The Los Angeles County Department of Public Health (DPH) works to protect and improve health and well-being in the largest county in the United States. Los Angeles County is home to over 10 million residents and has a racial/ethnic make-up of 48% Latino, 28% White, 15% Asian, 9% Black, 0.2% Native Hawaiian/Pacific Islander, and 0.2% Native American (Attachment 1). As good stewards of public health, in March 2020 DPH mounted an all-hands-on deck response to intervene, control, and stop the spread of COVID-19. 

COVID-19 outbreaks were initially handled by the existing Community and Field Services (CFS) Division, five distinct regional health offices that provide public health services across Los Angeles County’s 4,000 square miles. As the pandemic continued to unfold and the work became more than what the existing CFS structure could handle, the Outbreak Management Branch (OMB) was formed. OMB’s objective was to investigate and manage COVID-19 outbreaks by providing infection control guidelines and best practices to enforce requirements under Health Officer Orders and assist impacted sites mitigate COVID-19 spread. OMB was established by two Regional Health Officers and the Department’s Nursing Administration’s Directors. It later added a data science team and DPH’s Chief Compliance Officer. At its peak, the Branch’s workforce comprised nearly 500 permanent and contracted staff including physicians, nurses, public health investigators, and analysts. They managed hundreds of outbreaks daily. In addition to these professional staff, teams of health program analysts, administrative aids, contracts and grants, finance, and other Nursing Administration personnel provided operational support. 

After establishing OMB, it became clear that outbreaks were prevalent in skilled nursing facilities, congregate living settings, areas utilized by persons experiencing homelessness (PEH), worksites, and educational and day care settings. Each of these sectors required a unique set of protocols and recommendations to mitigate outbreaks. In response, OMB restructured its operations to have specific teams focus on setting-specific sectors. For example, to assist with an alarming rise in COVID-19 outbreaks at law enforcement agencies, a multidisciplinary group of OMB staff and partner agencies was created to tailor mitigation strategies, so they fit the specific needs of this sector (Attachment 2).  

The response to COVID-19 outbreaks also required new systems and processes to be established, including the creation of a new Data Science Team (DST) to serve as a backbone infrastructure for timely, real-world flow of data/information. The most significant transformations and improvements in outbreak management were achieved through this team, which helped to develop and implement data-driven administrative and clinical workflows. The team produced accurate, real-time dashboards, metrics, and protocols that informed decision-making throughout the pandemic.   

To meet the rapidly evolving challenges of the pandemic, OMB relied heavily upon collaborations and partnerships within the community and across the Department. For instance, OMB worked closely with DPH’s Acute Communicable Disease Control (ACDC), Environmental Health (EH), Health Facilities Inspection Division (HFID), the Office of Health Assessment and Epidemiology, Chronic Disease and Injury Prevention, and the Incident Command Structure’s planning and policy teams throughout the COVID-19 public health crisis. 

The emergence of the COVID-19 pandemic in 2020 brought about extraordinary challenges, suffering, and devastation felt around the world. For the 10 million residents of Los Angeles County, the impact of COVID-19 has been deeply painful. With over 27,000 COVID-19 related deaths in the county as of December 2021, the pandemic has caused a tremendous loss and burden for many families and communities. Furthermore, pre-COVID disparities in health outcomes across underserved communities in the region were greatly amplified during the health crisis.  

As good stewards of public health, DPH mounted an all-hands-on deck response to intervene, control, and stop the spread of COVID-19. On March 4, 2020, Los Angeles County declared a public health emergency and immediately activated an incident command structure (ICS) to mobilize its resources and respond to the unfolding crisis, which was at its height during the Winter of 2020-2021. Within the Department’s ICS, the Community and Field Services (CFS) Division, comprised of five regional offices, were tasked with managing the complex COVID-19 outbreaks that emerged throughout the county.  

Prior to the COVID-19 pandemic, these five CFS regional offices served as DPH’s field offices with frontline staff including physicians, nurses, public health investigators, and other providers who managed communicable diseases and other public health issues at a local level. Given its large size (approximately 4,000 square miles) and population (over 10 million residents), Los Angeles County is divided into eight geographical areas called Service Planning Areas (SPAs); the five regional offices were established to cover these eight SPAs. This CFS structure enabled DPH to tailor essential public health activities based on community needs and via a health equity perspective. For example, several offices prioritized working with PEH populations while others prioritized working with trauma and violence prevention efforts, including root causes of higher African American infant mortality.  

CFS was a natural fit to take on the responsibility of managing COVID-19 outbreaks. Its structure was already in place to manage communicable diseases regionally. However, as the pandemic persisted, CFS came to recognize early on that these outbreaks were more complex and significantly higher in volume/workload than any other infectious disease it has encountered previously. As such, CFS needed to expand its infrastructure to include more resources, more experts, and more collaborations with other DPH divisions/programs. Newer and more timely processes for information flow was also needed.  

As the pandemic continued to unfold and the work became more than the existing CFS structure could handle, the Outbreak Management Branch (OMB) was formed. OMB’s objective was to investigate and manage COVID-19 outbreaks by providing infection control guidelines and best practices to enforce requirements under Health Officer Orders and help impacted sites mitigate COVID-19 spread. Within a short period of time, DPH reassigned some of its public health physicians, nurses, public health investigators, and analysts from other programs to support this new Branch. Contracted staff were also hired. At its peak, the OMB workforce comprised nearly 500 permanent and contracted staff who managed hundreds of outbreaks daily across Los Angeles County. The attached epi-curve (Attachment 3) illustrates the large number of COVID-19 outbreaks these hundreds of staff have been tasked to mitigate. 

After establishing the OMB, it became clear that outbreaks were prevalent in skilled nursing facilities, congregate living settings, areas utilized by PEH, worksites, and educational and day care settings. As a result, OMB pivoted and quickly restructured itself to have defined teams that would focus on specific settings, while still being able to address outbreaks by region. This new structure allowed OMB staff to better meet the needs of the communities most impacted by COVID-19, including those already affected by existing inequities and disparate health outcomes. For example, the PEH team improved its capability and efficiency by bringing onboard experienced public health nurses and physicians who knew how to work with PEH in encampments and shelters. Based on growing need for this work, the PEH team eventually evolved into its own COVID-19 response branch.  

Another specialized team in OMB was the worksite team. Outbreak investigations at worksites were critical for helping employers implement time-sensitive public health strategies to slow down the spread of COVID-19. This was especially important for protecting front-line, essential workers across the county. As an example, in June 2020 a large garment manufacturer in Los Angeles County had a major COVID-19 outbreak. Their employees were low-wage workers, many of whom were non-English speaking. Twenty-five percent of their employees contracted COVID-19 and seven died. In response, OMB reached out and collaborated with this employer to stem the tide of the spread. With ACDC and EH assistance, the outbreak investigation team conducted site visits, identified gaps in the way COVID-19 protocols were implemented, and provided technical assistance to improve compliance and protect the workers at the various manufacturing facilities. At a time when vaccination against COVID-19 was not available, this effort was critical for helping low-wage workers who often live in crowded housing settings, situations where the virus can easily spread throughout a household.  

Finally, the local COVID-19 response required systems and data-driven processes that were relatively new to CFS and DPH. This need led to the creation of a Data Science Team (DST), led by a Medical Director/Science Officer and a Chief Epidemiologist reassigned from another Division to support outbreak investigation. This new team is staffed by 100+ epidemiologists and public health data analysts. It is currently responsible for compiling and providing real-time data to OMB and Department leadership so they can use the information for strategic planning and field decision-making. Among DST’s innovations included developing quality assurance metrics, carrying out quality improvement activities, collecting primary data when needed, and working with frontline staff to support outbreak investigation activities in the field. This use of such a skilled data team streamlined as well as enhanced the quality of the outbreak management processes. DST represented a new approach by DPH to improve data/information flow and support timely management of COVID-19 outbreaks.

In order to meet the challenges of COVID-19, OMB relied heavily upon collaborations and partnerships. OMB was established by two Regional Health Officers and the Department’s Nursing Administration’s Directors. The Branch later added a data science team and DPH’s Chief Compliance Officer. The Branch leadership team worked collaboratively with several key DPH divisions and programs including, but not limited to the Acute Communicable Disease Control division, Environmental Health, Health Facilities Inspection Division, Office of Health Assessment and Epidemiology, Chronic Disease and Injury Prevention, and ICS’s central planning and policy teams. In addition, teams of health program analysts, administrative aids, contracts and grants, finance, and other Nursing Administration’s staff helped facilitate OMB’s daily operations and supported its administrative processes, including the hiring and onboarding of new staff.  

At an internal level, several DPH units supported each other to provide protocol enhancements, expand staffing support, and provide educational and/or vaccination resources. These innovative partnerships and across group collaborations allowed the cross referrals and shared support to become reality. For example, prior to COVID-19 EH had a primary focus on enforcing regulations with worksites only; however, due to the complex nature of COVID-19, it became necessary that EH and OMB needed to work together to conduct site visits and ensure that sites were in compliance with COVID-19 safety protocols. Another example of collaboration/shared resources was how OMB coordinated not just outbreak investigations but also educational opportunities for employers through presentations and Q&A sessions and referral to the Mobile Vaccine Team unit to provide vaccination services at the employer’s site when needed.   

At an external level, OMB understood the importance of collaborating with impacted agencies, businesses, and facilities, whenever possible, to optimize effectiveness of infection control. With OMB’s infrastructure set up to address outbreaks in sector-specific settings, OMB’s frontline staff were able to focus on the most relevant needs of sector-specific communities based on known characteristics of COVID-19 spread in these sectors. During a six-month sample period between October 2020 and March 2021, the outbreak investigation teams implemented tailored mitigation strategies to over 300 sites across Los Angeles County, including settings in military/defense, state/local government, private sector industries, and education/college athletics. 

Over the course of the pandemic, the OMB team identified many outbreaks at law enforcement agencies around the county (Attachment 2). Los Angeles County is geo-politically complex, comprising 88 municipalities and a large unincorporated area, most with their own law enforcement agencies including the County’s Sheriff’s Department. OMB, under the leadership of two medical directors, created a Law Enforcement Engagement Unit (LEEU) to bi-directionally interface, engage, educate, assess, and recommend resources for managing outbreaks in this sector. The overarching goal of the LEEU was to prevent transmission of COVID-19 in all law enforcement agencies throughout the county. The LEEU eventually evolved into a multi-disciplinary team that included several medical directors, DPH’s Health Officer, DPH’s Chief Compliance Officer, OMB’s public health investigators, managers, physician specialists, health program analysts, DST’s data monitors, personnel from EH, regional health officers, ACDC, the Emergency Preparedness and Response division, and two local law enforcement agency representatives. 

Among the major issues encountered by OMB at several law enforcement outbreak sites were a frequent lack of knowledge about the mechanisms of COVID-19 transmission and how to control the infection spread. Examples of these deficiencies included inadequate symptom screening and social distancing, inadequate sanitizing of shared equipment, communal gatherings without masking with use of communal food, lack of PPE equipment along with insufficient funding for such equipment, and inconsistent use of barriers to prevent transmission at work locations. To assist the law enforcement agencies, the LEEU created five practical goals to attain: 1) increase education by creating an educational video; 2) arrange for free PPE to increase compliance with this equipment use while not exacerbating funding deficits; 3) redesign workspaces to allow for social distancing; 4) develop and implement signage to encourage mask-wearing; and 5) develop documentation protocols to ensure the mask-wearing mandate is followed. 

When COVID-19 vaccines became available, the LEEU also developed vaccine education presentations tailored to law enforcement personnel, especially for those at police stations experiencing outbreaks. The team worked very closely with the various police departments to develop digital signage for use as computer screen savers and for digital displays to promote masking and vaccination among various personnel in law enforcement. 

Another successful aspect of working with law enforcement agencies has been the LEEU’s collaboration with the DST, which tracked COVID-19 cases, conducted rapid surveys, and helped monitor improvements over time. This data/information flow allowed for timely course corrections and investigation/mitigation decision-making. The LEEU also engaged a police psychologist to better understand the thought processes of law enforcement officers to tailor their goals and recommendations for this sector.  

Finally, during the 2020-2021 Winter surge there was an outbreak at a major port in Los Angeles County. This port employs 133,000 people and had been reporting a high number of cases among their employees. Site visits found many violations of public health COVID-19 prevention protocols. Contact tracing at the port was difficult because personnel assignments changed daily and were distributed by a third party. The outbreak investigation team worked with the employer, the third party, and the union to fix the problems found: i.e., the team helped to implement best practices for infection prevention and clarified which entities were responsible for specific requirements in the DPH Health Officer Order. Similar to the efforts with law enforcement agencies, OMB, through this type of multi-disciplinary approach, was able to keep the port open and thus, prevented further spread of COVID-19 among the port’s workers and their families. 

The level of intervention provided by OMB likely avoided further spread of the virus and the costs associated with COVID-19 hospitalization and death. Based on methods from an article in JAMA, The COVID-19 Pandemic and the $16 Trillion Virus, regarding the economic burden from COVID-19, DPH estimates that Los Angeles County likely avoided an economic loss burden of $252,000,000 from OMB’s effort to manage >5,600 outbreaks in a timely and systematic way.

In establishing OMB, the most significant transformations of outbreak management came as a result of the workflow and information processes that DST created and implemented across the Branch and within DPH. For example, dashboards, metrics, and protocols were developed and/or refined to assist OMB and Department leadership and staff in making field and policy decisions as they relate to pandemic management.   

An example of modifying existing systems to improve OMB’s workflow was the technical assistance provided to ACDC to help refine its daily process(es) of downloading data generated by its Integrated Reporting, Investigation, and Surveillance Version 17 (IRIS-v17) database; IRIS is the main database that holds information on COVID-19 cases. DST developed and standardized IRIS data entry procedures and a codebook for the system. IRIS-v17 has been and became a more efficient database for informing, initiating, monitoring, and managing COVID-19 outbreak cases at the different sectors: Skilled Nursing Facilities (SNF), Residential Congregate Setting, Worksite/Place of Worship, Sports, Food Industry, Educational Sector/Daycare, and PEH. By working with ACDC, the DST reduced redundancies in generating multiple daily reports while providing the outbreak investigation teams with a much-needed series of daily updated reports to inform field operations. Another example of how OMB’s workflow was improved through DST efforts was the development and implementation of a biweekly Customer Relationship Manager (CRM) dashboard to ensure the timeliness and completeness of case and contact data (line lists), which were uploaded into the system so interviewers from the Case and Contact Interview Branch (CCIB) can call or conduct appropriate contact tracing and follow-ups. Since the inception of this quality improvement project, the number of days to receiving a line list per outbreak case decreased from 9 days in September 2020 to 6.19 days in January 2021. 

OMB’s DST also provided a significant level of operational support to OMB’s frontline staff. For example, within DST, a data analytics (Epi-Curve) unit was established to assist the outbreak investigators with plotting “epi-curves” for each outbreak. This DST function provided critical information in a timely manner, especially for the Education sector (Attachment 4) and for high profile cases (e.g., shipping and delivery, airlines) where real-time information was crucial for addressing public safety and concerns. The epi-curves that were generated provided daily, 3-day average, 7-day average charts, and/or customized charts as needed. To date, the Epi-Curve unit has created 1,047 epi-curves in support of the various outbreak management teams. The average turnaround time for completing an epi-curve is less than one business day (7 hours and 44 minutes).   

DST’s expertise and support became such an important part of DPH’s COVID-19 response, it was asked to handle other urgent COVID-19 related assignments that the Department had, including the tracking of vaccine distribution and administration.  

As OMB’s workforce rapidly expanded throughout the different surges of the pandemic, frequent communication was needed to exchange critical information such as updates, protocol changes, and new developments in virus epidemiology. To facilitate and improve these processes, OMB implemented several innovative approaches: e.g., daily meetings/teleconferences in a virtual platform for Branch leaders, managers and supervisors of each sector to connect; use of both standing as well as short, ad hoc meetings with key staff in the field; and weekly dissemination of an “OMBEE” newsletter that highlighted updates, Branch changes, and program successes. 

To maintain quality, professional standards of practice, OMB instituted and hosted numerous training opportunities to keep staff knowledge and skill sets as current as possible. For example, DPH Nursing Administration organized trainings/in-services for field staff and for orienting new hires; the Medical Leads organized learning sessions/round tables to disseminate current topics of the week; and DST provided its own data-related trainings to epidemiologists and other science staff. Among the training innovations was the longitudinal collaborations with experts from Emory University and the Centers for Disease Control and Prevention to develop and launch a 16-session weekly Grand Rounds for all staff within the Department. The series was well attended, averaging 188 participants per session. In addition, a Population Health Digest, a biweekly/monthly series of succinct notes on the latest scientific discoveries and research on COVID-19, was developed and shared with staff. This ongoing educational publication was partly supported by the UCLA Clinical and Translational Science Institute and the Medical Student PRIME-LA Program at the UCLA David Geffen School of Medicine.  

In addressing the challenges posted by the COVID-19 pandemic, DPH strategically utilized quality improvement approaches and the latest in professional education principles to provide rich resources and know-hows in support of physicians, nurses, outbreak investigators, and other field staff (in the frontline) so that they were and continue to be ready for mitigating the ebb and flow of COVID-19 outbreaks in Los Angeles County. The nimbleness of this core Branch intervention and infrastructure has served OMB well, especially for mitigating the virus’ spread in skilled nursing facilities, congregate living settings, worksites, and educational and daycare settings. The use of these novel approaches to infection control, outbreak management, and professional training are here to stay. It is a structure that CFS hopes to integrate beyond the current COVID-19 pandemic and use for the management of other types of disease outbreaks in Los Angeles County.