify time series trends in the last 15 days 

to detect 5-day periods of significant increase in patients being seen with CLI and can also be used to focus 

additional investigations and/or confirmatory testing.

• Interpretation/Limitations: 

» The purpose of syndromic surveillance is to find timely, more automated, indicators of a change in patterns 

of illness or health seeking behaviors in a community than is possible with case reporting. Syndromic 

data can initiate further confirmatory investigation. CLI is a non-specific syndromic measure and could be 

influenced by the circulation of other respiratory pathogens.

» The timeliest element of ED records is the patient chief complaint text describing their symptoms. The CLI 

syndrome is based in part on the patient’s chief complaint at presentation to the ED, which may or may not 

actually be COVID-19, but also includes visits that were assigned a COVID-19 diagnosis code.

» The data quality and completeness of chief complaint text and diagnostic codes can vary by reporting 

hospital and can affect the assessment of trends over time.

» In general, syndromic categorizations emphasize timeliness and sensitivity over specificity. As such, the 

CLI gating indictor may exhibit changes earlier than other indicators but may also include visits for other 

illnesses that have similar symptoms as COVID-19 (e.g., infections with other respiratory viruses). Interpretation of CLI data should always be considered in conjunction with other data and the local context. Data 

that track the presence of other respiratory illnesses (e.g., respiratory syncytial virus and influenza) circulating within the community may help in assessing whether CLI is due to the virus that causes COVID-19 or 

other viruses.
28

Downward trajectory of documented (confirmed and probable) cases within a 14-day period

• Description/Rationale: On April 5, 2020, the Council of State and Territorial Epidemiologists (CSTE) issued 

an interim COVID-19 position statement making COVID-19 a nationally notifiable disease and establishing 

confirmed and probable case definitions (www.cste.org/resource/resmgr/2020ps/interim-20-id-01_covid-19.

pdf). The case report gating indicator is intended to identify communities experiencing sustained decreases 

in the number of new cases occurring each day, an indication of decreases in disease transmission.

• Data Sources: Case report information for confirmed and probable cases collected by state and local 

jurisdictions and submitted to CDC; publicly available aggregated case count data (e.g., USAFacts: 

https://usafacts.org/visualizations/coronavirus-covid-19-spread-map/); US Census population estimates 

(used as denominator for incidence calculations)

• Assessing criteria for reduction in number of cases: To pass this criterion, a locality must either 1) have 

experienced 14 days of decreasing cases or 2) be in a low-incidence plateau. A locality that has a new 

outbreak or rebound cannot advance to the next phase unless they see another 14 days of decline.

• Defining 14 days of decreasing cases: To assess a downward trajectory, CDC uses a 3-day rolling average 

and applies a spline curve (described above). A period of 14 days of declining cases occurs when fewer cases 

are reported at the end of the 14 days compared with the number at the beginning of the period, using the 

3-day rolling average fitted with the spline curve to define the number of cases. In addition, a “grace period” 

of 5 days may be applied during a downward trajectory, during which cases may increase for no more than 

5 consecutive days. (If 5 days of consecutive increase occur, then the jurisdiction has met the criteria for 

rebound and is no longer in a downward trajectory.) Statistical coding used by CDC (using the R package) can 

be shared with state and local jurisdictions upon request.

• Defining a low incidence plateau

» A low-incidence plateau is defined as a very low number of new cases reported (below 10 cases per 

100,000 population over 2 weeks) with only minimal change in daily cases.

» To qualify for this category, a locality must previously have seen elevated case counts.

• Mitigation Phase Transitions: All the gating indicators as well as other information available locally should 

be used by jurisdictions when choosing to move through the community mitigation phases. Below is a 

framework for specifically evaluating whether the case report gating indicator is met with respect to these 

phase transitions. Note that the Opening Up America Again guideline specifies that either the case report 

gating indictor or the percent positive gating indicator should be met.

» Transition into Phase One: achieve 14 consecutive days of improvement (downward trajectory or near-zero 

incidence).

» Transition into Phase Two: achieve an additional 14 consecutive days of improvement (downward trajectory 

or near-zero incidence) without experiencing a rebound (defined below).

» Transition into Phase Three: achieve another 14 consecutive days of improvement (downward trajectory or 

near-zero incidence) without experiencing a rebound (defined below).

• Defining rebound

» A rebound occurs when the smoothed, 3-day average of case counts exhibits an increase over a 5 consecutive day period, following a downward trajectory of 14 or more days, including any grace period applied.
29

• Interpretation/Limitations:

» Case report data are a lagging indicator for assessing SARS-CoV-2 transmission in the community, as new 

cases are not identified until after the incubation period occurs, the ill person seeks testing or healthcare for 

their illness, and the information is reported to health officials.

» The choice of the dates used (e.g., onset date, report date) is critical in the interpretation of observed 

trends. If available, onset date is preferred because it improves timeliness of trend interpretation. However, 

because date of report is more likely to be available than date of illness onset, it is more frequently the date 

used to calculate trends. Whatever date is used, the assessment must account for the fact that very recent 

cases will not have been reported. Excluding recent onset dates or report dates (e.g., in the last 3 days or 

last week if onset dates are used) from assessment of trends should be considered to ensure that incomplete reporting of recent cases does not give the false appearance of downward trajectory.

» CDC analyses are typically based on the date of case report and not diagnosis or onset date because it 

is the most uniformly available date across jurisdictions. Preliminary analyses of national data show that 

there is typically an 8- to 10-day lag between the date of symptom onset and the date the case is reported 

to CDC, but this varies by jurisdiction.

» A sustained downward trajectory demonstrates improvement in daily case incidence but does not 

necessarily equate to a low disease burden. Communities should consider local resource capacity (e.g., 

availability of public health staff to conduct contact tracing) when determining appropriate incidence 

thresholds for making phase transition decisions.

Downward trajectory of positive tests as a percent of total tests within a 14-day period with stable or increasing test volume

• Description/Rationale: Laboratory test percent positive can be used in combination with, or as an alternative 

to, observing a decline in new case reports. In circumstances where testing is adequate and testing practices 

are largely stable, percent positive may be a reliable indicator of COVID-19 activity.

• Data Sources: Positive and negative SARS-CoV-2 test results reported by laboratories to state health departments. Data from the Census Bureau’s Population Estimates Program can be used to estimate state and county 

population denominators for per-capita test rates.

• Assessing Decreases: 

» Percent positive is calculated as the number of positive tests divided by the total test results, with total 

test results defined as the sum of positive tests and negative tests, excluding records where the test was 

not performed because the specimen was not usable or the test was cancelled. The number of tests with 

indeterminate results has been small, so not including these in the denominator of total test results should 

not affect interpretation of the trends observed.

» A jurisdiction must see a 14-day downward trajectory in percent positive (or near-zero percent positive) 

with up to 2–3 consecutive days of increasing or stable percent positive allowed as a grace period if data 

are inconsistent, while total test volume is stable or increasing.

» Methods to assess decreases in laboratory test positivity are similar to those used to assess decreases in ILI 

and CLI.

• Mitigation Phase Transitions: All the gating indicators as well as other information available locally should 

be used by jurisdictions when choosing to move through the community mitigation phases. Below is a 

framework for specifically evaluating whether the percent positive gating indicator is met with respect to 

these phase transitions. Note that in the Opening Up America Again guideline, the case report gating indictor 

or the percent positive gating indicator should be met.

» Transition into Phase One: achieve 14 or more consecutive days of decline in percent positive (or near-zero 

percent positive) while total test volume is stable or increasing.
30

» Transition into Phase Two: achieve an additional 14 or more consecutive days of decline in percent positive 

(or near-zero percent positive) while total test volume is stable or increasing.

» Transition into Phase Three: achieve an additional 14 or more consecutive days of decline in percent 

positive (or near-zero percent positive) while total test volume is stable or increasing.

» If a near-zero plateau has been reached, can meet if plateau is maintained over 14 consecutive days 

(2–3-day grace period)

• Identifying Rebound: Multi-day increases in percent positivity with stable or increasing testing volume 

should be assessed along with case report and CLI data to identify rebounds.

• Interpretation/Limitations: 

» The daily percent positive may fluctuate, particularly in areas with smaller populations. Total test volume 

may also vary by day of the week, based on the number of tests ordered or regular system maintenance at 

laboratories.

» The percent positive is driven by the number of people who are positive in a community and the number 

of people who are tested. Declines in percent positive may result from an expansion of testing to more 

people. Thus, it is important to track percent positive in combination with the number tested, whether 

measured as the total volume of all test results, or as total test results per capita. Percent positivity should 

only be used as an indicator of COVID-19 activity when per capita testing levels are stable over the time 

period being assessed.

» The percent positive may also be affected by a changing proportion of tests in people who are less likely 

to be infected, such as those who are asymptomatic or who have less severe symptoms. Few laboratories 

have fields indicating whether the person tested was asymptomatic or whether the patient was in an 

inpatient or outpatient setting at the time of testing. However, communities can stratify by data source to 

assess changes in the population tested over time, such as tracking the percent positive in hospital data 

separately from the percent positive in large commercial laboratories.

» The residence of the person tested may not be validated as thoroughly in laboratory data as in case data.

Patient zip code may be based on insurance billing data, and thus less likely to be complete and correct 

when the person tested is uninsured or on another family member’s plan.

» Provider zip code is generally accurate, when available. However, drive-up facilities might use a central zip 

code that does not reflect where the physical drive-up facility is located.

Joint interpretation of all four disease occurrence gating criteria

The four disease occurrence gating indicators should be interpreted collectively to reach a determination on the 

trajectory of COVID-19 activity within a jurisdiction, bearing in mind that the measures differ significantly in their 

lag, specificity, and sensitivity. Lab testing and syndromic data sources generally have less lag than COVID-19 

case report data relative to when transmission occurred. SARS-CoV-2 testing and COVID-19 case reports are more 

specific measures of COVID-19 activity than the CLI syndrome, but all three are likely far more specific than the 

ILI syndrome. The CLI syndrome likely has superior sensitivity to the other measures, as it is more likely to capture 

people with COVID-19 that were not tested. While downward trajectory for a period of 14 days is used for each 

of the disease occurrence gating indicators in the Opening Up America Again guideline, state and local jurisdictions should use judgment based on their knowledge of local disease surveillance practices and infrastructure in 

determining whether longer time periods (e.g., 21 or 28 days) are needed before moving to different community 

mitigation phases.
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Other Data Sources and Measures

The four disease occurrence gating indicators above provide insight into both the intensity and trajectory of the 

COVID-19 pandemic within jurisdictions. In addition, other epidemiologic data sources are available to local, 

state, and federal health officials and can be used to confirm trends observed in the disease occurrence gating 

indicators.

• COVID-19 hospital admissions: Depending on the overall COVID-19 incidence rate, the size of the jurisdiction, and the regional hospital referral patterns, hospitalizations for laboratory-confirmed COVID-19 can 

be an important measure to assess trajectory. Testing is likely more complete and less variable in hospitalized 

populations, providing more assurance that observed trends are not driven by testing practices. In addition 

to helping verify increases or decreases in the disease occurrence gating indicators, monitoring COVID-19 

hospital admissions (and discharges) can help assess the burden on local healthcare capacity.

• COVID-19 deaths: Depending on the overall COVID-19 incidence rate and the size of the jurisdiction, deaths 

due to COVID-19 may occur in high enough numbers to reliably assess the trajectory of the outbreak in the 

jurisdiction. Although they represent a small proportion of all COVID-19 illnesses and significantly lag the 

core disease occurrence gating indicators, vital records are a universally collected data source and should 

be available for review in all jurisdictions. Further, observing declines in newly reported COVID-19 deaths 

almost certainly indicates that demands on the healthcare system are waning. Care should be taken to 

understand the extent and variability in SARS-CoV-2 testing for deceased individuals in the jurisdiction when 

using death as a source of data to understand the overall trajectory of COVID-19 illnesses in the jurisdiction.

COVID-19 death data reported to CDC’s National Center for Health Statistics are published weekly by state 

(https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm).

• Measures of trajectory: The effective reproductive number (the average number of secondary cases from an 

infectious case in an a particular population at a specific point in time) and doubling time (the time required 

for the number of cases to double) are epidemiologic measures that can be used to characterize the speed 

with which illnesses are spreading in an outbreak. Although these measures can be imprecise, especially 

when calculated within smaller populations, they provide alternative ways to analyze and characterize the 

trajectory of COVID-19 activity.

Implied in the Core State Preparedness Responsibilities in the Opening Up America Again guideline is the need 

for jurisdictions to have confidence in the epidemiologic data being used to make assessments about the 

magnitude and trajectory of COVID-19 illnesses. In order for most of the gating indicators to be reliably assessed, 

1) rapid testing should be occurring as indicated for all clinical, public health, and infection prevention needs and 

2) all new symptomatic COVID-19 cases in the jurisdiction should be able to be rapidly identified through active 

surveillance of laboratories and healthcare facilities. In the absence of widespread testing and robust active 

surveillance, jurisdictions should be cautious when adjusting mitigation strategies based on the disease occurrence gating indicators. Several measures, listed below, can be helpful in providing an indirect assessment of the 

completeness of case ascertainment in a jurisdiction.

• COVID-19 case-fatality ratio: Case-fatality is defined as the proportion of COVID-19 cases result in death.

Although estimates of the percentage of symptomatic COVID-19 illnesses that result in death has varied 

widely, the overall percentage is likely lower than 1–2%. Although many factors contribute to disease 

severity, including the underlying health status of the population, jurisdictions that have very high COVID-19 

case-fatality ratios (above 5–10%) may be under-ascertaining COVID-19 illnesses. This could indicate that 

case reporting is an unreliable measure of true COVID-19 activity. In this situation it may be useful to examine 

measures for CLI syndrome or COVID-19 hospital admissions as measures of disease activity.
32

• High percent positive: Although changes in percent positive is an indicator in the Opening Up America Again 

guideline, very high proportions of SARS-CoV-2 positivity (e.g., >25%) may be an indicator that testing levels 

are not adequate and that COVID-19 illnesses are being under-ascertained in the jurisdiction, as it suggests 

that only a limited number of people with a high likelihood of being infected with SARS-CoV-2 are able to be 

tested. In this situation it also may useful to look at the CLI syndrome or at COVID-19 hospital admissions as 

measures of disease activity, since they are likely less susceptible to the influence of testing availability.

• Per capita testing: It is difficult to determine a widely applicable benchmark for a per capita level of 

SARS-CoV-2 testing that is sufficient to have confidence in the adequacy of COVID-19 case-ascertainment.

However, jurisdictions can consider evaluating their per capita testing to assist in judging whether testing 

levels are adequate for effective COVID-19 surveillance.

• Proportion of cases with an unknown source: Improvements in case ascertainment and contact tracing should 

lead to a lower proportion of new cases with an unknown exposure to SARS-CoV-2. Jurisdictions can consider 

tracking the proportion of new COVID-19 cases without a documented exposure source (e.g., travel to a highincidence region or country, exposure to someone with a confirmed case of COVID-19, attending and event or 

going to a setting with suspected SARS-CoV-2 transmission). Although difficult to achieve, jurisdictions that 

have fewer than 50% of new cases with an unknown exposure source likely have likely achieved high levels of 

case ascertainment, interviewing, and contact tracing.

Hospital Indicators

Capacity to treat all patients without crisis care

• Description/Rationale: Capacity indicators, including percentage of inpatients and ICU beds occupied and 

PPE supplies, help identify areas where additional healthcare capacity needs may exist now or in the future.

• Data sources: Data within HHS Protect, including from CDC’s National Healthcare Safety Network (NHSN) (a 

healthcare infection associated tracking system), provide information on inpatient and ICU bed occupancy, 

staffing shortages, and PPE supplies.

• Assessing indicator: All three measures of treating patients without crisis care should be met before a jurisdiction moves to the next community mitigation phase.

• Mitigation Phase Transitions: All the gating indicators as well as other information available locally should 

be used by jurisdictions when choosing to move through the community mitigation phases. Below is a 

framework for specifically evaluating whether the hospital indicators are met with respect to these phase 

transitions.

» Transition into Phase One: Inpatient and ICU beds <80% full for 7 consecutive days AND no staff shortages 

for 7 consecutive days AND PPE supplies adequate and available for >4 days.

» Transition into Phase Two: Inpatient and ICU beds <75% full for 7 consecutive days AND no staff shortages 

for 7 consecutive days AND PPE supplies adequate and available for >4 days.

» Transition into Phase Three: Inpatient and ICU beds <70% full for 7 consecutive days AND no staff shortages 

for 7 consecutive days AND PPE supplies adequate and available for >15 days.

• Interpretation/Limitations:

» Hospitals within the same jurisdiction may be at different stages with regard to these measures. Public 

health officials should assess the status of the jurisdiction’s hospital capacity overall and consider whether 

resources (e.g., clinical staff, PPE) could be re-allocated to address differential needs.
33

Robust testing program

• Description/Rationale: 

» The percentage of positive diagnostic tests for SARS-CoV-2 can be used as an indirect measure of 

agreement between testing demand and test availability. A target frequency of negative tests (e.g., 80% 

negative) must be established as an indicator of “adequate” availability of tests. This threshold can then be 

used to monitor for regional shortages and target distribution of testing resources to areas with greatest 

need.

» Timeliness of results is another measure of laboratory testing capacity, and prompt results are essential for 

effective contact tracing.

• Data sources: Positive and negative SARS-CoV-2 test results reported by laboratories to state health departments. Median time between test order and results can be calculated from the reported laboratory data.

• Assessing indicator: Both criteria for a robust testing program should be met before a jurisdiction moves 

to the next community mitigation phase. The metric for percentage positive tests can be assessed as the 

percentage of positive of viral tests among all tests with a result for 14 consecutive days. An alternative 

would be to have daily percent positive below the phase transition threshold for 14 consecutive days.

• Mitigation Phase Transitions: All the gating indicators as well as other information available locally should 

be used by jurisdictions when choosing to move through the community mitigation phases. Below is a 

framework for specifically evaluating whether the indicators for a robust testing program are met with 

respect to these phase transitions.

» Transition into Phase One: Percentage positive tests ≤20% for 14 days AND median time from test order to 

result <4 days.

» Transition into Phase Two: Percentage positive tests ≤15% for 14 days AND median time from test order to 

result <3 days.

» Transition into Phase Three: Percentage positive tests ≤10% for 14 days AND median time from test order to 

result <2 days.

• Interpretation/Limitations:

» This indicator refers to tests for current infection (e.g., nucleic acid (PCR) or antigen tests). Serology (i.e., 

antibody) testing metrics should not be used for this indicator.

» Lags in test reporting may lead to incomplete data for calculating percent positive tests for the most recent 

few days. Jurisdictions should calculate percent positive for the most recent 14 days with near-complete 

testing data.

Additional Considerations

Overall Incidence Level

The disease occurrence gating indicators all pertain to assessing the trajectory of COVID-19 activity, but do not 

specify that COVID-19 incidence should reach an absolute level to move through the mitigation phases. Jurisdictions should be cautious in pivoting from a general community mitigation approach back toward an identification 

and containment approach until incidence is low enough and resources adequate to 1) attempt an initial 

interview for nearly all new COVID-19 cases within one day of health department notification, 2) to rapidly isolate 

all newly identified COVID-19 cases, and 3) to initiate appropriate follow up (isolation, self-monitoring, and rapid 

testing of symptomatic contacts) for nearly all identified contacts of newly identified cases. Incidence should 

also be low enough that health departments can respond to large outbreaks (e.g., nursing home outbreaks) 
34

that require substantial resources to investigate and control. Declines in incidence should also be enough for 

healthcare capacity to not only meet current demands, but to be able to comfortably surge in the event of an 

increase in cases (e.g., availability of acute care beds, critical care beds, ventilators, and adequate PPE).

Special Populations and Settings

Infections in high-risk settings and populations can disproportionately impact localized transmission and the 

ability of public health capacity to keep pace with follow up needs such as contract tracing and screening. Efforts 

should be taken to monitor infections in some specific populations and settings, including but not limited to 

healthcare personnel, patients in healthcare facilities (e.g., nursing homes, dialysis centers, long term care facilities), and residents of congregate living settings (e.g., prisons, youth homes, shelters). In addition, identification 

of illnesses at work places (e.g., meat and poultry processing facilities) or events with the potential for “explosive 

spread” (e.g., mass gatherings) may warrant adjustment of community mitigation measures in the absence of 

community-wide changes in the disease occurrence gating indicators.

Neighboring Jurisdictions

When making decisions about adjusting community mitigation measures, state and local jurisdictions also 

should coordinate with officials in neighboring areas to assess the burden and trajectory of COVID-19 illnesses 

in the surrounding region. Neighboring or nearby jurisdictions with significantly higher incidence or with 

increasing COVID-19 activity could reintroduce SARS-CoV-2 to a jurisdiction, jeopardizing improvements within 

the jurisdiction.

Measures of Mobility and Social Distancing

If available, it may be important to understand the knowledge, attitudes and behaviors of the community as it 

relates to the public health guidance provided within the local jurisdiction. Survey data and data on mobility 

can be useful in understanding if community members are aware of and following established social distancing 

and isolation guidelines and informing changes in the mitigation strategies used. Several publicly available data 

sources currently exist that generate measures of social distancing and mobility, frequently based on mobile 

phone location services or social media data.

Summary

The disease occurrence gating indicators in the Opening Up America Again guideline provide states and communities insight into the trajectory of the COVID-19 pandemic in their jurisdiction. The disease occurrence gating 

indicators should be evaluated collectively, considering their relative strengths and weaknesses, in the context 

of other epidemiologic data available for the jurisdiction. The hospital indicators are designed to help decision 

makers understand the health system’s ability to handle a potential surge in cases. These indicators are part 

of the broad assessment jurisdictions should undertake when deciding when and how to adjust community 

mitigation strategies for COVID-19.
35

Table 5. Gating Criteria Summary

Gating Criteria Threshold for entering

Phase 1

Threshold for entering

Phase 2

Threshold for entering

Phase 3

Decreases in ED and/

or outpatient visits for 

influenza-like illness (ILI)

Decreases in ED and/or 

outpatient visits for COVIDlike illness (CLI)

Downward trajectory of ILI/

CLI (or minimal ILI activity or 

near pre-pandemic level of 

CLI ED visits) reported over a 

14-day period

• Uses a 3-day average in a 

cubic smoothing spline 

• 14 consecutive days 

of decline required 

but can use a 2–3 day 

grace period if data are 

inconsistent 

• Look at both total 

visits for ILI/CLI and 

percentage of visits for 

ILI/CLI

• 14th day must be lower 

than 1st day

• If near pre-pandemic 

level of CLI ED visits has 

been reached, can meet 

if pre-pandemic level 

is maintained over 14 

consecutive days (2–3 

day grace period)

Downward trajectory of ILI/

CLI (or minimal ILI activity 

or near pre-pandemic level 

of CLI ED visits) reported 

for at least 14 days after 

entering Phase 1 without 

experiencing a rebound

• Same criteria but for a 

second 14-day period

• Rebound is determined 

if the trajectory increases 

in a 5-day period

Downward trajectory of ILI/

CLI (or minimal ILI activity 

or near pre-pandemic level 

of CLI ED visits) reported 

for at least an additional 14 

days after entering Phase 

2 without experiencing a 

rebound

• Same criteria but for a 

second 14-day period

• Rebound is determine if 

the trajectory increases 

in a 5-day period

Continued on the next page 
36

Gating Criteria Threshold for entering

Phase 1

Threshold for entering

Phase 2

Threshold for entering

Phase 3

Decreases in newly 

identified COVID-19 cases

Downward trajectory 

(or near-zero incidence) of 

documented cases over a 

14-day period

• Uses a 3-day average in a 

cubic smoothing spline 

• 14 consecutive days of 

decline required but 

can use up to a 5-day 

grace period if data are 

inconsistent 

• 14th day must be lower 

than 1st day

• To be near-zero 

incidence, must have 

fewer than 10 cases per 

100k population over 

14 days) and must have 

previously had elevated 

cases 

Downward trajectory 

(or near-zero incidence) of 

documented cases for at 

least 14 days after entering 

Phase 1

• Same criteria as Phase 1 

for another 14 days

• Rebound is defined as 

having 5 consecutive 

days of increase

Downward trajectory 

(or near-zero incidence) of 

documented cases for at 

least 14 days after entering 

Phase 2

• Same criteria as Phase 2 

for another 14 days

• Rebound is defined as 

having 5 consecutive 

days of increase

Decreases in newly 

identified COVID-19 cases

Downward trajectory (or 

near-zero incidence) of 

documented cases over a 

14-day period

• Uses a 3-day average in a 

cubic smoothing spline 

• 14 consecutive days of 

decline required but 

can use up to a 5-day 

grace period if data are 

inconsistent 

• 14th day must be lower 

than 1st day

• To be near-zero 

incidence, must have 

fewer than 10 cases per 

100k population over 

14 days) and must have 

previously had elevated 

cases

Downward trajectory (or 

near-zero percent positive) 

of positive tests as a 

percent of total tests for 14 

days after entering Phase 1 

(flat or increasing volume 

of tests)

• Same criteria as Phase 1 

for another 14 days

• Rebound is defined 

as having multi-day 

increases in percent 

positivity with stable 

or increasing testing 

volume.

• Look at positive results 

and cases when 

assessing for rebound

Downward trajectory (or 

near-zero percent positive) 

of positive tests as a 

percent of total tests for at 

least 14 days after entering 

Phase 2 (flat or increasing 

volume of tests)

• Same criteria as Phase 1 

for another 14 days

• Rebound is defined 

as having multi-day 

increases in percent 

positivity with stable 

or increasing testing 

volume.

• Look at positive results 

and cases when 

assessing for rebound

Continued on the next page 
37

Gating Criteria Threshold for entering

Phase 1

Threshold for entering

Phase 2

Threshold for entering

Phase 3

Decreases in percentage of 

SARS-CoV-2 tests positive 

Downward trajectory 

(or near-zero percent 

positive) of positive tests 

as a percent of total tests 

over a 14-day period (flat or 

increasing volume of tests)

• Divide total positive 

results by total positive + 

negative 

• Remove incomplete and 

inconclusive results

• 14 consecutive days of 

downward trend with up 

to 2–3 consecutive days 

of a grace period due to 

data inconsistency 

• 14th day must be lower 

than 1st day

• If a near-zero plateau has 

been reached, can meet 

if plateau is maintained 

over 14 consecutive days 

(2–3 day grace period)

• Test volume must remain 

the same or be increasing 

to use this criterion

• Should include all test 

results from all labs

Downward trajectory 

(or near-zero percent 

positive) of positive tests 

as a percent of total tests 

for 14 days after entering 

Phase 1 (flat or increasing 

volume of tests)

• Same criteria as Phase 1 

for another 14 days

• Rebound is defined 

as having multi-day 

increases in percent 

positivity with stable 

or increasing testing 

volume.

• Look at positive results 

and cases when 

assessing for rebound

Downward trajectory 

(or near-zero percent 

positive) of positive tests 

as a percent of total tests 

for at least 14 days after 

entering Phase 2 (flat or 

increasing volume of tests)

• Same criteria as Phase 1 

for another 14 days

• Rebound is defined 

as having multi-day 

increases in percent 

positivity with stable 

or increasing testing 

volume.

• Look at positive results 

and cases when 

assessing for rebound

Treat all patients without 

crisis care

Jurisdiction inpatient & ICU 

beds <80% full 

Staff shortage in last week 

= no

PPE supplies adequate for 

>4 days

Jurisdiction inpatient & ICU 

beds <75% full 

Staff shortage in last week 

= no

PPE supplies adequate for 

>4 days

Jurisdiction inpatient & ICU 

beds <70% full

Staff shortage in last week 

= no

PPE supplies adequate for 

>15 days

Robust testing program Test availability such that % 

positive tests <20% for 14 

days

Median time from test order 

to result <4 days 

Test availability such that % 

positive tests <15% for 14 

days

Median time from test order 

to result <3 days

Test availability such that % 

positive tests <10% for 14 

days

Median time from test order 

to result <2 days
38

Appendix F: Setting Specific Guidance

CDC offers this interim guidance to assist establishments as they open. CDC will update this guidance as it learns 

more about COVID-19 and best practices to prevent its spread.

This guidance is meant to supplement the decision tools CDC released on May 14, 2020. It lists specific practices 

that employers may find helpful at particular stages of the COVID-19 outbreak. This guidance sets forth a menu of 

safety measures, from which establishments may choose those that make sense for them in the context of their 

operations and local community, as well as state and local regulations and directives.

INTERIM GUIDANCE FOR CHILD CARE PROGRAMS 

The gradual scale up of activities towards pre-COVID-19 operating practices at childcare programs is crucial to 

helping parents and guardians return to work. Many states have closed schools for the academic year and, with 

summer quickly approaching, an increasing number of working parents may need to rely on these programs.

CDC’s Interim Guidance for Administrators of US K-12 Schools and Child Care Programs and supplemental 

Guidance for Child Care Programs that Remain Open provide recommendations for operating childcare programs 

in low, moderate, and significant mitigation communities. In communities that are deemed significant mitigation 

areas by state and local authorities, childcare programs should be closed. However, childcare programs can 

choose to remain open to serve children of essential workers, such as healthcare workers. All decisions about 

following these recommendations should be made locally, in collaboration with local health officials who can 

help determine levels of COVID-19 community transmission and the capacities of the local public health system 

and healthcare systems. CDC is releasing this interim guidance, laid out in a series of three steps, to inform a 

gradual scale up of operations. The scope and nature of community mitigation suggested decreases from Step 1 

to Step 3. Some amount of community mitigation is necessary across all steps until a vaccine or therapeutic drug 

becomes widely available.

Scaling Up Operations

• In all Steps:

» Establish and maintain communication with local and State authorities to determine current mitigation 

levels in your community.

» Protect and support staff, children, and their family members who are at higher risk for severe illness.

» Provide staff from higher transmission areas (earlier Step areas) telework and other options as feasible to 

eliminate travel to childcare programs in lower transmission (later Step) areas and vice versa.

» Follow CDC’s supplemental Guidance for Child Care Programs that Remain Open.

» Encourage any other community groups or organizations that use the childcare facilities also follow this 

guidance.

• Step 1: Restrict to children of essential workers.

• Step 2: Expand to all children with enhanced social distancing measures.

• Step 3: Remain open for all children with social distancing measures.
39

Safety Actions

Promote healthy hygiene practices (Steps 1–3)

• Teach and reinforce washing hands and covering coughs and sneezes among children and staff.

• Teach and reinforce use of cloth face coverings among all staff. Face coverings are most essential at times 

when social distancing is not possible. Staff should be frequently reminded not to touch the face covering 

and to wash their hands frequently. Information should be provided to all staff on proper use, removal, and 

washing of cloth face coverings.

• Have adequate supplies to support healthy hygiene behaviors, including soap, hand sanitizer with at least 60 

percent alcohol (for staff and older children who can safely use hand sanitizer), paper towels, and tissues.

• Post signs on how to stop the spread of COVID-19, properly wash hands, promote everyday protective 

measures, and properly wear a face covering.

Intensify cleaning, disinfection, and ventilation (Steps 1–3)

• Clean, sanitize, and disinfect frequently touched surfaces (for example, playground equipment, door handles, 

sink handles, drinking fountains) multiple times per day and shared objects between use.

• Avoid use of items (for example, soft or plush toys) that are not easily cleaned, sanitized, or disinfected.

• Ensure safe and correct application of disinfectants and keep products away from children.

• Ensure that ventilation systems operate properly and increase circulation of outdoor air as much as possible 

such as by opening windows and doors. Do not open windows and doors if doing so poses a safety or health 

risk (for example, allowing pollens in or exacerbating asthma symptoms) to children using the facility.

• Take steps to ensure that all water systems and features (for example, drinking fountains or decorative 

fountains) are safe to use after a prolonged facility shutdown to minimize the risk of Legionnaires’ disease and 

other diseases associated with water.

Promote social distancing

• Steps 1 and 2

» Ensure that classes include the same group of children each day and that the same childcare providers 

remain with the same group each day, if possible.

» Restrict mixing between groups.

» Cancel all field trips, inter-group events, and extracurricular activities (Step 1).

» Limit gatherings, events, and extracurricular activities to those that can maintain social distancing, support 

proper hand hygiene, and restrict attendance of those from higher transmission areas (Step 2; Note: 

restricting attendance from those in Step 1 areas).

» Restrict nonessential visitors, volunteers, and activities involving other groups at the same time.

» Space out seating and bedding (head-to-toe positioning) to 6 feet apart if possible.

» Close communal use spaces, such as game rooms or dining halls, if possible; if this is not possible, stagger 

use and disinfect in between uses.

» If a cafeteria or group dining room is typically used, serve meals in classrooms instead. Put each child’s meal 

on a plate, to limit the use of shared serving utensils and ensure the safety of children with food allergies.

» Stagger arrival and drop-off times or put in place other protocols to limit direct contact with parents as 

much as possible.
40

• Step 3

» Consider keeping classes together to include the same group of children each day, and consider keeping 

the same childcare providers with the same group each day.

» Allow minimal mixing between groups. Limit gatherings, events, and extracurricular activities to those that 

can maintain social distancing, support proper hand hygiene, and restrict attendance of those from higher 

transmission areas (Step 1 or 2 areas).

» Continue to space out seating and bedding (head-to-toe positioning) to 6 feet apart, if possible.

» Consider keeping communal use spaces closed, such as game rooms, playgrounds, or dining halls, if 

possible; if this is not possible, stagger use and disinfect in between uses.

» Consider continuing to plate each child’s meal, to limit the use of shared serving utensils and ensure the 

safety of children with food allergies.

» Consider limiting nonessential visitors, volunteers, and activities involving other groups. Restrict attendance of those from higher transmission areas (Step 1 or 2 areas).

» Consider staggering arrival and drop-off times or putting in place other protocols to limit close contact 

with parents or caregivers as much as possible.

• Limit sharing (Steps 1–3)

» Keep each child’s belongings separated and in individually labeled storage containers, cubbies, or areas 

and taken home each day and cleaned, if possible.

» Ensure adequate supplies to minimize sharing of high-touch materials to the extent possible (art supplies, 

equipment etc. assigned to a single child) or limit use of supplies and equipment by one group of children 

at a time and clean and disinfect between use.

» If food is offered at any event, have pre-packaged boxes or bags for each attendee instead of a buffet or 

family-style meal.

» Avoid sharing of foods and utensils.

» Avoid sharing electronic devices, toys, books, other games, and learning aids.

» Prevent risk of transmitting COVID-19 by avoiding immediate contact (such as shaking or holding hands, 

hugging, or kissing).

• Train all staff (Steps 1–3)

» Train all staff in the above safety actions. Consider conducting the training virtually, or, if in-person, ensure 

social distancing is maintained.

Monitoring and Preparing

Check forsigns and symptoms(Steps 1–3)

• Screen children upon arrival, if possible. Establish routine, daily health checks on arrival, such as temperature 

screening of both staff and children. Options for daily health check screenings for children are provided in 

CDC’s supplemental Guidance for Child Care Programs that Remain Open and in CDC’s General Business FAQs

for screening staff.

• Implement health checks (e.g.temperature checks and symptom screening) screenings safely and respectfully, and with measures in place to ensure confidentiality as well as in accordance with any applicable privacy 

laws or regulations. Confidentiality should be maintained.
41

• Employers and childcare directors may use examples of screening methods in CDC’s supplemental Guidance 

for Child Care Programs that Remain Open as a guide.

• Encourage staff to stay home if they are sick and encourage parents to keep sick children home.

Plan for when a staff member, child, or visitor becomes sick (Steps 1–3)

• Identify an area to separate anyone who exhibits COVID-like symptoms during hours of operation, and ensure 

that children are not left without adult supervision.

• Establish procedures for safely transporting anyone sick to their home or to a healthcare facility, as appropriate.

• Notify local health officials, staff, and families immediately of any possible case of COVID-19 while maintaining 

confidentiality consistent with the Americans with Disabilities Act (ADA) and other applicable federal and 

state privacy laws.

• Close off areas used by any sick person and do not use them until they have been cleaned. Wait 24 hours 

before you clean or disinfect to reduce risk to individuals cleaning. If it is not possible to wait 24 hours, wait 

as long as possible. Ensure safe and correct application of disinfectants, and keep disinfectant products away 

from children

• Advise sick staff members or children not to return until they have met CDC criteria to discontinue home 

isolation.

• Inform those who have had close contact to a person diagnosed with COVID-19 to stay home and self-monitor 

for symptoms, and to follow CDC guidance if symptoms develop. If a person does not have symptoms follow 

appropriate CDC guidance for home isolation.

Maintain healthy operations (Steps 1–3)

• Implement flexible sick leave policies and practices, if feasible.

• Monitor absenteeism to identify any trends in employee or child absences due to illness. This might indicate 

spread of COVID-19 or other illness. Have a roster of trained back-up staff in order to maintain sufficient 

staffing levels.

• Designate a staff person to be responsible for responding to COVID-19 concerns. Employees should know who 

this person is and how to contact them.

• Create a communication system for staff and families for self-reporting of symptoms and notification of 

exposures and closures.

• Support coping and resilience among employees and children.

Steps 1–3

• It is very important to check State and local health department notices daily about spread of COVID-19 in the 

area and adjust operations accordingly.

• Where a community is deemed a significant mitigation community, childcare programs should close, except 

for those caring for the children of essential workers, such as the children of health care workers.

• In the event a person diagnosed with COVID-19 is determined to have been in the building and poses a risk to 

the community, programs may consider closing for a few days for cleaning and disinfection.
42

INTERIM GUIDANCE FOR SCHOOLS AND DAY CAMPS 

As communities consider a gradual scale up of activities towards pre-COVID-19 operating practices in centers 

for learning, such as K–12 schools and summer day camps, CDC offers the following recommendations to keep 

communities safe while resuming peer-to-peer learning and providing crucial support for parents and guardians 

returning to work. These recommendations depend on community monitoring to prevent COVID-19 from 

spreading. Communities with low levels of COVID-19 spread and those with confidence that the incidence of 

infection is genuinely low (e.g., communities that remain in low transmission or that have entered Step 2 or 3) 

may put in place the practices described below as part of a gradual scale up of operations. All decisions about 

following these recommendations should be made in collaboration with local health officials and other state 

and local authorities who can help assess the current level of mitigation needed based on levels of COVID-19 

community transmission and the capacities of the local public health and healthcare systems, among other 

relevant factors. CDC is releasing this interim guidance, laid out in a series of three steps, to inform a gradual scale 

up of operations. The scope and nature of community mitigation suggested decreases from Step 1 to Step 3.

Some amount of community mitigation is necessary across all steps until a vaccine or therapeutic drug becomes 

widely available.

Scaling Up Operations

• In all Steps:

» Establish and maintain communication with local and state authorities to determine current mitigation 

levels in your community.

» Protect and support staff and students who are at higher risk for severe illness, such as providing options 

for telework and virtual learning.

» Follow CDC’s Guidance for Schools and Childcare Programs.

» Provide teachers and staff from higher transmission areas (earlier Step areas) telework and other options as 

feasible to eliminate travel to schools and camps in lower transmission (later Step) areas and vice versa.

» Encourage any other external community organizations that use the facilities also follow this guidance.

• Step 1: Schools that are currently closed, remain closed. E-learning or distance learning opportunities should 

be provided for all students. Support provision of student services such as school meal programs, as feasible.

Camps should be restricted to children of essential workers and for children who live in the local geographic 

area only.

• Step 2: Remain open with enhanced social distancing measures and for children who live in the local 

geographic area only.

• Step 3: Remain open with distancing measures. Restrict attendance to those from limited transmission areas 

(other Step 3 areas) only.

Safety Actions

Promote healthy hygiene practices (Steps 1–3)

• Teach and reinforce washing hands and covering coughs and sneezes among children and staff.

• Teach and reinforce use of face coverings among all staff. Face coverings may be challenging for students 

(especially younger students) to wear in all-day settings such as school. Face coverings should be worn by 

staff and encouraged in students (particularly older students) if feasible and are most essential in times when 
43

physical distancing is difficult. Information should be provided to staff and students on proper use, removal, 

and washing of cloth face coverings. Face coverings are not recommended for babies or children under the 

age of 2, or for anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable 

to remove the covering without assistance. Cloth face coverings are meant to protect other people in case 

the wearer is unknowingly infected (many people carry COVID-19 but do not have symptoms). Cloth face 

coverings are not surgical masks, respirators, or personal protective equipment.

• Have adequate supplies to support healthy hygiene behaviors, including soap, hand sanitizer with at least 

60 percent alcohol (for staff and older children who can safely use hand sanitizer), paper towels, tissues, and 

no-touch trash cans.

• Post signs on how to stop the spread of COVID-19, properly wash hands, promote everyday protective 

measures, and properly wear a face covering.

Intensify cleaning, disinfection, and ventilation (Steps 1–3)

• Clean and disinfect frequently touched surfaces within the school and on school buses at least daily (for 

example, playground equipment, door handles, sink handles, drinking fountains) as well as shared objects (for 

example, toys, games, art supplies) between uses.

• To clean and disinfect school buses, see guidance for bus transit operators.

• Ensure safe and correct application of disinfectants and keep products away from children.

• Ensure ventilation systems operate properly and increase circulation of outdoor air as much as possible such 

as by opening windows and doors. Do not open windows and doors if they pose a safety or health risk (e.g., 

allowing pollens in or exacerbating asthma symptoms) risk to children using the facility.

• Take steps to ensure that all water systems and features (for example, drinking fountains, decorative 

fountains) are safe to use after a prolonged facility shutdown to minimize the risk of Legionnaires’ disease and 

other diseases associated with water.

Promote social distancing

• Step 1 and 2

» Ensure that student and staff groupings are as static as possible by having the same group of children stay 

with the same staff (all day for young children, and as much as possible for older children).

» Restrict mixing between groups.

» Cancel all field trips, inter-group events, and extracurricular activities (Step 1).

» Limit gatherings, events, and extracurricular activities to those that can maintain social distancing, support 

proper hand hygiene, and restrict attendance of those from higher transmission areas (Step 2; Note: 

restricting attendance from those in Step 1 areas).

» Restrict nonessential visitors, volunteers, and activities involving other groups at the same time.

» Space seating/desks to at least 6 feet apart.

» Turn desks to face in the same direction (rather than facing each other), or have students sit on only one 

side of tables, spaced apart.

» Close communal use spaces such as dining halls and playgrounds if possible; otherwise stagger use and 

disinfect in between use.

» If a cafeteria or group dining room is typically used, serve meals in classrooms instead. Serve individually 

plated meals and hold activities in separate classrooms and ensure the safety of children with food 

allergies.
44

» Stagger arrival and drop-off times or locations, or put in place other protocols to limit close contact with 

parents or caregivers as much as possible.

» Create social distance between children on school buses (for example, seating children one child per seat, 

every other row) where possible.

• Step 3

» Consider keeping classes together to include the same group of children each day, and consider keeping 

the same child care providers with the same group each day.

» Allow minimal mixing between groups. Limit gatherings, events, and extracurricular activities to those that 

can maintain social distancing, support proper hand hygiene, and restrict attendance of those from higher 

transmission areas (Step 1 or 2 areas).

» Continue to space out seating and bedding (head-to-toe positioning) to 6 feet apart, if possible.

» Consider keeping communal use spaces closed, such as game rooms or dining halls, if possible; if this is not 

possible, stagger use and disinfect in between uses.

» Consider continuing to plate each child’s meal, to limit the use of shared serving utensils and ensure the 

safety of children with food allergies.

» Consider limiting nonessential visitors, volunteers, and activities involving other groups. Restrict attendance of those from higher transmission areas (Step 1 or 2 areas).

» Consider staggering arrival and drop-off times or locations, or put in place other protocols to limit close 

contact with parents or caregivers as much as possible.

Limit sharing (Steps 1–3)

• Keep each child’s belongings separated from others’ and in individually labeled containers, cubbies, or areas 

and taken home each day and cleaned, if possible.

• Ensure adequate supplies to minimize sharing of high touch materials to the extent possible (art supplies, 

equipment etc. assigned to a single student/camper) or limit use of supplies and equipment by one group of 

children at a time and clean and disinfect between use.

• If food is offered at any event, have pre-packaged boxes or bags for each attendee instead of a buffet or 

family-style meal. Avoid sharing of foods and utensils.

• Avoid sharing electronic devices, toys, books, and other games or learning aids.

Train all staff (Steps 1–3)

• Train all teachers and staff in the above safety actions. Consider conducting the training virtually, or, if 

in-person, ensure that social distancing is maintained.

Check for signs and symptoms (Steps 1–3)

• If feasible, conduct daily health checks (e.g. temperature screening and/or symptoms checking) of staff and 

students safely, respectfully, as well as in accordance with any applicable privacy laws or regulations. Confidentiality should be maintained.

• School and camp administrators may use examples of screening methods in CDC’s supplemental Guidance 

for Child Care Programs that Remain Open as a guide for screening children and CDC’s General Business FAQs

for screening staff.

• Encourage staff to stay home if they are sick and encourage parents to keep sick children home.
45

Plan for when a staff member, child, or visitor becomes sick (Steps 1–3)

• Work with school administrators, nurses, and other healthcare providers to identify an isolation room or 

area to separate anyone who exhibits COVID-like symptoms. School nurses and other healthcare providers 

should use Standard and Transmission-Based Precautions when caring for sick people. See: What Healthcare 

Personnel Should Know About Caring for Patients with Confirmed or Possible COVID-19 Infection.

• Establish procedures for safely transporting anyone sick home or to a healthcare facility.

• Notify local health officials, staff, and families immediately of a possible case while maintaining confidentiality 

consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state privacy laws.

• Close off areas used by a sick person and do not use before cleaning and disinfection. Wait 24 hours before 

you clean and disinfect. If it is not possible to wait 24 hours is, wait as long as possible.Ensure safe and correct 

application of disinfectants and keep disinfectant products away from children.

• Advise sick staff members and children not to return until they have met CDC criteria to discontinue home 

isolation.

• Inform those who have had close contact to a person diagnosed with COVID-19 to stay home and self-monitor 

for symptoms and to follow CDC guidance if symptoms develop. If a person does not have symptoms follow 

appropriate CDC guidance for home isolation.

Maintain healthy operations (Steps 1–3)

• Implement flexible sick leave policies and practices, if feasible.

• Monitor staff absenteeism and have a roster of trained back-up staff.

• Monitor health clinic traffic. School nurses and other healthcare providers play an important role in 

monitoring health clinic traffic and the types of illnesses and symptoms among students.

• Designate a staff person to be responsible for responding to COVID-19 concerns. Employees should know 

who this person is and how to contact them.

• Create a communication system for staff and families for self-reporting of symptoms and notification of 

exposures and closures.

• Support coping and resilience among employees and children.

Closing

Steps 1–3

• Check state and local health department notices daily about transmission in the area and adjust operations 

accordingly.

• In the event a person diagnosed with COVID-19 is determined to have been in the building and poses a risk to 

the community, programs may consider closing for a short time (1–2 days) for cleaning and disinfection.
46

INTERIM GUIDANCE FOR EMPLOYERS WITH WORKERS AT HIGH RISK

As workplaces consider a gradual scale up of activities towards pre-COVID-19 operating practices, it is particularly 

important to keep in mind that some workers are at higher risk for severe illness from COVID-19. These workers 

include individuals over age 65 and those with underlying medical conditions. Such underlying conditions 

include, but are not limited to, chronic lung disease, moderate to severe asthma, hypertension, severe heart 

conditions, weakened immunity, severe obesity, diabetes, liver disease, and chronic kidney disease that requires 

dialysis. Workers at higher risk for severe illness should be encouraged to self-identify, and employers should 

avoid making unnecessary medical inquiries. Employers should take particular care to reduce workers’ risk of 

exposure to COVID-19, while making sure to be compliant with relevant Americans with Disabilities Act (ADA) 

and Age Discrimination in Employment Act (ADEA) regulations. First and foremost, this means following CDC

and the Occupational Safety and Health Administration (OSHA) guidance for reducing workplace exposure for 

all employees. All decisions about following these recommendations should be made in collaboration with local 

health officials and other state and local authorities who can help assess the current level of mitigation needed 

based on levels of COVID-19 community transmission and the capacities of the local public health and healthcare 

systems. In addition, the guidance offered below applies to workplaces generally; specific industries may require 

more stringent safety precautions. Finally, there may be essential workplaces in which the recommended 

mitigation strategies are not feasible. CDC is releasing this interim guidance, laid out in a series of three steps, to 

inform a gradual scale up of operations. The scope and nature of community mitigation suggested decreases from 

Step 1 to Step 3. Some amount of community mitigation is necessary across all steps until a vaccine or therapeutic 

drug becomes widely available.

Scaling Up Operations

• In all Steps:

» Establish and maintain communication with local and state authorities to determine current mitigation 

levels in your community.

» Protect employees at higher risk for severe illness by supporting and encouraging options to telework.

» Consider offering workers at higher risk duties that minimize their contact with customers and other 

employees (e.g., restocking shelves rather than working as a cashier), if agreed to by the worker.

» Encourage any other entities sharing the same work space also follow this guidance.

» Provide employees from higher transmission areas (earlier Step areas) telework and other options as 

feasible to eliminate travel to workplaces in lower transmission (later Step) areas and vice versa.

• Step 1: Scale up only if business can ensure strict social distancing, proper cleaning and disinfecting 

requirements, and protection of their workers and customers; workers at higher risk for severe illness are 

recommended to shelter in place.

• Step 2: Scale up only if business can ensure moderate social distancing, proper cleaning and disinfecting 

requirements, and protection of their workers and customers; workers at higher risk for severe illness are 

recommended to shelter in place.

• Step 3: Scale up only if business can ensure limited social distancing, proper cleaning and disinfecting 

requirements, and protection of their workers and customers.
47

Safety Action

Promote healthy hygiene practices (Steps 1–3)

• Enforce hand washing, covering coughs and sneezes, and using cloth face coverings when around others 

where feasible;

• however, certain industries may require face shields.

• Ensure that adequate supplies to support healthy hygiene behaviors, including soap, hand sanitizer with at 

least 60 percent alcohol, tissues, paper towels, and no-touch trash cans.

• Post signs on how to stop the spread of COVID-19 properly wash hands, promote everyday protective 

measures, and properly wear a face covering.

Intensify cleaning, disinfection, and ventilation (Steps 1–3)

• Clean and disinfect frequently touched surfaces at least daily and shared objects between use.

• Avoid use or sharing of items that are not easily cleaned, sanitized, or disinfected.

• Ensure safe and correct application of disinfectants.

• Ensure that ventilation systems operate properly and increase circulation of outdoor air as much as possible 

such as by opening windows and doors. Do not open windows and doors if doing so poses a safety risk to 

individuals and employees using the workspace.

• Take steps to ensure that all water systems and features (for example, drinking fountains, decorative 

fountains) are safe to use after a prolonged facility shutdown to minimize the risk of Legionnaires’ disease and 

other diseases associated with water.

Promote social distancing (Steps 1–3)

• Limit service to drive-throughs, curbside take out, or delivery options, if possible (Step 1).

• Consider installing physical barriers, such as sneeze guards and partitions, and changing workspace layouts to 

ensure all individuals remain at least 6 feet apart.

• Close communal spaces, such as break rooms, if possible (Step 1) or stagger use and clean and disinfect in 

between uses (Steps 2 & 3).

• Encourage telework for as many employees as possible.

• Consider rotating or staggering shifts to limit the number of employees in the workplace at the same time.

• Replace in-person meetings with video- or tele-conference calls whenever possible.

• Cancel all group events, gatherings, or meetings of more than 10 people (Step 1), of more than 50 people 

(Step 2), and any events where social distancing of at least 6 feet cannot be maintained between participants 

(all Steps).

• Restrict (Step 1) or consider limiting (Step 2) any nonessential visitors, volunteers, and activities involving 

external groups or organizations.

• Limit any sharing of foods, tools, equipment, or supplies.

Limit travel and modify commuting practices (Steps 1–3)

• Cancel all non-essential travel (Step 1) and consider resuming non-essential travel in accordance with state 

and local regulations and guidance (Steps 2 & 3).
48

• Ask employees who use public transportation to consider using teleworking to promote social distancing.

• Train all managers and staff in the above safety actions. Consider conducting the training virtually, or if 

in-person, ensure that social distancing is maintained.

Monitoring and Preparing

Checking for signs and symptoms (Steps 1–3)

• Consider conducting routine, daily health checks (e.g., temperature and symptom screening) of all employees.

• If implementing health checks, conduct them safely and respectfully, and in accordance with any applicable 

privacy laws and regulations. Confidentiality should be respected. Employers may use examples of screening 

methods in CDC’s General Business FAQs as a guide.

• Encourage employees who are sick to stay at home.

Plan for when an employee becomes sick (Steps 1–3)

• Employees with symptoms (fever, cough, or shortness of breath) at work should immediately be separated 

and sent home.

• Establish procedures for safely transporting anyone sick to their home or to a healthcare facility.

• Notify local health officials, staff, and customers (if possible) immediately of a possible case while maintaining 

confidentiality consistent with the Americans with Disabilities Act (ADA) and other applicable federal and 

state privacy laws.

• Close off areas used by the sick person until after cleaning and disinfection Wait 24 hours to clean and 

disinfect. If it is not possible to wait 24 hours, wait as long as possible before cleaning and disinfecting. Ensure 

safe and correct application of disinfectants and keep disinfectant products away from children.

• Inform those who have had close contact to a person diagnosed with COVID-19 to stay home and self-monitor 

for symptoms, and to follow CDC guidance if symptoms develop. If a person does not have symptoms follow 

appropriate CDC guidance for home isolation.

• Sick employees should not return to work until they have met CDC’s criteria to discontinue home isolation.

Maintain healthy operations (Steps 1–3)

• Implement flexible sick leave and other flexible policies and practices, such as telework, if feasible.

• Monitor absenteeism of employees and create a roster of trained back-up staff.

• Designate a staff person to be responsible for responding to COVID-19 concerns. Employees should know who 

this person is and how to contact them.

• Create and test communication systems for employees for self-reporting and notification of exposures and 

closures.

• Support coping and resilience among employees.

Closing

Steps 1–3

• Check state and local health department notices daily about transmission in the area and adjust operations 

accordingly.

• Be prepared to consider closing for a few days if there is a case of COVID-19 in the workplace or for longer if 

cases increase in the local area.
49

INTERIM GUIDANCE FOR RESTAURANTS AND BARS 

This guidance provides considerations for businesses in the food service industry (e.g., restaurants and bars) on 

ways to maintain healthy business operations and a safe and healthy work environment for employees, while 

reducing the risk of COVID-19 spread for both employees and customers. Employers should follow applicable 

Occupational Safety and Health Administration (OSHA) and CDC guidance for businesses to plan and respond 

to COVID-19. All decisions about implementing these recommendations should be made in collaboration with 

local health officials and other state and local authorities who can help assess the current level of mitigation 

needed based on levels of COVID-19 community transmission and the capacities of the local public health and 

healthcare systems. CDC is releasing this interim guidance, laid out in a series of three steps, to inform a gradual 

scale up of activities towards pre-COVID-19 operating practices. The scope and nature of community mitigation 

suggested decreases from Step 1 to Step 3. Some amount of community mitigation is necessary across all steps 

until a vaccine or therapeutic drug becomes widely available.

Scaling Up Operations

• In all Steps:

» Establish and maintain communication with local and state authorities to determine current mitigation 

levels in your community.

» Consider assigning workers at high risk for severe illness duties that minimize their contact with customers 

and other employees (e.g., managing inventory rather than working as a cashier, managing administrative 

needs through telework).

» Provide employees from higher transmission areas (earlier Step areas) telework and other options as 

feasible to eliminate travel to workplaces in lower transmission (later Step) areas and vice versa.

• Step 1: Bars remain closed and restaurant service should remain limited to drive-through, curbside take out, 

or delivery with strict social distancing.

• Step 2: Bars may open with limited capacity; restaurants may open dining rooms with limited seating 

capacity that allows for social distancing.

• Step 3: Bars may open with increased standing room occupancy that allows for social distancing; restaurants 

may operate while maintaining social distancing.

Safety Actions

Promote healthy hygiene practices (Steps 1–3)

• Enforce hand washing, covering coughs and sneezes, and use of a cloth face coverings by employees when 

near other employees and customers.

• Ensure adequate supplies to support healthy hygiene practices for both employees and customers including 

soap, hand sanitizer with at least 60 percent alcohol (on every table, if supplies allow), paper towels, and 

tissues.

• Post signs on how to stop the spread of COVID-19 properly wash hands, promote everyday protective 

measures, and properly wear a face covering.

Intensify cleaning, disinfection, and ventilation (Steps 1–3)

• Clean and disinfect frequently touched surfaces (for example, door handles, workstations, cash registers) 

at least daily and shared objects (for example, payment terminals, tables, countertops/bars, receipt trays, 

condiment holders) between use. Use products that meet EPA’s criteria for use against SARS-CoV-2 and that 
50

are appropriate for the surface. Prior to wiping the surface, allow the disinfectant to sit for the necessary 

contact time recommended by the manufacturer. Train staff on proper cleaning procedures to ensure safe 

and correct application of disinfectants.

• Make available individual disinfectant wipes in bathrooms.

• Wash, rinse, and sanitize food contact surfaces, food preparation surfaces, and beverage equipment after use.

• Avoid using or sharing items such as menus, condiments, and any other food. Instead, use disposable or 

digital menus, single serving condiments, and no-touch trash cans and doors.

• Use touchless payment options as much as possible, when available. Ask customers and employees to 

exchange cash or card payments by placing on a receipt tray or on the counter rather than by hand. Clean and 

disinfect any pens, counters, or hard surfaces between use or customer.

• Use disposable food service items (utensils, dishes). If disposable items are not feasible, ensure that all 

non-disposable food service items are handled with gloves and washed with dish soap and hot water or in a 

dishwasher. Employees should wash their hands after removing their gloves or after directly handling used 

food service items

• Use gloves when removing garbage bags or handling and disposing of trash and wash hands afterwards

• Avoid using food and beverage containers or utensils brought in by customers.

• Ensure that ventilation systems operate properly and increase circulation of outdoor air as much as possible 

such as by opening windows and doors. Do not open windows and doors if doing so poses a safety risk to 

employees, children, or customers.

• Take steps to ensure that all water systems and features (for example, drinking fountains, decorative 

fountains) are safe to use after a prolonged facility shutdown to minimize the risk of Legionnaires’ disease

and other diseases associated with water.

Promote social distancing

Step 1

• Limit service to drive-through, delivery, or curb-side pick-up options only.

• Provide physical guides, such as tape on floors or sidewalks to ensure that customers remain at least 6 feet 

apart in lines or ask customers to wait in their cars or away from the establishment while waiting to pick up 

food. Post signs to inform customers of food pickup protocols.

• Consider installing physical barriers, such as sneeze guards and partitions at cash registers, or other food 

pickup areas where maintaining physical distance of 6 feet is difficult.

• Restrict the number of employees in shared spaces, including kitchens, break rooms, and offices to maintain 

at least a six-foot distance between people.

• Rotate or stagger shifts to limit the number of employees in the workplace at the same time.

Step 2

• Provide drive-through, delivery, or curb-side pick-up options and prioritize outdoor seating as much as 

possible.

• Reduce occupancy and limit the size of parties dining in together to sizes that ensure that all customer 

parties remain at least 6 feet apart (e.g., all tables and bar stools 6 feet apart, marking tables/stools that are 

not for use) in order to protect staff and other guests.
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• Provide physical guides, such as tape on floors or sidewalks and signage on walls to ensure that customers 

remain at least 6 feet apart in lines or waiting for seating.

• Ask customers to wait in their cars or away from the establishment while waiting to be seated. If possible, 

use phone app technology to alert patrons when their table is ready to avoid touching and use of “buzzers.”

• Consider options for dine-in customers to order ahead of time to limit the amount of time spent in the 

establishment.

• Avoid offering any self-serve food or drink options, such as buffets, salad bars, and drink stations.

• Install physical barriers, such as sneeze guards and partitions at cash registers, bars, host stands, and other 

areas where maintaining physical distance of 6 feet is difficult.

• Limit the number of employees in shared spaces, including kitchens, break rooms, and offices to maintain at 

least a six-foot distance between people.

Step 3

• Provide drive-through, delivery, or curbside pick-up options and prioritize outdoor seating as much as 

possible.

• Consider reducing occupancy and limiting the size of parties dining in together to sizes that ensure that all 

customer parties remain at least 6 feet apart (e.g., all tables and bar stools 6 feet apart, marking tables/stools 

that are not for use) in order to protect staff and other guests.

• Provide physical guides, such as tape on floors or sidewalks and signage on walls, to ensure that customers 

remain at least 6 feet apart in lines or waiting for seating.

• If possible, use phone app technology to alert patrons when their table is ready to avoid touching and use 

of “buzzers.” 

• Consider options for dine-in customers to order ahead of time to limit the amount of time spent in the 

establishment.

• Avoid offering any self-serve food or drink options, such as buffets, salad bars, and drink stations.

• Install physical barriers, such as sneeze guards and partitions at cash registers, bars, host stands, and other 

areas where maintaining physical distance of 6 feet is difficult.

Train all staff (Steps 1–3)

• Train all employees in the above safety actions while maintaining social distancing and use of face coverings

during training.

Monitoring and Preparing

Checking for signs and symptoms (Steps 1–3)

• Consider conducting daily health checks (e.g., temperature and symptom screening) of employees.

• If implementing health checks, conduct them safely and respectfully, and in accordance with any applicable 

privacy laws and regulations. Confidentiality should be respected. Employers may use examples of screening 

methods in CDC’s General Business FAQs as a guide.

• Encourage staff who are sick to stay at home.
52

Plan for when an employee becomes sick (Steps 1–3)

• Employees with symptoms of COVID-19 (fever, cough, or shortness of breath) at work should immediately be 

sent to their home.

• Inform those who have had close contact to a person diagnosed with COVID-19 to stay home and self-monitor 

for symptoms, and to follow CDC guidance if symptoms develop. If a person does not have symptoms follow 

appropriate CDC guidance for home isolation.

• Establish procedures for safely transporting anyone sick to their home or to a healthcare facility.

• Notify local health officials, staff, and customers (if possible) immediately of any possible case of COVID-19 

while maintaining confidentiality consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state privacy laws.

• Close off areas used by a sick person and do not sure them until after cleaning and disinfection. Wait 24 hours 

before cleaning and disinfecting. If it is not possible to wait 24 hours, wait as long as possible. Ensure safe and 

correct application of disinfectants and keep disinfectant products away from children.

• Advise sick staff members not to return until they have met CDC’s criteria to discontinue home isolation.

Maintain healthy operations (Steps 1–3)

• Implement flexible sick leave and other flexible policies and practices, such as telework, if feasible.

• Monitor absenteeism of employees and create a roster of trained back-up staff.

• Designate a staff person to be responsible for responding to COVID-19 concerns. Employees should know 

who this person is and how to contact them.

• Create and test communication systems for employees for self-reporting and notification of exposures and 

closures.

• Support coping and resilience among employees.

Closing

Steps 1–3

• Check state and local health department notices about transmission in the area daily and adjust operations 

accordingly.

• Be prepared to consider closing for a few days if there is a case of COVID-19 in the establishment and for 

longer if cases increase in the local area.
53

INTERIM GUIDANCE FOR MASS TRANSIT ADMINISTRATORS 

Mass transit is critical for many Americans to commute to and from work and to access essential goods and 

services. This guidance provides considerations for mass transit administrators to maintain healthy business 

operations and a safe and healthy work environment for employees, while reducing the risk of COVID-19 spread 

for both employees and passengers. Administrators should follow applicable guidance from the CDC and 

Occupational Safety and Health Administration (OSHA) for reducing workplace exposure. All decisions about 

following these recommendations should be made in collaboration with local health officials and other state 

and local authorities who can help assess the current level of mitigation needed based on levels of

COVID-19 community transmission and the capacities of the local public health and healthcare systems. CDC 

is releasing this interim guidance, laid out in a series of three steps, to inform a gradual scale up of activities 

towards pre-COVID-19 operating practices. The scope and nature of community mitigation suggested decreases 

from Step 1 to Step 3. Some amount of community mitigation is necessary across all steps until a vaccine or 

therapeutic drug becomes widely available.

Resuming Full Service

• In all Steps:

» Adjust routes between areas experiencing different levels of transmission (between areas in different 

Steps), to the extent possible.

» Provide employees from higher transmission areas (earlier Step areas) telework and other options as 

feasible to eliminate travel to workplaces in lower transmission (later Step) areas and vice versa.

» Establish and maintain communication with state and local health officials to determine current 

mitigation levels in the communities served. Decisions about how and when to resume full service should 

be based on these levels.

» Follow CDC’s guidance on what bus transit operators, rail transit operators, transit maintenance workers, 

and transit station workers need to know about COVID-19.

» Consider assigning workers at high risk of severe illness duties that minimize their contact with passengers 

and other employees

» Conduct worksite hazard assessments to identify COVID-19 prevention strategies, such as appropriate use 

of cloth face coverings or personal protective equipment (PPE), and follow the prevention strategies.

• Step 1: Restrict ridership to essential critical infrastructure workers in areas needing significant mitigation 

and maintain strict social distancing as much as possible.

• Step 2: Maintain social distancing between transit riders and employees as much as possible.

• Step 3: Encourage social distancing as much as possible.

Safety Actions

Promote healthy hygiene practices (Steps 1–3)

• Enforce everyday preventive actions such as hand washing, covering coughs and sneezes, and use of a cloth 

face covering by employees when around others, as safety permits. Provide employees with appropriate 

personal protective equipment as necessary and as available. Communicate with the public about the 

importance of hygiene, covering coughs and sneezes, and using cloth face coverings while using mass 

transportations, including posting signs in transit stations and vehicles on how to stop the spread of 

COVID-19, properly wash hands, promote everyday protective measures, and properly wear a face covering.
54

• Ensure adequate supplies to support healthy hygiene behaviors for transit operators, employees, and 

passengers in stations, including soap, hand sanitizer with at least 60 percent alcohol, paper towels, tissues, 

and no-touch trash cans.

• Post signs on how to stop the spread of COVID-19 properly wash hands, promote everyday protective 

measures, and properly wear a face covering.

Intensify cleaning, disinfection, and ventilation (Steps 1–3)

• Clean and disinfect frequently touched surfaces (for example, kiosks, digital interfaces such as touchscreens 

and fingerprint scanners, ticket machines, turnstiles, handrails, restroom surfaces, elevator buttons) at least 

daily or between use as feasible.

• Clean and disinfect the operator area between operator shifts.

• Use touchless payment and no-touch trash cans and doors as much as possible, when available. Ask 

customers and employees to exchange cash or credit cards by placing in a receipt tray or on the counter 

rather than by hand and wipe any pens, counters, or hard surfaces between each use or customer.

• Avoid using or sharing items that are not easily cleaned, sanitized, or disinfected, such as disposable transit 

maps.

• Ensure safe and correct application of disinfectants.

• Use gloves when removing garbage bags or handling and disposing of trash and wash hands afterwards.

• Ensure that ventilation systems operate properly and increase circulation of outdoor air as much as possible 

such as by opening windows and doors. Do not open windows and doors if they pose a safety risk to 

passengers or employees, or other vulnerable individuals.

• Take steps to ensure that all water systems and features (for example, drinking fountains, decorative 

fountains) are safe to use after a prolonged facility shutdown to minimize the risk of Legionnaires’ disease

and other diseases associated with water.

Promote social distancing

Step 1 and Step 2

• Institute measures to physically separate or create distance of at least 6 feet between all occupants to the 

extent possible. This may include:

» Asking bus passengers to enter and exit the bus through rear doors, while allowing exceptions for persons 

with disabilities.

» Closing every other row of seats.

» Reducing maximum occupancy of buses and individual subway and train cars and increasing service on 

crowded routes as appropriate.

• Provide physical guides to ensure that customers remain at least 6 feet apart while on vehicles and at transit 

stations and stops. For example, floor decals, colored tape, or signs to indicate where passengers should not 

sit or stand can be used to guide passengers.

• Install physical barriers, such as sneeze guards and partitions at staffed kiosks and on transit vehicles to the 

extent practicable.

• Close communal spaces, such as break rooms, if possible; otherwise, stagger use and clean and disinfect in 

between uses.
55

Step 3

• Consider or continue instituting measures to physically separate or create distance between occupants.

• Provide physical guides to help customers maintain physical distance while on vehicles and at transit stations 

and stops. For example, floor decals, colored tape, or signs to indicate where passengers should not sit or 

stand can be used to guide passengers.

• Install or maintain physical barriers, such as sneeze guards and partitions at staffed kiosks and on transit 

vehicles to the extent practicable.

Train employees (Steps 1–3)

• Train all employees in the above safety actions while maintaining social distancing during training.

Monitoring and Preparing

Checking for signs and symptoms (Steps 1–3)

• Consider conducting daily health checks (e.g., temperature screening and/or symptom checking) of all 

employees.

• If implementing health checks, conduct them safely and respectfully, and in accordance with any applicable 

privacy laws and regulations. Confidentiality should be respected. Employers may use examples of screening 

methods in CDC’s General Business FAQs as a guide.

• Encourage staff who are sick to stay at home.

Plan for when an employee becomes sick (Steps 1–3)

• Employees with symptoms of COVID-19 (fever, cough, or shortness of breath) at work should immediately be 

sent home.

• Inform those who have had close contact to a person diagnosed with COVID-19 to stay home and self-monitor 

for symptoms, and to follow CDC guidance if symptoms develop. If a person does not have symptoms follow 

appropriate CDC guidance for home isolation.

• Establish procedures for safely transporting anyone sick to their home or to a healthcare facility.

• Notify local health officials, staff, and customers (if possible) immediately of any possible case of COVID-19 

while maintaining confidentiality consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state privacy laws.

• Close off areas used by a sick person and do not use until after cleaning and disinfection. Wait 24 hours 

before cleaning and disinfecting. If 24 hours is not feasible, wait as long as possible. Ensure safe and correct 

application of disinfectants and keep disinfectant products away from children. Affected vehicles can be used 

immediately after cleaning and disinfection.

• Advise sick staff members not to return until they have met CDC’s criteria to discontinue home isolation.

• Implement safety practices for critical infrastructure workers who may have had exposure to a person with 

suspected or confirmed COVID-19.

Maintain healthy operations (Steps 1–3)

• Implement flexible sick leave and other flexible policies and practices, if feasible.

• Monitor absenteeism of employees and create a roster of trained back-up staff.
56

• Designate a staff person to be responsible for responding to COVID-19 concerns. Employees and customers 

should know who this person is and how to contact them.

• Create and test communication systems for employees and customers for self-reporting of symptoms and 

notification of exposures and closures.

• Support coping and resilience among employees.

Adjusting Service

Steps 1–3

• Coordinate with state and local health department officials about transmission in the area as frequently as 

possible and adjust operations accordingly.

• Be prepared to consider adjusting services as appropriate if the community mitigation level increases in the 

local area.

• Continue communication with staff and the public about decision-making.

CS317132-A May 26, 2020 12:53 PM

cdc.gov/coronavirus