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Recommendations for Culturally and Linguistically Appropriate Contact Tracing

for the Control of COVID-19

Graphic from The Washington Post

As the United States moves into the next phase of the COVID-19 pandemic, effective
contact tracing will be vital to the control of the spread of the virus, especially as state
and local health departments begin to lift or loosen shelter-in-place and stay-at-home
orders.1 The Centers for Disease Control and Prevention (CDC) defines COVID-19 case
investigation and contact tracing as:

Case investigation is the identification and investigation of clients with confirmed


and probable diagnoses of COVID-19, and contact tracing is the subsequent
identification, monitoring, and support of their contacts who have been exposed
to, and possibly infected with, the virus. Prompt identification, voluntary
quarantine [also referred to as self-quarantine], and monitoring of these
COVID-19 contacts can effectively break the chain of disease transmission and
prevent further spread of the virus in a community.2
1
Centers for Disease Control and Prevention,
https://www.cdc.gov/coronavirus/2019-ncov/php/open-america/contact-tracing.html#case-investig
ation​; Walensky RP, del Rio C. From mitigation to containment of the COVID-19 pandemic:
putting the SARS-CoV-2 genie back in the bottle. JAMA. 2020;323(19):1889-1890; Rubin R.
Building an “army of disease detectives” to trace COVID-19 contacts. JAMA. May 21, 2020,
doi:10.1001/jama.2020.8880, ​https://jamanetwork.com/journals/jama/fullarticle/2766558 
2
Centers for Disease Control and Prevention, Interim Guidance for Health Departments for
Developing a COVID-19 Case Investigation & Contact Tracing Plan, May 15, 2020,

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May 22, 2020
The key elements of effective COVID-19 contact tracing are:

● widespread, continuous diagnostic viral testing for COVID-19 across a


community
● case investigation or follow-up with those who test positive
● supporting isolation and health monitoring of those who test positive for at least
14 days, including referrals and linkages to needed treatment
● comprehensive identification and rapid notification of all contacts of the individual
who tests positive
● supporting self-quarantine and health monitoring of those contacts for at least 14
days, and
● repeating the protocol for any contacts who subsequently test positive.3

Graphic from Resolve to Save Lives

https://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdf
(page 4)
3
Association of State and Territorial Health Officials, A Coordinated National Approach to Scaling
Public Health Capacity for Contact Tracing and Disease Investigation, 2020,
https://www.astho.org/COVID-19/A-National-Approach-for-Contact-Tracing/​; National Association
of County & City Health Officials, Building COVID-19 Contact Tracing Capacity in Health
Departments to Support Reopening America Safely, April 16, 2020,
https://www.naccho.org/uploads/full-width-images/Contact-Tracing-Statement-4-16-2020.pdf​;
Resolve to Save Lives, COVID-19 Contact Tracing Playbook,
https://contacttracingplaybook.resolvetosavelives.org/

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May 22, 2020
“Isolation” is used to refer to individuals who have tested positive (regardless of whether
they are experiencing symptoms), while “quarantine” is used to refer to individuals who
have been in contact with, or exposed to, individuals who have tested positive. For now,
the recommended period of time for isolation is at least 14 days from the date of the test,
and for self-quarantine, at least 14 days from the date of the last contact with the
individual who has tested positive.

While there is general agreement on these elements of effective contact tracing


programs, ​there has been little attention on how COVID-19 contact tracing should be
implemented in diverse communities.4 This is even more vital as preliminary data
indicate racial and ethnic disparities in COVID-19 cases and deaths, specifically among
Blacks,5 Latinx,6 American Indian,7 Native Hawaiian, and Pacific Islander populations.8
The CDC itself has noted:

History shows that severe illness and death rates tend to be higher for racial and
ethnic minority groups during public health emergencies.​ ​Addressing the needs
of vulnerable populations in emergencies includes improving day-to-day life and
harnessing the strengths of these groups.9

The CDC’s interim guidance on contact tracing, issued on May15, 2020, states:

Culturally and linguistically diverse minority populations are growing in the United
States. These populations include racial and ethnic minorities, members of tribal
nations, immigrants (i.e., those born outside the United States) and refugees.
They may be at higher risk for COVID-19 or worse health outcomes due to a
number of reasons including living conditions, work circumstances, underlying
health conditions, and limited access to care.

4
California Pan-Ethnic Health Network Letter to California Governor and Department of Public
Health, May 19, 2020,
https://cpehn.org/sites/default/files/cpehn_contact_tracing_letter_5.19.2020_2.pdf
5
Eligon J, Burch ADS, Searcey D, Oppel RA. ​Black Americans face alarming rates of coronavirus
infection in some states. ​New York Times, April 7, 2020,
https://www.nytimes.com/2020/04/07/us/coronavirus-race.html​; Thebault R, Tran AB, Williams V.
The coronavirus is infecting and killing African Americans at an alarming rate. Washington Post
April 7, 2020,
https://www.washingtonpost.com/nation/2020/04/07/coronavirus-is-infecting-killing-black-america
ns-an-alarmingly-high-rate-post-analysis-shows/?arc404=true​; Yancy CW. COVID-19 and African
Americans. JAMA. 2020;323(19):1891-1892
6
Jordan M, Oppel RA. For Latinos and COVID-19, doctors are seeing an ‘alarming’ disparity.
New York Times, May 9, 2020,
https://www.nytimes.com/2020/05/07/us/coronavirus-latinos-disparity.html
7
Akee R. COVID-19 impact on indigenous people in the U.S. EconFact, May 12, 2020,
https://www.pbs.org/newshour/nation/how-covid-19-is-impacting-indigenous-peoples-in-the-u-s
8
Pacific Islander COVID-19 Response Team, ​https://pi-copce.org/covid19response/
9
​https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html

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May 22, 2020
It is important that case investigations and contact tracing are conducted in a
culturally appropriate manner, which includes meaningfully engaging community
representatives from affected communities, collaborating with community-serving
organizations, respecting the cultural practices in the community, and taking into
consideration the social, economic and immigration contexts in which these
communities live and work.10
Accordingly, the National Council of Asian Pacific Islander Physicians (NCAPIP) offers
the following recommendations for implementing culturally and linguistically appropriate
contact tracing for the control of COVID-19: 

1. In partnership with diverse community groups and physician organizations, the


CDC and tribal, territorial, state, and local health departments11 should
immediately co-design and make widely available plain language, culturally and
linguistically appropriate community education materials about contact tracing in
multiple languages and in alternate formats accessible by individuals with
disabilities
2. The CDC and tribal, territorial, state, and local health departments should
highlight the confidentiality and privacy protections in contact tracing programs to
reassure community members that any personal health information will not be
shared with law enforcement, police, or immigration enforcement agencies, or
used for any other purposes
3. In partnership with diverse community groups, tribal, territorial, state, and local
health departments should immediately co-design and implement culturally and
linguistically appropriate contact tracing programs
4. The federal government and tribal, territorial, state, and local health departments
should ensure equitable access to testing for COVID-19, including removing cost
and other barriers to testing
5. The federal government and tribal, territorial, state, and local health departments
should ensure equitable access to treatment for COVID-19, including expansions
of Medicaid and suspension of implementation of the Department of Homeland
Security public charge test during this national public health emergency
6. Tribal, territorial, state, and local health departments should ensure language
assistance services, and communications access for individuals with disabilities,
in all contact tracing activities
7. Tribal, territorial, state, and local health departments should ensure that all
necessary wraparound services and supports for isolation and self-quarantine,
including housing, food, childcare, income, and other supports are culturally and
linguistically appropriate, and are available without cost

10
Centers for Disease Control and Prevention, Interim Guidance for Health Departments for
Developing a COVID-19 Case Investigation & Contact Tracing Plan, May 15, 2020,
https://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdf
(page 31)
11
COVID-19 contact tracing should remain the responsibility of the CDC and tribal, territorial,
state, and local health departments as a public health function rather than being conducted by the
private sector, such as large employers.

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May 22, 2020
8. Tribal, territorial, state, and local health departments should collect and confirm
comprehensive self-reported demographic data from all contacts as part of
contact tracing, including zip code of residence, age, sex, race, ethnicity, primary
language, disability status, sexual orientation, and gender identity
9. Tribal, territorial, state, and local health departments should hire and partner with
community-based organizations to deploy culturally and linguistically concordant
contact tracers to meet the needs of diverse communities
10. Tribal, territorial, state, and local health departments should continuously monitor
and publicly report all contact tracing activities stratified by demographic data to
identify and immediately address any identified disparities in access to testing
and treatment, and in participation and adherence to contact tracing protocols
About NCAPIP
NCAPIP is a national health policy organization that represents physicians committed to
the advancement of the health and well-being of Asian American, Native Hawaiian, and
Pacific Islander communities. NCAPIP’s board members and physician networks include
recognized leaders of national, state, and local physician organizations, medical groups,
and independent practice associations. NCAPIP’s board members and physician
networks include both primary care physicians (general internists, family physicians, and
pediatricians) as well as specialty physicians. NCAPIP’s board members and physician
networks practice in a variety of settings, including solo and small group physician
practices, multi-specialty medical groups, community health centers, local health
departments, private and public hospitals, integrated health delivery systems, and
academic health centers.

Background on Contact Tracing in Culturally Diverse Communities


In 2011, the U.S. Department of Health and Human Services (HHS) developed principles
for emergency preparedness and culturally diversity.12 While focused on preparing for
emergency responses to disasters, these principles are applicable to the unprecedented
national public health emergency currently resulting from the COVID-19 pandemic.13
HHS convened a national expert panel that developed the following consensus
statement:

The integration of racially and ethnically diverse communities into public health
emergency preparedness is essential to a comprehensive, coordinated federal,
state, tribal, territorial and local strategy to protect the health and safety of all
persons in the United States. Such a strategy must recognize and emphasize the
importance of distinctive individual and community characteristics such as

12
National Consensus Panel on Emergency Preparedness and Cultural Diversity, Guidance for
Integrating Culturally Diverse Communities into Planning for and Responding to Emergencies,
U.S. Department of Health and Human Services Office of Minority Health, 2011,
https://www.hhs.gov/sites/default/files/ocr/civilrights/resources/specialtopics/emergencypre/omh_
diversitytoolkit.pdf
13
Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease
(COVID-19) Outbreak, March 13, 2020,
https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-con
cerning-novel-coronavirus-disease-covid-19-outbreak/

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May 22, 2020
culture, language, literacy and trust and promote the active involvement and
engagement of diverse communities to influence understanding of, participation
in and adherence to public health emergency preparedness actions. Additionally,
this strategy much acknowledge the critical commitment to developing effective
and sustainable services, programs and policies and building mutual
accountability. Only through these comprehensive, unified efforts can we work to
counter the legacy of racial and ethnic disparities and ensure that quality and
equality for all communities form the foundation of the Nation’s planning for any
and all public health emergencies.

Three of the principles developed by the national expert panel were:

● Engaging community representatives to design, implement, and evaluate


emergency risk communication strategies, ensuring that they are culturally and
linguistically appropriate.
● Coordinating information, resources, and actions across organizations and
diverse communities to maximize compliance and adherence to preparedness
practices.
● Ensuring the availability of funds to develop and sustain activities that strengthen
diverse communities’ ability to prepare, respond to, and recover from emergency
events.

These themes also are included in the World Health Organization (WHO) May 2020
guidance on contact tracing for COVID-19:14

Critical elements of the implementation of contact tracing are community


engagement and public support; careful planning and consideration of local
contexts, communities, and cultures; a workforce of trained contact tracers and
supervisors; logistics support to contact tracing teams; and a system to collate,
compile, and analyse data in real-time.

Culturally and Linguistically Appropriate Community Education Explaining


Contact Tracing
As the implementation of contact tracing programs increases nationwide,15 there is an
immediate need for plain language and culturally and linguistically appropriate
community education materials in multiple languages and multiple formats explaining

14
​https://www.who.int/publications-detail/contact-tracing-in-the-context-of-covid-19
15
Alltucker K, O’Donnell J. ’50 states, 50 different approaches’: States scramble to hire
COVID-19 contact tracers. USA Today, May 13, 2020,
https://www.usatoday.com/story/news/health/2020/05/13/coronavirus-states-scramble-hire-covid-
19-contact-tracers/3088014001/

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what contact tracing is, and how to comply with a contact tracing protocol. The CDC
acknowledges that communication with the public about contact tracing is critical:

Engagement of the public with contact tracers must be widely accepted in order
to protect friends, family, and community members from future potential
infections. Key public officials and community leaders will need to be engaged
and supportive of contact tracing efforts. Consider reaching out to community
leaders as part of the neighborhood-level contact tracing team. To be successful,
a community will need public awareness, and understanding and acceptance of
contact tracing and the need for contacts to separate themselves from others
who are not exposed. Community members need to take responsibility to follow
the guidance from public health agencies.16

The WHO explains:

Contact tracing begins with engaging communities about the disease, how to
protect individuals and their communities, and how to suppress transmission.
Contact tracing requires individuals to agree to daily monitoring, to be willing to
report signs or symptoms of COVID-19 promptly, and to be prepared to go into
quarantine for at least 14 days or into isolation if they become symptomatic.
Engagement with communities and their leaders should help identify potential
challenges for contact tracing including language and literacy, access to food and
medical care for other illnesses, education, information, as well as stigma and
marginalization. Special consideration should be given to planning contact tracing
for at-risk and vulnerable groups, including, but not limited to, minority groups,
homeless persons, migrant workers, refugees, and others.
Communication about contact tracing should emphasize solidarity, reciprocity,
and the common good. By participating in contact tracing, communities will
contribute to controlling local spread of COVID-19, [and] vulnerable people will be
protected…

Physicians from racial and ethnic minority and other medically underserved communities
can be credible and trusted spokespersons to help educate communities about contact
tracing. ​Health departments should be immediately partnering with local medical
societies, state medical associations, and racial and ethnic minority physician
organizations to conduct community education about contact tracing.

Since the essential elements of any contact tracing program should be the same, there
could be standardization of community education materials, both in plain language
English, translated into multiple languages spoken throughout the U.S., and made
available in multiple formats for individuals with disabilities.

To date, the Centers of Disease Control (CDC) has made general community education
materials about COVID-19 available in multiple languages, although not all the materials

16
​https://www.cdc.gov/coronavirus/2019-ncov/php/principles-contact-tracing.html

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May 22, 2020
are available in all languages.17 State and local health departments and community and
volunteer efforts have supplemented these CDC materials with materials in additional
languages and in alternative formats, e.g, videos, social media-ready graphics, etc.18
Again, these materials are not yet available in all languages.

However, ​the CDC has yet to provide any community education materials about contact
tracing​.19 Some state and local health departments have begun to describe their contact
tracing programs on their websites,20including videos.21 Academic institutions and
organizations supporting contact tracing also have information and videos available.22
None of these materials are yet available in languages other than English.

Moreover, there are examples across the federal government for engaging diverse
communities that could provide some important models for the CDC and tribal, territorial,
state, and local health departments developing and implementing contact tracing
programs for COVD-19. For example, for Census 2020, the Department of Commerce
developed downloadable materials in multiple languages and for specific racial and
ethnic populations (including for Asians and for Native Hawaiians and Pacific Islanders),
and other diverse communities (educators, faith communities, LGBTQ+ communities).23

All contact tracing programs should have clear policies and protocols about protecting
the confidentiality and privacy of all information obtained, as well as reassuring
individuals that any and all data collected (about COVID-19 status, other health
conditions, place of residence, health insurance status, employment and income,
immigration status, about other members of the household, etc.) will not be shared with
law enforcement, police or immigration enforcement authorities. ​The identity of
individuals testing positive should never be shared with contacts.​ All contact information,
including names, phone numbers, email addresses, and home addresses are personal

17

https://www.cdc.gov/coronavirus/2019-ncov/communication/print-resources.html?Sort=Date%3A
%3Adesc
18
COVID-19 Information in Languages in Addition to English, May 1, 2020,
https://ignatiusbau.com/2020/05/01/covid-19-information-in-languages-in-addition-to-english/
19
CDC does have a webpage about isolation and quarantine that is available in English, Spanish,
Chinese, Vietnamese, and Korean, but the webpage does not refer to, or explain contact tracing:
https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine-isolation.html
20
Commonwealth of Massachusetts:
https://www.mass.gov/info-details/learn-about-the-community-tracing-collaborative​; North
Carolina: ​https://www.communitycarenc.org/carolina-community-tracing-collaborative​; San
Francisco, California:
https://sfmayor.org/article/san-francisco-launches-innovative-contact-tracing-program-strengthen-
coronavirus-response
21
Commonwealth of Massachusetts:
https://www.youtube.com/watch?v=aV990fAGeOk&feature=youtu.be
22
Johns Hopkins Bloomberg School of Public Health:
https://www.youtube.com/watch?v=dNmk_sL-xyo​; Partners in Health:
https://www.pih.org/ma-response
23
​https://2020census.gov/en/partners/outreach-materials.html

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health information that are protected from disclosure under federal privacy laws, i.e., the
Health Insurance Portability and Accountability Act (HIPAA).24 The CDC interim guidance
on contact tracing states unequivocally: “all aspects of case investigation and contact
​ ublic education
tracing must be voluntary, confidential, and culturally appropriate”.25​ P
activities and materials about COVID-19 should highlight and emphasize these
confidentiality and privacy elements of contact tracing programs. 

Recommendations
● In partnership with diverse community groups and physician organizations, the
CDC, and tribal, territorial, state, and local health departments should
immediately co-design and make widely available plain language, culturally and
linguistically appropriate community education materials about contact tracing in
multiple languages and in alternate formats accessible by individuals with
disabilities
● The CDC and tribal, territorial, state, and local health departments should
highlight the confidentiality and privacy protections in contact tracing programs to
reassure community members that any personal health or other information will
not be shared with law enforcement, police, or immigration enforcement
agencies, or used for any other purposes
● In partnership with diverse community groups, tribal, territorial, state, and local
health departments should immediately co-design and implement culturally and
linguistically appropriate contact tracing programs

Testing, Case-Finding, and Access to Treatment for COVID-19 in Diverse


Communities
Diagnostic viral testing for COVID-19 needs to be broadly and consistently available and
accessible in order for contact tracing to be effective. Individuals at all levels of risk for
COVID-19 need to be able to easily access testing, and then be able to learn of the
results as soon as possible so that those testing positive can begin isolation and health
monitoring, secure access to needed treatment, and their contacts can be identified and
traced.

24
There has been media coverage of potential technology tools to assist with contact tracing,
such as the partnership between Apple and Google to develop an app to use the Bluetooth
capabilities in iPhones for users to opt-in to be identified and alert contacts if they later test
positive. Albergotti R, Harwell D. Apple and Google clash with health officials over virus-tracking
apps. Washington Post, May 15, 2020,
https://www.washingtonpost.com/technology/2020/05/15/app-apple-google-virus/​ The American
Civil Liberties Union has raised privacy and confidentiality concerns about over-reliance on
technology for contact tracing. ACLU issues governance principles for COVID-19 contact tracing
technologies, May 18, 2020,
https://www.aclu.org/press-releases/aclu-issues-governance-principles-covid-19-contact-tracing-t
echnologies 
25
Centers for Disease Control and Prevention, Interim Guidance for Health Departments for
Developing a COVID-19 Case Investigation & Contact Tracing Plan, May 15, 2020,
https://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdf
(page 36)

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May 22, 2020
Despite significant investments by the federal, state, and local governments, there
currently remain systemic cost, supply chain, laboratory capacity, geographic, and
logistical access barriers to testing for COVID-19 that limits its availability, with lag times
of several days to learn test results.26 Continued shortages of personal protective
equipment (PPE) for those administering the tests may also limit the availability of the
tests. Even where testing capacity has been expanded, there remains confusion about
who is eligible for testing, as well as a lack of trust - particularly in racial and ethnic
minority communities - about getting tested.

There also remain inconsistencies in the number of diagnostic tests being reported by
state health departments and the number of being reported by the CDC.27 Most recently,
it has been discovered that the CDC and several states have been counting both
diagnostic tests and serological antibody tests as “tests”, artificially inflating and
confusing the data about COVID-19 incidence.28

As of this writing, there are an estimated 300,000 diagnostic tests being conducted each
day nationwide, while about three times that number of tests will be needed for effective
contact tracing.29 Those numbers of daily tests then need to be sustained for months as
the 14-day cycles of isolation and self-quarantine are completed. The Harvard Global
Health Institute recently estimated the gaps in COVID-19 testing for each state:30

26
Ketchum K, O’Connor L. COVID-19 testing problems started early, U.S. still playing from
behind. Modern Healthcare, May 11, 2020,
https://www.modernhealthcare.com/technology/covid-19-testing-problems-started-early-us-still-pl
aying-behind​; Connor K. Coronavirus test: how long does it take and when will I know my
COVID-19 results? Cnet, May 12, 2020,
https://www.cnet.com/health/coronavirus-test-how-long-does-it-take-and-when-will-i-know-my-cov
id-19-results/
27
Meyer R, Madrigal AC. State and federal data don’t match up. The Atlantic, May 17, 2020,
https://www.theatlantic.com/health/archive/2020/05/cdc-publishing-covid-19-test-data/611764/
28
Madrigal AC, Meyer R. ‘How could the CDC make that mistake?” The Atlantic, May 21, 2020,
https://www.theatlantic.com/health/archive/2020/05/cdc-and-states-are-misreporting-covid-19-test
-data-pennsylvania-georgia-texas/611935/
29
Thompson S, Ellperin J, Dennis B. As coronavirus testing expands, a new problem arises: not
enough people to test. Washington Post, May 17, 2020,
https://www.washingtonpost.com/health/as-coronavirus-testing-expands-a-new-problem-arises-n
ot-enough-people-to-test/2020/05/17/3f3297de-8bcd-11ea-8ac1-bfb250876b7a_story.html
30
Stein R, Worth C, Hurt A. U.S. coronavirus testing still falls short. How is your state doing?
National Public Radio, May 7, 2020,
https://www.npr.org/sections/health-shots/2020/05/07/851610771/u-s-coronavirus-testing-still-falls
-short-hows-your-state-doing#res851618829​;
https://globalepidemics.org/2020/05/07/hghi-projected-tests-needed-may15/ 

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May 22, 2020
While the surge in COVID-19 cases needing hospitalization in places like New York City
seem to have subsided, there remain racial and ethnic and income disparities in
accessing treatment for COVID-19.31Commentators have noted that many crisis
standards of care may inadvertently perpetuate inequities if their assumptions and
criteria do not consider health equity.32 For example, if life expectancy is one of the

31
Farmer B. Long-standing racial and income disparities seen creeping into COVID-19 care.
Kaiser Health News, April 6, 2020,
https://khn.org/news/covid-19-treatment-racial-income-health-disparities/​; Eligon J, Burch ADS.
Questions of bias in Covid-19 treatment add to the mourning for Black families. New York Times,
May 12, 2020, ​https://www.nytimes.com/2020/05/10/us/coronavirus-african-americans-bias.html
32
Manchanda EC, Couillard C, Sivashanker K. Inequity in crisis standards of care. N Engl J Med.
May 13, 2020, ​doi:10.1056/NEJMp201135​,

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May 22, 2020
criteria for prioritizing the allocation of scarce health care resources (such as intensive
care unit beds or ventilators), then racial and ethnic minorities, individuals with
disabilities, and other medically underserved populations with lower average life
expectancies because of health and other inequities will have less access to those
scarce health care resources.

In addition, there has been under-reported morbidity and mortality from delayed care for
pre-existing conditions; racial and ethnic minority and other medically underserved
patients are more likely to experience these otherwise preventable health outcomes.33
These disparities will be exacerbated as unemployment rates continue to increase, and
individuals continue to lose access to employer-based health insurance coverage or are
unable to access Medicaid, especially racial and ethnic minority and low-income
Americans. Most immigrants are ineligible for Medicaid for 5 years,34 many states have
not expanded Medicaid,35 and Pacific Islanders from the Freely Associated States are
still blocked from enrolling in Medicaid.36 Ensuring equitable access to needed treatment
for COVID-19 – and other pre-existing conditions – will be critical to any contact tracing
program.

Another significant challenge to broad testing will be the actual and perceived barriers to
testing and treatment for immigrants.37 While the Families First Coronavirus Response
Act made all uninsured individuals eligible for free testing for COVID-19 and the
Coronavirus Aid, Relief, and Economic Security (CARES) Act provided $100 billion to
hospitals to treat the uninsured, it is not clear how uninsured immigrants will be able to
access COVID-19 testing and treatment, and that access may depend on Medicaid
policies that are different in every state​. These uncertainties will result in continuing

https://www.nejm.org/doi/full/10.1056/NEJMp2011359​; Mello MM, Persad G, White DB.


Respecting disability rights – toward improved standards of care N Engl J Med. May 19, 2020,
doi:10.1056/NEJMp2011997, ​https://www.nejm.org/doi/full/10.1056/NEJMp2011997 
33
Artiga S, Garfield R, Orgera K. Communities of color at higher risk for health and economic
challenges due to COVID-19. Kaiser Family Foundation, April 7, 2020,
https://www.kff.org/coronavirus-covid-19/issue-brief/communities-of-color-at-higher-risk-for-health
-and-economic-challenges-due-to-covid-19/
34
Broder T, Moussavian A, Blazer J. Overview of Immigrant Eligibility for Federal Programs,
National Immigration Law Center, 2015,
https://www.nilc.org/issues/economic-support/overview-immeligfedprograms/
35
Kaiser Family Foundation, Status of State Action on Medicaid Expansion, April 27, 2020,
https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-t
he-affordable-care-act/?activeTab=map&currentTimeframe=0&selectedDistributions=status-of-m
edicaid-expansion-decision&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22a
sc%22%7D
36
Asian & Pacific Islander American Health Forum, Letter to Congressional Leaders on COFA
and COVID-19, May 7, 2020,
https://www.apiahf.org/wp-content/uploads/2020/05/20.05.07-APIAHF-Letter-to-Congressional-Le
aders_COFA-and-COVID.pdf
37
Duncan WL, Horton S. Serious challenges and potential solutions for immigrant health during
COVID-19. Health Affairs Blog, April 13, 2020,
https://www.healthaffairs.org/do/10.1377/hblog20200416.887086/full/

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May 22, 2020
confusion and misinformation among immigrant communities about eligibility for
COVID-19 testing and treatment. Since immigration law is extremely complex and there
are dozens of different immigration statuses (and many immigrant families and
households include individuals with different immigration statuses, e.g. an
undocumented parent with U.S. citizen children), it will continue to be challenging to
disseminate consistent and accurate information about immigrant access to COVID-19
testing and treatment.38 As long as there are actual or perceived fears and concerns
about eligibility, immigrants will face barriers in fully participating in contact tracing
programs.39

In addition, the Department of Homeland Security’s new public charge test, which
became effective on February 24, 2020, will remain a significant deterrent for immigrants
in accessing COVID-19 testing and treatment.40 That new public charge test expanded
the reasons that an individual might be denied lawful permanent residence, or a “green
card” to include receipt of Medicaid (with some exceptions). Although DHS issued a
statement on March 13 seeking to clarify that COVID-19 testing and treatment accessed
through Medicaid would not be considered as part of the public charge test,41 the
statement is confusing, and has not been well-disseminated by DHS. To date, attempts
to suspend the implementation of the new public charge test during the COVID-19
pandemic through litigation and legislation have not succeeded, but are ongoing.42
Addressing and overcoming immigrant fears and concerns about public charge will be
another significant challenge to effective contact tracing in immigrant communities.

Recommendations
● The federal government, and tribal, territorial, state, and local health departments
should ensure equitable access to testing for COVID-19, including removing cost
and other barriers to testing
● The federal government and tribal, territorial, state, and local health departments
should ensure equitable access to treatment for COVID-19, including expansions
of Medicaid and suspension of implementation of the Department of Homeland
Security public charge test during this national public health emergency
38
​https://protectingimmigrantfamilies.org/
39
The Coronavirus Immigrant Protection Act (H.R.6437 and S.3609) would ensure that all
immigrants have access to COVID-19 testing and treatment, provide $100 million to the CDC for
community education about COVID-19 in multiple languages, and suspend the implementation of
the public charge test,
https://www.nilc.org/2020/04/03/coronavirus-immigrant-families-protection-act-introduced/
40
Khafagy A. Some immigrants avoid New York hospitals because of the public charge rule.
Documented, May 21, 2020,
https://documentedny.com/2020/05/21/some-immigrants-avoid-new-york-hospitals-because-of-th
e-public-charge-rule/
41
U.S. Citizenship and Immigration Services, Public Charge, updated March 11, 2020,
https://www.uscis.gov/green-card/green-card-processes-and-procedures/public-charge
42
Runyeon FG. Judge says virus changes debate over ‘public charge’ rule. Law360, May 18,
2020,
https://www.law360.com/health/articles/1274705/judge-says-virus-changes-debate-over-public-ch
arge-rule

13
May 22, 2020
Supporting Isolation, Quarantine, and Health Monitoring with Culturally and
Linguistically Appropriate Services
Those who test positive for COVID-19 will be asked to isolate at home for at least 14
days, maintaining physical distance from others. Isolation is more restrictive than
shelter-in-place or stay-at-home orders, which allow individuals to leave home to shop
for groceries, pick up food, exercise, and other essential tasks (such as picking up
medication from a pharmacy). The individual in isolation may need cleaning supplies,
cloth face coverings, gloves, a thermometer, and other supplies. Individuals who are
isolating should also be provided resources and referrals for emotional support and
mental health issues that may be present or emerge with learning of the positive test
result, and during the 14-day period of isolation. Of course, explaining isolation and how
to monitor one’s own health (and what symptoms would require going to the hospital or
emergency department) requires culturally and linguistically appropriate
communications, including addressing issues of health literacy, language access, and
appropriate communications with individuals with disabilities. The CDC interim guidance
on contact tracing states explicitly: “all instructions [for isolation and monitoring] should
be provided in a patient’s primary language”.43 Some contact tracing programs will
integrate technology tools to support monitoring, including automated interactive calls or
text messages; those technologies also need to be culturally and linguistically
appropriate.44
 
In addition, wraparound services to support isolation or self-quarantine must be readily
available and accessible, including non-COVID-19 related medication and health care,
housing, food, childcare, other caregiving, laundry, trash removal, internet access, and
income support. The need for these wraparound services may be extremely challenging,
especially as contact tracing increases and there are thousands of individuals that need
to isolate at home for 14 days. For example, in places in which there are significant
numbers of homeless individuals, temporary housing will need to be secured. Moreover,
many individuals who do have housing may not have a separate room (and bathroom),
that they can use for isolation, or live in multi-generation households with others that
would be at high risk if infected, and would also need alternative housing for the 14-day
period.45 An individual may not have the economic means to order food online or for
delivery, and may not have the capacity to prepare meals without violating physical
distancing guidelines with other members of the household. An individual may be a

43
Centers for Disease Control and Prevention, Interim Guidance for Health Departments for
Developing a COVID-19 Case Investigation & Contact Tracing Plan, May 15, 2020,
https://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdf
(page 16)
44
Toren M. Privacy and cultural sensitivity are priorities for the health department’s coronavirus
contact-tracing taskforce. SF Weekly, April 16, 2020,
https://www.sfweekly.com/news/the-health-department-is-building-a-coronavirus-contact-tracing-t
askforce/
45
New York City is providing temporary housing at local hotels for individuals who cannot safely
isolate or self-quarantine at home:
https://www1.nyc.gov/site/helpnownyc/get-help/covid-19-hotel-program.page

14
May 22, 2020
parent who has to take care of children at home (and for now, support online schooling
at home), or has other caregiver responsibilities that need substitute arrangements to
manage these caregiving responsibilities.

Accordingly, effective contact tracing requires a robust system of referrals and real-time
linkages to housing, food, childcare, income, and other supports that themselves are
culturally and linguistically appropriate. For example, if a self-quarantined individual
needs to access the local food bank to arrange for delivery of meals, that food bank
needs to be able to communicate with individuals in multiple languages and to have the
capability to make meal deliveries to all neighborhoods. The contact tracers need to act
as case managers to ensure that these supports are actually accessed and meet the
needs of the individual in isolation or self-quarantine.

Health departments developing and implementing contact tracing programs should look
to some of the innovative work being implemented by health plans, hospitals and health
systems, physician groups, community health centers, social service providers, and
community-based organizations to identify and address health-related social needs and
address the social determinants of health through strengthened referrals and linkages
between health care providers and social services providers. Models such as the
Centers for Medicare and Medicaid Services’ Accountable Health Communities46 and
accountable communities for health47 have compiled and are using localized community
resource directories of housing, food, and other social services to ensure effective
linkages.48 Contact tracing programs should leverage these resources to support
individuals in isolation and self-quarantine.49

And finally, while COVID-19 legislation has provided some immediate financial relief
through the economic impact payments, enhanced and extended unemployment
benefits, and the Paycheck Protection Program and other assistance to small
businesses, these measures are likely to be insufficient to financially support an
individual in isolation or self-quarantine for 14 days, especially as the pandemic
continues through the summer and fall. An individual may work in a job without paid sick
leave, or they may work as an independent contactor or be self-employed, so that
isolation or self-quarantine means loss of income that cannot be replaced. In order for
these individuals to successfully isolate, alternative income support must be offered. A

46
​https://innovation.cms.gov/innovation-models/ahcm
47
George Washington University Milken Institute School of Public Health, Funders Forum for
Accountable Communities for Health, Inventory of Accountable Communities for Health,
https://accountablehealth.gwu.edu/ACHInventory
48
Cartier Y, Fitchenberg C, Gottlieb L. Community Resource Referral Platforms: A Guide for
Health Care Organizations, University of California San Francisco Social Interventions Research
& Evaluation Network, 2019,
https://sirenetwork.ucsf.edu/sites/sirenetwork.ucsf.edu/files/wysiwyg/Community-Resource-Referr
al-Platforms-Guide.pdf 
49
Similarly to many other services that relied on face-to-face encounters prior to COVID-19, many
of these services will need to be adapted to physical distancing requirements, using virtual
communications and contacts, and home drop-offs and deliveries.

15
May 22, 2020
bipartisan group of national health leaders has proposed a stipend of $50 a day for those
in isolation or self-quarantine, which would cost an estimated $30 billion over the next 18
months.50

Note on Civil Rights and Civil Liberties


Requirements to isolate or self-quarantine, and more general requirements to
shelter-in-place/stay at home, are being imposed through public health laws.51
Depending on the jurisdiction, individuals in violation of these public health orders may
be issued citations with penalties that include both fines and jail time. While there has yet
to be widespread citations, unfortunately, there already is evidence of inequitable
enforcement in places such as New York City and Ohio, where Black and Latinx
residents have been disproportionately issued citations for not complying with physical
distancing orders.52 While participation in contact tracing, isolation, and self-quarantine
will remain largely voluntary, communities should remain vigilant in monitoring and
ensuring the equitable implementation and support for contact tracing in all communities,
and any disparities in the use of law enforcement related to COVID-19 public health
orders.53

Since health departments are relying on voluntary compliance with isolation and
self-quarantine recommendations, they are not issuing individual termination of isolation
or quarantine orders, or “return to work” letters. There are two ways to confirm when it is
safe to end isolation or self-quarantine.54 First, a COVID-19 viral test-based strategy
requires ​an individual’s fever resolving without the use of fever-reducing medication,
respiratory symptoms improving, and two consecutive negative COVID-19 viral tests 24

50
Ordonez F. Ex-Officials call for $46 billion for tracing, isolating in next coronavirus package.
National Public Radio, April 27, 2020,
https://www.npr.org/2020/04/27/845165404/ex-officials-call-for-46-billion-for-tracing-isolating-in-n
ext-coronavirus-packa
51
Gostin LO, Wiley LF. Governmental public health powers during the COVID-19 epidemic.
JAMA. April 2, 2020, doi:10.1001/jama.2020.5460,
https://jamanetwork.com/journals/jama/fullarticle/2764283
52
Southall A. NYC commissioner denies racial bias in social distancing policing. ​New York Times,
May 13,
2020,​https://www.nytimes.com/2020/05/13/nyregion/nypd-social-distancing-race-coronavirus.html
; Kaplan J, Hardy B. Early data shows Black people are being disproportionately arrested for
social distancing violations, ProPublica, May 8, 2020,
https://www.propublica.org/article/in-some-of-ohios-most-populous-areas-black-people-were-at-le
ast-4-times-as-likely-to-be-charged-with-stay-at-home-violations-as-whites
53
Civil rights organizations have created a website that lists public health orders and monitors
their enforcement: ​https://communityresourcehub.org/covid19-policing/
54
Lee BY. How long does it take to recover from COVID-19 and return to work? Forbes, May 5,
2020,
https://www.forbes.com/sites/brucelee/2020/05/05/how-long-does-it-take-to-recover-from-covid-1
9-coronavirus-and-return-to-work/

16
May 22, 2020
hours apart.55 Individuals in self-quarantine who do not develop any symptoms also
would need the two consecutive negative COVID-19 viral tests 24 hours apart to
complete the quarantine period.

However, as of May 3, 2020, the CDC continues to recommend a “no-test”, or


symptom-based, termination of an isolation or quarantine period. In other words, the
CDC is not recommending that individuals to be tested for COVID-19, with negative
results as a condition for completing the period of isolation or self-quarantine. Instead,
the CDC recommends that any individual who has experienced symptoms of COVID-19
remain in isolation or self-quarantine for at least 10 days since symptoms first appeared,
and for at least 3 days after recovery, defined as “​resolution of fever without the use of
fever-reducing medications with progressive improvement or resolution of other
symptoms” (e.g., cough, shortness of breath)​.56 If symptoms did not appear immediately
or recovery has taken longer, then these time periods may extend beyond the general
14-day isolation or self-quarantine period. For contacts in self-quarantine who do not
develop symptoms, then the self-quarantine period will be completed after 14 days from
the presumed date of contact, without the need for a COVID-19 viral test (with a negative
result).

These guidelines for ending isolation and self-quarantine will continue to be very
confusing, and also will continue to change, as testing - including serological testing for
antibodies - becomes more widely available, and more and more employers expect
assurances that it is “safe” for their employees to return to work. It is uncertain whether
there will be equitable access to all this follow-up testing for everyone in isolation and
self-quarantine. 

Recommendations
● Tribal, territorial, state, and local health departments should ensure language
assistance services, and communications access for individuals with disabilities,
in all contact tracing activities
● Tribal, territorial, state, and local health departments should ensure that all
necessary wraparound services and supports for isolation and self-quarantine,
including housing, food, childcare, income, and other supports are culturally and
linguistically appropriate, and are available without cost

Notifying and Following Up with Contacts through Culturally and Linguistically


Appropriate Communications and Supports
The key step in contact tracing is working with the individual who tests positive to
remember and identify all potential contacts that might have been exposed so that the
contact tracer can contact them. The CDC interim guidance on contact tracing

55
​Gander K. CDC guidelines on untested COVID-19 patients ending self-isolation could be
helping virus spread, say doctors. Newsweek, May 13
2020,​https://www.newsweek.com/cdc-guidelines-untested-covid-19-patients-self-isolation-corona
virus-spread-1503605
56
​https://www.cdc.gov/coronavirus/2019-ncov/community/strategy-discontinue-isolation.html

17
May 22, 2020
recommends: “a patient will ideally be interviewed by a case investigator who is fluent in
their primary language. If this is not possible, health departments should provide
interpretation services, ideally by an individual with an understanding of the patient’s
cultural background”.57

Even though the contact tracer will never identify the infected person to the contacts, this
process requires trust and understanding of the contact tracing protocol. For example, it
is useful to collect as much demographic data about contacts as possible but the
individual who has tested positive may not know all the demographic characteristics of
the contacts. The CDC interim guidance on contact tracing states: “core demographic
variables should be included in case investigation and contact tracing forms, including
detailed race and ethnicity, as well as preferred language”, and the CDC’s sample forms
include questions about gender, tribal affiliation, and use of an interpreter, and suggest
using either HHS58 or Census59 categories for race and ethnicity.60 ​NCAPIP strongly
recommends the use of disaggregated race and ethnicity categories, with response
options for Asian that, at a minimum, include Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and Other Asian; and response options for Native
Hawaiians and Pacific Islanders that, at a minimum, include Native Hawaiian, Samoan,
Chamorro, and Other Pacific Islander. 

The contact tracer can utilize multiple types of communication (phone, text, email,
videoconferencing, in-person visit, etc.) to reach the contacts. The contact tracer must
be able to access qualified health care interpreters to communicate with individuals who
speak languages in addition to English, and to use communications appropriate for
individuals with disabilities, e.g. free telecommunications relay services for individuals
who are deaf or hard of hearing.61 The contact tracer can confirm or supplement the
demographic data about the contact through the self-reports of the contacts themselves.

Contacts will be educated about COVID-19, be informed about the availability of testing,
asked to self-quarantine and maintain physical distance from others for 14 days since
the date of contact. Contacts will be asked what supports they need to successfully
complete the period of self-quarantine, and offered any needed housing, food, childcare,

57
Centers for Disease Control and Prevention, Interim Guidance for Health Departments for
Developing a COVID-19 Case Investigation & Contact Tracing Plan, May 15, 2020,
https://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdf
(page 13)
58
U.S. Department of Health and Human Services Office of Minority Health, Data Collection
Standards for Race, Ethnicity, Primary Language, Sex, and Disability Status, 2011.
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=23
59
U.S. Census, Census 2020: Questions Asked on the Form,
https://2020census.gov/en/about-questions.html
60
Centers for Disease Control and Prevention, Interim Guidance for Health Departments for
Developing a COVID-19 Case Investigation & Contact Tracing Plan, May 15, 2020,
https://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdf
(page 31 and Appendix C: Data Elements for Case Investigation and Contact Tracing Forms)
61
​https://www.fcc.gov/consumers/guides/telecommunications-relay-service-trs

18
May 22, 2020
income, and other supports. Contact tracers will follow-up with them, as frequently as
daily, to monitor their health and adherence to self-quarantining. Of course, contacts who
do test positive or begin to experience symptoms will need referrals and real-time
linkages to appropriate treatment.

Finally, these contact tracing programs will require regional coordination, referrals, and
linkages because contacts will not necessarily be limited to the geographic boundaries of
any state, county, city, or other local jurisdiction.

Recommendation
● Tribal, territorial, state, and local health departments should collect and confirm
comprehensive self-reported demographic data from all contacts as part of
contact tracing, including zip code of residence, age, sex, race, ethnicity, primary
language, disability status, sexual orientation, and gender identity62
Hiring a Culturally and Linguistically Concordant Contact Tracer Workforce
The ​Johns Hopkins Bloomberg School of Public Health Center for Health Security
estimates that up to 100,000 contact tracers for COVID-19 will need to be hired, trained,
and deployed over the next few months;63 others have estimated the need to be 300,000
contact tracers.64 New York state is planning on hiring 17,000 contact tracers,65
California is planning on hiring 20,000, and in early May, National Public Radio reported
plans from 44 states and the District of Columbia to hire over 67,000 contact tracers.66
The George Washington University Mullan Institute has developed a calculator for state
and local health departments to estimate the number of contact tracers that they will
need.67 For each state or county, the calculator includes the number of residents, and
the percentages of residents who are racial and ethnic minorities, non-English speaking,
living in poverty, and over age 65. The number of contact tracers per 100,000 population

62
The Commonwealth of Massachusetts announced on May 13, 2020 that it will begin collecting
sexual orientation and gender identity data for COVID-19 cases and contact tracing,
https://www.governor.pa.gov/newsroom/gov-wolf-announces-inclusion-of-gender-identity-sexual-
orientation-or-expression-in-covid-19-data-collection/
63
Watson C, Cicero, A, Blumestock J, Fraser M. National Plan to Enable Comprehensive
COVID-19 Case Finding and Contact Tracing in the U.S, ​Johns Hopkins Bloomberg School of
Public Health Center for Health Security, ​April 10, 2020,
https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2020/200410-national-p
lan-to-contact-tracing.pdf
64
Fox M. ‘We need an army’: Hiring of coronavirus trackers seen as key to curbing disease
spread. STAT, April 13, 2020,
https://www.statnews.com/2020/04/13/coronavirus-health-agencies-need-army-of-contact-tracers/
65
Voytko L. NY will hire contact tracing ‘army’ of 17,00 to battle coronavirus, Cuomo says.
Forbes, April 30, 2020,
https://www.forbes.com/sites/lisettevoytko/2020/04/30/ny-will-hire-contact-tracing-army-of-17000-t
o-baattle-coronavirus-cuomo-says/#726efcd81bf3
66
Simmons-Duffin S. States nearly doubled plans for contact tracers since NPR surveyed them
10 days ago. National Public Radio, May 7, 2020,
https://www.npr.org/sections/health-shots/2020/04/28/846736937/we-asked-all-50-states-about-th
eir-contact-tracing-capacity-heres-what-we-learne
67
​https://www.gwhwi.org/estimator-613404.html

19
May 22, 2020
can be adjusted, depending on the number of COVID-19 cases reported for that
jurisdiction.

One of the important ways to ensure culturally and linguistically appropriate contact
tracing is hiring and using contact tracers who are culturally and linguistically concordant
with the communities they will be working in. The CDC references this concordance in its
guidance on qualifications for contact tracers, which include: “​excellent and sensitive
interpersonal, cultural sensitivity, and interviewing skills such that they can build and
maintain trust with patients and contacts” and “cultural competency appropriate to the
local community”.68 In its recently issued interim guidance on contact tracing, the CDC
states more explicitly: “​to be effective, case investigation and contact tracing requires
staff with adequate training, language skills, cultural sensitivity, supervision, and access
to social and medical support for clients and their contacts“ and “to help build trust,
jurisdictions should try to employ public health staff who are of the same racial and
ethnic background as the affected community and are fluent in their preferred language.”
69

Similarly, the WHO recommends:

Ideally, contact tracers are recruited from their own community and have an
appropriate level of literacy, strong communication skills, local language
proficiency, and an understanding of context and culture. They should be
recruited from their own communities same communities, they should be familiar
with and trained on the basics of COVID-19 transmission, prevention and control
measures, how to monitor signs and symptoms, as well as the ethics of public
health surveillance and quarantine.

The Association of State and Territorial Health Officials also notes:

As part of this rapid workforce expansion, public health leaders and hiring
officials should consider prioritizing the recruitment of individuals from the
communities in which the investigators will be working and who reflect the
diversity of the communities being served. Because contact investigation is
based on trust, the ability to quickly build trust requires cultural knowledge and
humility that makes community membership vital to success. As such, additional
contact investigators could include the workforce that is part of and trusted by the
communities in which they are working whenever possible. Individuals from the
community are more likely to speak the language and understand the community
traditions and norms.70

68
​https://www.cdc.gov/coronavirus/2019-ncov/php/principles-contact-tracing.html
69
Centers for Disease Control and Prevention, Interim Guidance for Health Departments for
Developing a COVID-19 Case Investigation & Contact Tracing Plan, May 15, 2020,
https://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdf
(pages 5 and 31)
70
Association of State and Territorial Health Officials, A Coordinated National Approach to
Scaling Public Health Capacity for Contact Tracing and Disease Investigation, 2020,
https://www.astho.org/COVID-19/A-National-Approach-for-Contact-Tracing/​;

20
May 22, 2020
Some local health departments are shifting staff from other roles, or staff from other local
department such as libraries, into contact tracing positions.71 Individuals who were in
public-facing roles such as librarians have skills and experience that make them effective
contact tracers. Others are calling for community-based organizations to partner with
them in contact tracing activities, as well as individual volunteers to become contact
tracers.72 If health departments ask community-based organizations to be partners in
contact tracing, there should be financial support for such partnerships because those
community-based organizations already are experiencing losses of funding while
demand for services increases during the pandemic.

Community health workers, health insurance enrollment assisters, health care


navigators, peer mental health specialists, health educators, health care interpreters,
care coordinators, case managers, social workers, and other community-based/peer
health workers all would be ideal candidates to become hired and trained as contact
tracers. Many of these types of health care workers already work at community-based
organizations, community health centers, and solo and small group physician practices
and could be quickly trained and activated as contact tracers. Peace Corps and
AmeriCorps workers who may have been recalled from their assignments during the
pandemic and who may have cross-cultural skills and experiences also are good
candidates to become contact tracers.73 In diverse communities, being a peer from the
local community may be a more important qualification than education level or
professional degrees.74 While each tribal, territorial, state, and local health department
needs to make hiring decisions that make sense for their specific context and
organizational capabilities, ensuring culturally and linguistically concordant contact
tracers will be a key to effectiveness.

For reference, other federal departments have developed ways of hiring large numbers
of culturally and linguistically appropriate workforces for community outreach, education,
and engagement. For example, the U.S. Census Bureau has prioritized the hiring of
culturally and linguistically concordant enumerators, estimating that it would need to hire
up to 500,000 workers for Census 2020. The Census Bureau explains: “​Hiring local field
staff will be critical to ensuring a complete and accurate count, especially for
hard-to-reach communities. Local candidates bring relevant language skills and cultural

71
Fortin J. So you want to be a contact tracer? New York Times, May 18, 2020,
https://www.nytimes.com/2020/05/18/health/coronavirus-contact-tracing-jobs.html
72
Santa Clara Department of Public Health,
https://www.sccgov.org/sites/covid19/Pages/contact-tracing.aspx
73
Ortiz E. Contact tracing proposal by Sen. Warren, Rep. Levin would create ‘containment corps’,
NBC News, April 23, 2020,
https://www.nbcnews.com/politics/politics-news/contact-tracing-proposal-sen-warren-rep-levin-wo
uld-create-containment-n1190331
74
Wessler J, Feliciano A. Correcting NYC’s health disparities starts with how we do contact
tracing, CityLimits, May 11, 2020,
https://citylimits.org/2020/05/11/opinion-correcting-nycs-health-disparities-starts-with-how-we-do-
contact-tracing/

21
May 22, 2020
familiarity that allow them to access residents who might otherwise keep their doors
closed to Census takers from outside the neighborhood.”75 However, the Census Bureau
had years to plan for and implement its hiring, while contact tracers will need to be hired,
trained, and deployed rapidly in the coming weeks and months. 

Regardless of whether hiring culturally and linguistically concordant contact tracers is


feasible, all health departments should include training on culturally and linguistically
appropriate communications, outreach, and engagement skills for all contact tracers.
The CDC’s sample training plan for COVID-19 contact tracers include curricula on
language assistance services, communication with the deaf and hard of hearing, health
literacy, standards for culturally and linguistically appropriate services,76 cultural humility,
and implicit bias.77 The California Pan-Ethnic Health Network also recommends training
on trauma and trauma-informed approaches.78 All contact tracers should receive training
on how to address issues of trust of public health authorities (especially among Black,
Latinx, American Indian, Native Hawaiian, and Pacific Islander communities), language
access for individuals who speak languages in addition to English, and inclusive
communications for individuals with disabilities. For example, contact tracers should be
able to have evidence-based conversations about the racial and ethnic disparities in
COVID-19 cases and deaths, and be able to answer questions about those disparities.
Moreover, contact tracers should be knowledgeable about the fears and concerns of
immigrants, and potential confusion and misinformation, about the relevance of
COVID-19 testing and treatment to the DHS public charge test.

Recommendations
● Tribal, territorial, state, and local health departments should hire and partner with
community-based organizations to deploy culturally and linguistically concordant
contact tracers to meet the needs of diverse communities
● Tribal, territorial, state, and local health departments should continuously monitor
and publicly report all contact tracing activities stratified by demographic data to

75
​https://www.censusoutreach.org/census-enumerators
76
U.S. Department of Health and Human Services Office of Minority Health, Cultural Competency
Program for Disaster Preparedness and Response,
https://thinkculturalhealth.hhs.gov/education/disaster-personnel
77

https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/contact-tracer-sample-training-plan.p
df
78
California Pan-Ethnic Health Network (CPEHN) Letter to California Governor and Department
of Public Health, May 19, 2020,
https://cpehn.org/sites/default/files/cpehn_contact_tracing_letter_5.19.2020_2.pdf​; CPEHN
references the training materials on trauma-informed approaches available from the Substance
Abuse and Mental Health Services Administration, SAMHSA’s Concept of Trauma and Guidance
for a Trauma-Informed Approach, 2014,
https://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Inf
ormed-Approach/SMA14-4884

22
May 22, 2020
identify and immediately address any identified disparities in access to testing
and treatment, and in participation and adherence to contact tracing protocols

Conclusion
Successfully emerging from the COVID-19 pandemic will require effective contact tracing
programs to control the spread of the virus by breaking the chains of continued
transmission. This paper articulates reasons why culturally and linguistically appropriate
contact tracing is vital to effective contact tracing in diverse communities. Given the
emerging evidence of racial and ethnic disparities in COVID-19 incidence and mortality,
ensuring culturally and linguistically appropriate contact tracing should be an urgent and
immediate priority for the CDC, for tribal, territorial, state, and local health departments,
and for all Americans who are committed to working together to end this pandemic.

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May 22, 2020