Due to the characteristics of the SARS-CoV-2 virus, including its highly contagious nature and ability to spread in the pre-symptomatic period and from minimally or asymptomatic individuals, certain mitigation efforts are paramount in decreasing transmission. We have learned the importance of social distancing, personal and environmental and hand hygiene, as well as the use of facial coverings, for decreasing the spread of this disease.1
While awaiting for new treatments and the US eases up on social distancing, timely contact tracing and testing will become even more vital. Contact tracing
is, the process of identification of persons who may have come into contact with an infected person and subsequent collection of further information about these contacts,
The challenges of organizing and training
the necessary individuals to perform contact tracing is no simple task. Estimates of the number of contact tracers that will be needed in the US to adequately perform this vital effort lie at 100,000-300,000.2
Cheng et. al. noted the need to contact 2761 close contacts of the first 100 confirmed patients infected with SARS-CoV-2 in Taiwan.3,4
At a time when the US healthcare workforce has insufficient resources to address many of the needs created by the Pandemic, mobilizing the necessary workforce to accomplish this massive task creates challenges.5
The opportunity to impact disease transmission grows in proportion to the number of patients receiving care and the number of workers in the facility. Given that contact tracing is especially resource-intensive, large medical centers are generally in a better position to
undertake this challenge compared to community hospitals and long term care settings. They have more resources to create and implement the technology necessary to support contact tracing, greater ability to absorb staff absences, and more flexibility to reassign staff based on need. In this occupational setting, economies of scale may be found for contact tracing.
Some health systems and large organizations have turned to inhouse occupational and environmental medicine (OEM) providers to manage the task of contact tracing. Health systems must be able to adapt their available resources rapidly and efficiently in order to best confront the pandemic. For efficiency,OEM physicians will need to team up with other providers and staff, seek out and provide proper training for the contact tracers, and support them while managing the overall process and monitoring outcomes.6,7
In one large academic medical center and health system, large scale contact tracing is being accomplished through a model that relies on OEM leadership working with role-based teams to conduct exposure evaluation, contact identification, screening, individual risk assessment and coordination of work restrictions and testing. Digital tools that integrate with existing Occupational Health tracking databases are utilized. Leaders in the site, unit, or department are able to collaborate in generating an accurate list of potentially exposed personnel.8
Some core principles are:9
The actual number of staff needed is large and varies depending on a number of factors including but not limited to:
- Occupational Medicine / Public health staff should:
- Work with patients to recall all their close contacts* during the timeframe they may have been infectious
- Warn exposed individuals (close contacts) of their potential exposure rapidly & sensitively
- Protect patient privacy by not revealing identity of exposure source except as needed to ascertain exposure status
- Provide the contacts education, information, and support to understand their risk, and how to quarantine, self-monitor for illness, and their potential for asymptomatic spread
- Monitor identified close contacts for symptoms
- Support those that develop symptoms and provide assistance for isolation
- Contacts should:
- Stay home
- Physically distance10 for 14 days after their last exposure to the infected individual
- Check their temperature 2X/day
- Self-monitor for symptoms of COVID19 such as cough or shortness of breath11
- If symptoms occur, contacts should:
- Promptly self-isolate & notify public health staff
- Be promptly evaluated for infection and need for medical care.
- The projected number of daily cases based on the baseline population
- The actual daily number of cases
- The number of contacts identified.
for contact tracing are needed to adequately record, manage & analyze exposure-related information and facilitate the following activities:12
The Johns Hopkins Bloomberg School of Public Health offers a free training course for contact tracers. The description can be found at: https://www.jhsph.edu/news/news-releases/2020/johns-hopkins-and-bloomberg-philanthropies-with-new-york-state-launch-online-course-to-train-army-of-contact-tracers-to-slow-spread-of-COVID-19.html
- Case investigation & contact tracing
- Contact follow-up and monitoring
- Facilitation of timely testing and clinical services
- Collaboration with public health authorities
- Developing user-friendly data interfaces to integrate multiple data streams and connectivity options with other digital devices should be considered
- Reporting to describe the impact of exposures on the institution and the effect of mitigation activities
- Reporting to monitor the progress and outcomes of contact tracing
- Data sharing agreements as needed (e.g. with local, tribal, state, and federal jurisdictions)
- Adoption of emerging technologies that can assist with communication, medical monitoring, and strategies to amplify contact tracing in order to allow for scaling up contact tracing as needed.13
In summary, contact tracing in a large healthcare organization is a powerful tool in the pandemic response. It can be feasible and sustainable with appropriate resource allocation. Important considerations when establishing a contact tracing operation include: a robust data management system, a staff training curriculum developed by occupational clinicians, process standardization, redeployment of staff, managing staff as operations are progressively increased and case counts increase, maintaining privacy of information, complying with local and state-specific requirements, and working seamlessly with all stakeholders. One individual or group will not be able to accomplish this task alone. We will best succeed through our collective sharing of knowledge, flexibility, innovation, and teamwork.
1) Kucharski A, Klepac P, Conlan A, Kissler S, et. al. & CMMID COVID-19 working group; Effectiveness of isolation, testing, contact tracing and physical distancing on reducing transmission of SARS-CoV-2 in different settings; Last update: 23-04-2020; Accessed on 5-8-20 at: https://cmmid.github.io/topics/covid19/tracing-bbc.html.
2) Simmons-Duffin, S.; States Nearly Double Plans for Contact Tracers Since NPR Surveyed Them 10 Days Ago; Shots Health News from NPR; May 7, 2020; https://www.npr.org/sections/health-shots/2020/04/28/846736937/we-asked-all-50-states-about-their-contact-tracing-capacity-heres-what-we-learne.
3) Hao-Yuan Cheng, MD, MSc1; Shu-Wan Jian, DVM, MPH1; Ding-Ping Liu, PhD1; Ta-Chou Ng, BSc2; Wan-Ting Huang, MD3; Hsien-Ho Lin, MD, ScD2,4; for the Taiwan COVID-19 Outbreak Investigation Team Author Affiliations; Article Information, JAMA Intern Med. Published online May 1, 2020. doi:10.1001/jamainternmed.2020.2020. Accessed on 5-8-20 at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2765641?resultClick=1.
4) Steinbrook R; Contact Tracing, Testing, and Control of COVDI-19 – Learning from Taiwan, Editor’s Note; JAMA Intern Med. Published online May 1, 2020; Accessed on 5-8-20 at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2765640?resultClick=1.
5) Toner E, Waldhorn R, Veenema T, Adalja A, Meyer D, Martin E, Sauer L, Watson M, Daugherty Biddison L, Cicero A, Inglesby T; National Action Plan for Expanding and Adapting the Healthcare System for the Duration of the COVID Pandemic, Johns Hopkins Bloomberg School of Public Health Center for Health Security; May 5, 2020; https://www.centerforhealthsecurity.org/our-work/publications/national-action-plan-for-expanding-and-adapting-the-healthcare-system-for-the-duration-of-the-covid-pandemic.
6) COVID-19 Contact Tracing Training: Guidance, Resources, and Sample Training Plan. CDC. Accessed on 5-9-20 at: https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/contact-tracing-training-plan.pdf.
7) COVID-19 Contact Tracing Training: Guidance, Resources and Sample Training Plan. CDC. Accessed on 5-9-20 at: https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/index.html.