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As the COVID-19 pandemic continues to surge, it is unlikely that contact tracing within healthcare will become anything less than critical.
A novel disease comes with novel problems and in this new era of coronavirus disease 2019 (COVID-19), there have been so many things challenging infection prevention efforts. From personal protective equipment (PPE) roadblocks to changing isolation precautions, this has been a minefield not only for infection prevention, but also public health. As of this writing, the United States is facing a backlog in testing, delaying results for up to 10 or even 14 days in some areas. Concurrently, there is unabated transmission through many southern states, worrying many that significant second waves are already in play.
As the United States works to increase testing capacity and hospitals adjust to ensure they can handle surges, one of the biggest pieces to COVID-19 response is contact tracing. This function of public health works to reduce the potential for secondary transmission following the identification of a single case. Resource intense, contact tracing is a cornerstone of public health and outbreak response.
Contact tracing is not new, but rather a tried-and-true measure of public health response to outbreaks and infectious diseases. When someone tests positive for SARS-CoV-2/COVID-19, contact tracers work to interview the positive person and identify who they may have come into contact with so they can then be informed and quarantine for 14 days if needed. Contact tracing is an approach that has been successfully used for outbreaks ranging from Ebola to foodborne illnesses, like salmonella. More recently, it’s been used in response to COVID-19 and has been extremely successful in countries that have opted to heavily invest in such efforts from the beginning.
As a study in Scientific American notes: “Large-scale contact-tracing programs in places such as South Korea and Germany have been instrumental in suppressing the novel coronavirus, SARS-CoV-2. Within days of detecting its first case on January 20, South Korea created an emergency response committee that quickly developed wide-scale virus testing, followed by an extensive scaling up of the nation’s network of contact tracers.”1
In the United States though, we have struggled with contact tracing, with efforts woefully under-resourced. Estimates have put the needs of the United States at 100,000 contact tracers. Sadly though, this has not been the case, with states like Arkansas having 900 contact tracers for the whole state. Florida, which is experiencing a large surge in cases, has 291 tracers per 100,000 residents.1
In the conversations about contact tracing, many may not realize that infection preventionists have been doing this for decades within the walls of healthcare facilities. There is often an assumption that public health departments solely do contact tracing, but when healthcare workers or patients have infections like tuberculosis, pertussis, or varicella, the IP works to identify exposed patients and staff to notify and work with occupational health regarding quarantine or post-exposure prophylaxis. From measles outbreaks to staff working with pertussis, I have done contact tracing as an infection preventionist since the day I began in the profession. Public health efforts tend to come into play when there are community-based exposures beyond the hospitals, or if we need assistance with larger exposures. Joint efforts are often employed for large exposures, such as measles.2
In hospitals, it is common to have infection preventionists manage contact tracing and COVID-19 has been no exception. Especially in the early days of the disease when testing was more challenging to obtain, it was not uncommon to have patients hospitalized for several days without consideration for the disease, especially when we were learning about the range of symptoms.
When a patient is identified as having COVID-19, review of their movement throughout the hospital and the use of isolation precautions comes into play. Infection preventionists review and trace the patient’s movements, when isolation precautions were employed, and work to identify potential points of time when there could have been exposures due to a lack of isolation. This was more common in the beginning and prior to many hospitals moving to mandated universal masking for entire healthcare facilities. Once these points in time are reviewed, identifying staff interacting with the patient during periods without isolation becomes key. Pulling a “line list” of those staff who cared for or interacted with the patient during this timeframe is important as it not only allows for notification, but also coordination with occupational health. For COVID-19, this means following the US Centers for Disease Control and Prevention (CDC) definition of exposure and identifying those staff who interacted with the patient without PPE (mask and eye protection) within six feet and for more than fifteen minutes. From there, it comes down to identifying those staff exposed and ensuring they’re aware of the potential exposure. While the CDC allows healthcare workers to continue working post-exposure as they are essential, they are to quarantine for the 14 days following the exposure. For many though, the critical need for healthcare workers is vital and ensuring they are vigilant in masking following this exposure is vital.
In the event that a healthcare worker or staff member is found to be positive, the same processes apply. Ultimately, contact tracing is about building relationships and trust to ensure that people feel comfortable discussing potential exposures and feel safe about discussing times they might have been unmasked.3 Contact tracing occurs within their department/unit and then any patients they interacted with. Since the use of universal masking in healthcare facilities, this has greatly diminished those meeting the definition for exposure.
Unfortunately, one piece we’re seeing more of are exposures during interactions with coworkers in breakrooms, walks to the coffee shop, etc. Too often we focus on the risk from patient interactions, which means we fail to really communicate the risk of interaction with our coworkers without masks on.
Perhaps one of the biggest challenges in contact tracing is pulling these line lists and identifying anyone who interacted with that staff member or patient. Chart review and emailing leaders of departments that might not be documented in the medical record, such as environ- mental services (EVS), is time intensive. Moreover, as much as we’d like electronic medical records to be able to rapidly pull such data, it’s often imperfect and still requires reaching out to leaders of those other departments.
This presents an opportunity though, for technology to perhaps innovate a new approach to tracking interactions and movements within healthcare. Some suggestions have ranged from using Bluetooth identification badges to log employees going in and out of the patients’ room. This is a challenge I’m hoping the COVID-19 pandemic has brought to light and will spark innovative approaches that can be utilized far beyond the pandemic. While many are focusing on PPE efforts to help drive change and establish more sustainable supply chains, contact tracing is one that also needs re-vamping. The importance of privacy shouldn’t be ignored
and hopefully approaches that focus on patient-facing interactions can help support that.
As the COVID-19 pandemic continues to surge, it is unlikely that contact tracing within healthcare will become anything less than critical. While it may be easier with the universal masking efforts, it becomes increasingly difficult as more healthcare workers become positive.
For many of us in surging areas like Arizona or Texas, keeping above the water can be a full-time task. There are ranges of how we approach this as well—do we cease con-tact tracing in COVID-19 cohorts with the assumption that the proper measures are taken? Allow self-reporting? Ultimately, hospitals pose a unique environment for contact tracing and heavily rely on infection preventionists to perform it. As we move to a sustainable COVID-19 response and potentially living with it in a more endemic nature, what will contact tracing look like?
SASKIA V. POPESCU, PHD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities.
Aschwanden, C. Contact tracing, a key way to slow COVID-19, is badly underused by the U.S. Scientific American. 07-21-20. https://www.scientificamerican.com/article/contact-tracing-a-key-way-to-slow-covid-19-is-badly-underused-by-the-u-s/
Centers for Disease Control and Prevention. Notes from the field: lack of measles transmission to susceptible contacts from a health care worker with probable secondary vaccine failure — Maricopa County, Arizona, 2015.” Accessed February 12, 2017. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a5.htm.
Centers for Disease Control and Prevention. Contact Tracing. CDC website. https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/contact-tracing.html