In March, when we started seeing the alarming data and news stories about COVID-19, it reminded me of being a Peace Corps volunteer. For a year in the 1990s, I worked in a district hospital in Malawi, Africa, in the middle of the HIV/AIDS epidemic. It was a different disease and a different epidemic, but we had similar problems. There was no cure and we lacked adequate diagnostics or personal protection equipment. We got through the worst of the crisis by professionals coming together and trying things, learning from mistakes and eventually implementing evidence-based approaches.
When the government of Massachusetts launched the COVID-19 Community Tracing Collaborative, I offered to help. Currently, the collaborative is a startup with a remote workforce of more than 1,600 case investigators, contact tracers, and resource coordinators who are assisting local health departments across the 351 towns and cities of Massachusetts. We're trying to help them understand the situation in their locales and care for their residents so we can stop this pandemic.
At its core, contact tracing is about reaching out to COVID-positive people and making a human connection. We call people at probably one of the most difficult, vulnerable times in their lives because they have an illness that doesn't have a known cure yet. They're unable to work. It doesn't matter if you're in Massachusetts or Kentucky or Minnesota, it's going to be the same. So, we express our concern, we assess their ability to isolate. We try to link them to services if needed, such as food delivery, access to necessary medicines, and rent support.
We also ask people who have positive tests to tell us who they've been in contact with and the locations where they've been. We call those contacts and inform them that they've been exposed to COVID and walk them through the next steps of testing and quarantining. This requires trust in human interactions for all these interactions to be successful.
Over the years, and especially over the last few months, I’ve learned that to stop outbreaks and limit the spread of COVID-19, an effective contact tracing program must respond to the unique circumstances of state and local health departments. Effective contact tracing needs to incorporate cutting-edge technology, innovative data collection and analytics, and stringent information-security practices. Positive cases must safely isolate at home until they are no longer symptomatic and have shed the virus. Contacts should get tested if possible or otherwise stay home until the symptoms or the 14-day quarantine period has passed.
Just like I wanted to offer to help in my home state of Massachusetts, I thought it was important to share more of what I’ve learned here by offering a five-step approach to contact tracing, as well some additional tips to building a successful operation.
Five-step contact tracing
- Identify the right platform for data collection, analysis, and reporting; such platforms should have industry-standard data security controls and produce actionable information.
- Using data from health departments and testing facilities, a case investigator calls a COVID-positive case to make sure that they are isolating and have the care and supports they need to make it through the illness.
- The case investigator asks the positive case about whom he or she has been in contact with and where they met. The case investigator records the answer.
- Next, a contact tracer notifies the contacts that they have been exposed to COVID-19 and advises them to stay home or quarantine elsewhere for 14 days.
- Stronger contact tracing programs will connect cases and contacts to social services and supports, if necessary, so that they can stay home safely and recover.
Tips for Standing up a Successful Contact Tracing Program
- Prepare for difficult discussions. Case investigators and contact tracers are calling people during some of the most vulnerable days of their lives, when both their health and economic security is at risk. Positive cases may be symptomatic or asymptomatic. Some cases will be recovering, so the conversation will be positive, but others will be extremely anxious about testing positive. Still others will have painful symptoms and trouble breathing. Many people will be emotionally and physically exhausted and facing financial ruin. They may not have enough food, medicine, or adequate health care. They may feel stigmatized or guilty for exposing others. They could be experiencing violence in their home, or they could be suicidal. Only well-trained and -prepared interviewers should make these calls.
- Collect information on social services. This information is critical because the pandemic has further exposed and worsened health and economic disparities. To be prepared, collect information on services, including local food and medicine delivery. Remember, positive cases will need help to isolate at home. They and their contacts will need information on testing sites. Be sure to also have information on domestic violence and child protective services. Know the numbers of local and national hotlines, including those for people at risk for suicide or violence. Many cases and contacts are out of work and may need help with rent, a mortgage payment, or utilities, so make sure that local, state, and national resources are available.
- Ensure that your technology, data platforms, and systems fit their purpose. Your systems should simplify the process of capturing and reporting data. An effective contact tracing program will capture only the information that is essential to local and state health departments—no more, no less. To earn public trust and ensure broad participation in your contact tracing program, personal and sensitive information should be handled according to the stringent processes that protect it. Data should also be reported in a manner that is actionable; that is, it should be presented to health departments with recommendations designed to help them care for residents, stop outbreaks, and anticipate and prevent further transmission. Mapping capabilities are helpful as well because they can show community leaders and residents the clusters of outbreaks. Whether an outbreak occurs at a nursing facility, a grocery store, or a public beach, the data should help health departments understand who and how many people were affected, where the high-risk locations are, and how to prevent further transmission.
- Collect information to identify the behaviors and conditions linked to outbreaks. When investigating cases and tracing contacts, it may be possible to ask people about their behaviors and the behaviors of others at the time of exposure. This information will help public health experts to better understand what led to the outbreak, such as whether an event was indoors or outdoors, whether people were practicing social distancing, or whether there was access to personal protective equipment. As different types of businesses and public areas open, it be important to understand the patterns in outbreaks so that we can anticipate and prevent them.
- Stay with your cases and contacts. Contact tracing requires public support and trust. One way to build both is for case investigators and contact tracers to continue to communicate with their cases and contacts until symptoms have resolved or the isolation and quarantine period has ended. People appreciate hearing from someone who cares. Staying in touch is also an important way to collect critical information on symptoms and time to recovery.
- Engage your community, build trust, and partner closely with local organizations. Contact tracing programs will be most effective and efficient if they are built in close partnership with local organizations, which know their communities best. From health care to social service networks, these organizations have a keen sense of a community’s strengths and vulnerabilities across every population that call the community home. Successful programs will blend this comprehensive understanding with expert contact tracers and advanced data platforms to mount the best possible defense against COVID-19.