Contact Tracing: What’s Needed to Contain Coronavirus Outbreaks
By Debra Wood, RN, Contributor
Contact tracing offers a way to curtail the spread of COVID-19 and similar infectious disease outbreaks in the future. But, after weeks of shutdowns and social distancing from the first wave of this novel coronavirus, how will it work as we reopen the United States and prepare for returning to work?
“We need to dramatically scale-up contact tracing for the nation,” said Crystal Watson, DrPH, assistant professor at Johns Hopkins Bloomberg School of Public Health in Baltimore. “Contact tracing is a core public health tool. It’s not new, but we do not have enough capacity in our system.”
Before contact tracing can take place, people must be tested for the virus. Testing remains in short supply in many parts of the country, reported Shandy Dearth, MPH, director of undergraduate epidemiology education at Indiana University in Indianapolis.
Those testing shortages could hamper contact tracing and containment.
“We need to do more testing to find more cases,” said Emily Gurley PhD, associate scientist at Johns Hopkins Bloomberg School of Public Health. “You cannot contact trace on cases you do not find.”
How Contact Tracing Works
Once a positive case of the coronavirus is identified through testing, the person is placed in isolation or, if seriously ill, in the hospital in an isolation room. The contact tracer has the task of questioning the infected person about who he or she has had contact with in the prior two weeks. The tracer then sets about to track down those people—ideally within 24 hours—builds a relationship with them, places them in quarantine for 14 days, and monitors and supports them during that time. At the end of the quarantine, each person is tested for the coronavirus again.
Contact tracing “is used to break chains of transmission, to manage epidemics at an ongoing low level, to prevent future waves, and to enable us to get back to work in a much safer way,” Watson said.
Ramping up: Recruiting and training additional tracers
A new workforce tool developed by researchers at George Washington University, in Washington, D.C., estimates that the United States will need 184,000 contact tracers to safely reopen the country.
The Association of State and Territorial Health Officials (ASTHO) is the national nonprofit organization representing public health agencies in the United States, the U.S. Territories, and the District of Columbia, and over 100,000 public health professionals these agencies employ. ASTHO members, the chief health officials of these jurisdictions, formulate and influence sound public health policy and ensure excellence in state-based public health practice.
ASTHO's primary function is to track, evaluate, and advise members on the impact and formation of public or private health policy which may affect them and to provide them with guidance and technical assistance on improving the nation's health. They and The Johns Hopkins Center for Health Security estimate public health departments employ about 2,200 tracers, and the country needs to add at least 100,000 more contact tracers to quickly identify, isolate, support, and retest people who have been exposed to the coronavirus.
“It’s a tool we have to ramp up to meet the challenge of COVID-19,” Gurley said. “While contact tracing is not new, this disease is different. That makes it more difficult to control than other diseases.”
Health departments will need to hire and repurpose staff. That may include pulling from the large numbers of unemployed individuals. They also may partner with other entities, such as Massachusetts has done with Partners in Health, which hires, trains and supervises the tracers.
The New York State Health Department has partnered with Johns Hopkins University and former New York City Mayor Mike Bloomberg to prepare 30 contact tracers for every 100,000 people, between 6,400 and 17,000 new tracers. The university is creating an online curriculum for the tracers and an online exam to ensure competency.
“Our goal is to take people with no background in public health and get them ready to absorb the training,” Gurley said.
Contact tracers should have strong people skills and be good at gaining a person’s trust, Gurley said.
In San Francisco, the health department has brought on university staff, employees from other city departments and medical students to become contact tracers.
California Gov. Gavin Newsom announced in April that the state plans to train 10,000 contact tracers. Some of those employees will come from the state workforce.
ASTHO considers three tiers of contact tracers:
- 1st tier: Laypeople
- 2nd tier: Professional disease investigation specialists who can supervise the lay teams
- 3rd tier: Advanced COVID-19 professionals and clinical specialists
In certain settings, such as hospitals, skilled nursing facilities or large corporations, occupational health nurses could help with contact tracing within their organization.
The Centers for Disease Control and Prevention (CDC) also is scaling up its workforce, Watson said.
“This is an unprecedented effort to conduct contact tracing on this scale,” Watson said. “I do think it is achievable.”
CarePredict of Fort Lauderdale, Florida, has created the PinPoint Toolset to provide contact and location tracing in senior living facilities. Residents, staff and visitors wear a bracelet and a beacon system is installed in the institution. It was originally developed to monitor older adults and the notify staff if the person fell or had another problem. But when COVID-19 came along, the leadership team modified the system to contact trace.
The collection of data includes the time of day the contact occurred, the duration and location. It also can identify surfaces touched. The system knows exactly how long individuals were in close contact. That information can be shared with public health officials.
“The public health tracers are very, very important,” said Jerry Wilmink, PhD, chief business officer for CarePredict. “Our contact tracing will support conventional contact tracing efforts. Both are needed."
Wilmink reported that the artificial intelligence digital program could be modified for use in other industries, such as cruise ships, factories and hotels.
“These important, sophisticated tools allow us to get back to a new normal,” Wilmink said.
Apple and Google also are working on a contract tracing tool. It would require all users to upgrade their device’s operating system, download an app, and for the person who tests positive, to self-report via technology.
California has started investigating using apps to help track where COVID-19-positive patients have been and with whom they’ve had contact.
The CDC has developed minimum and preferred criteria for evaluating digital contact tracing tools for COVID-19.
“Technologies should support the public health workforce,” Gurley said. “Technology can be a support all along the way, but it never takes the place of personal interaction that will have to happen to be effective.”
For more information:
Contract Tracing Workforce Estimator – George Washington University
PinPoint Toolset for Senior Care Facilities - CarePredict
Preliminary Criteria for the Evaluation of Digital Contact Tracing Tools for COVID-19 – CDC
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