COVID-19 Contact Tracing Conundrums: Insights From the Front Lines

Abstract

COVID-19 contact tracing is an induction social network intervention in which the structure of the social network is leveraged to deploy proven COVID-19 interventions such as testing and social distancing. The Howard Brown Health organization has rapidly expanded to include COVID-19 testing, contact tracing, and linkage to resources since the first cases were identified in Chicago, Illinois. COVID-19 is penetrating the most vulnerable networks in the United States; existing inequities are widening as community resources and organizations have had to place services on hold.

Here we address several questions that arise as organizations build capacity for contact tracing, including questions involving the potential impact of contact tracing, stakeholders who could be involved, the timing of contact tracing deployment, and the impact potential for digital technology.

Contact tracing is critical at later stages of epidemic decline given the potential for isolated outbreaks as larger events, schools, stadiums, and festivals reopen. Local contact tracing efforts can have other indirect benefits with respect to limiting transmission, such as increasing testing rates and addressing structural barriers through provision of life-saving resources and access to crucial social support.

The end of April 2020 marked the rapid escalation of contact tracing at the local, regional, and federal levels to decrease the rate of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) transmission and the number of COVID-19 cases. Partners for Health, for example, was one of the first agencies to develop a robust contact tracing plan, partnering with the Massachusetts COVID-19 Community Tracing Collaborative and the Massachusetts Department of Public Health.^1,2 Similarly, the National Opinion Research Center, a prominent survey research organization, launched time-sensitive contact tracing efforts in Delaware and Maryland.^3,4

Several of these early adopters used guidelines and training methodologies for contact tracing created by the Association of State and Territorial Health Officials and Johns Hopkins University.^5,6 The Centers for Disease Control and Prevention has designated $10.25 billion toward COVID-19 resources through the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases agreement, which includes scalable contact tracing of confirmed or suspected cases of COVID-19.^7,8

Until very recently, contact tracing remained underdeveloped for much of the nation. As several sites move toward growing this work, lessons can be learned from the vantage point of Howard Brown Health (HBH), an early adopter of COVID-19 contact tracing. HBH, a federally qualified health center located in Chicago, Illinois, has rapidly expanded its services and service areas to include COVID-19 testing and linkage to resources in areas with long-standing disinvestment and racialized policies. COVID-19 contact tracing was initiated when the first HBH patient was diagnosed at the organization on March 13, 2020.

As an early adopter, HBH was faced with difficult questions around the legitimacy and effectiveness of contact tracing; we have organized this article to address these concerns. We also define several significant questions that should be addressed by government and partnering agencies that are rapidly scaling up contact tracing in the United States to mitigate the COVID-19 pandemic.

PURPOSE OF COVID-19 CONTACT TRACING

From our experience, we see 3 clear objectives of contact tracing. First, the main function of contact tracing is to interrupt transmission of SARS-CoV-2 within social networks. COVID-19 contact tracing is an induction social network intervention in which the structure of the social network is leveraged to deploy proven COVID-19 interventions such as testing and social distancing.¹⁰ During stay-at-home orders, HBH found that more than 70% of household members linked to an index case patient had either a COVID-19 diagnosis or symptoms of COVID-19 (HBH, unpublished data, 2020). People located outside index case patients’ homes were significantly less likely to contract or demonstrate symptoms of COVID-19 (HBH, unpublished data, 2020). Household network clusters and bridges to other network clusters require immediate intervention to diminish transmission to other connected networks.^9,10

The second function of contact tracing is to check in with index clients diagnosed with COVID-19. Misinformation and bias pertaining to COVID-19 are common in widely accessed social and news media.¹¹ This can result in problematic decision-making that is not informed by medical professionals and COVID-19 experts. Currently there is no standardized protocol for health care providers to deliver comprehensive education about SARS-CoV-2 transmission, the role of self-quarantine, or the significance of symptom duration to their immediate networks during the testing encounter. High-demand testing facilities are often hurried, with staff working over capacity to satiate the need for testing, making it difficult to have these conversations.¹²

Test results can create network micro-shocks that require ongoing consultation and guidance from health professionals to address and alleviate client anxiety. More than 70% of clients contacted by HBH contact tracers continue to have basic questions about COVID-19 transmission, which can exacerbate underlying anxiety, depression, or obsessive–compulsive tendencies (HBH, unpublished data, 2020).

Third, we have found that COVID-19 is penetrating the most vulnerable networks in poor, underserved, stigmatized, and marginalized communities. In Chicago and around the United States, Black and Brown communities experience structural barriers attributable to poverty, housing instability or homelessness, food insecurity, and lack of access to basic health care. The COVID-19 pandemic has only widened these existing inequities, as community resources and organizations have had to place services on hold to follow Centers for Disease Control and Prevention guidelines.¹³ Although Black individuals in Illinois account for only approximately 14% of the population, they accounted for 23% of positive cases and 30% of COVID-related deaths in May 2020.¹⁴ We still do not have a complete picture of how COVID-19 affects marginalized groups, as many of these groups are unable to access health care services as a result of their disenfranchisement.^12–14

Immigrant populations have been especially vulnerable during this time, fearful that accessing COVID-19-related services could affect their opportunity to gain permanent residency.¹⁵ Incidents of US Immigration and Customs Enforcement obtaining testing rosters to facilitate raids, many of which were conducted during stay-at-home orders, prevent at-risk undocumented populations from receiving testing or treatment.¹⁶ In July 2020, Immigration and Customs Enforcement confirmed 3000 positive cases of COVID-19 in detention centers across the country; despite the increasing number of positive cases, the agency continues to transport undocumented immigrants to detention centers across the United States and to other countries such as Haiti, El Salvador, and Honduras.^16,17 A tailored public health approach to marginalized groups is necessary, and contact tracing has the potential to provide access to systems and structures that, when resourced properly, can provide needed services and social support.

DEPLOYING COVID-19 CONTACT TRACING

At the individual level, COVID-19 contact tracing should be deployed as early as possible to have the greatest impact in limiting further transmission events.⁷ Transmission rate studies estimate that peak transmissibility occurs 1 day before symptom onset, but the infectious period can begin approximately 2 days prior to symptoms appearing.¹⁸ Public health agencies and organizations should work to isolate incidents earlier than the current standard to decrease transmission rates.¹⁹ However, contact tracing outside the 10-day transmission period is still beneficial in reducing transmission as a result of network dynamics and, in particular, network changes that can result from awareness of test results.¹⁹

Ideally, contact tracing would start at the time of the exposure or transmission event (Figure 1 ); however, tracing at the time of exposure is nearly impossible. The next potential contact tracing initiation would occur at symptom onset or, for an asymptomatic individual with a potential COVID-19 exposure, the testing event. Contact tracing initiation typically occurs too late in the progression of COVID-19, starting a week or more after onset, making it difficult to interrupt transmission events.^5,6

FIGURE 1—

Howard Brown Health COVID-19 Contact Tracing Timeline: Chicago, IL, 2020–2021

One HBH testing site with a 60% positivity rate began piloting presumptive contact tracing before or immediately after sample collection among symptomatic clients and before a result is known (Figure 1; HBH, unpublished data, 2020). Presumptive contact tracing is an untested approach aimed at initiating contact tracing earlier in the continuum to reduce transmission events and rates, but such tracing requires adequate resources in communities with high prevalence. Despite resource limitations, delayed contact tracing can still be beneficial and even more so if network members are engaged in testing and isolation.

Finally, at a macro level, contact tracing can be deployed at all phases of an epidemic. As the United States continues to combat COVID-19 transmission, the importance of trusted leaders in persuading communities to engage in early tracing efforts will be fundamental in halting further outbreaks, as seen in other countries around the world.²⁰ During the Ebola crisis of 2014–2015, enlisting local leaders was an approach that helped to build a trusting relationship between public health officials and the community, and this effort had a positive impact on uptake of interruption interventions.²¹ Local leaders to whom communities can relate can bolster feelings of shared identity and foster in-group assurance and adherence to public health recommendations.²² Contact tracing is critical at later stages of epidemic decline given the potential for isolated outbreaks as larger events, schools, stadiums, and festivals reopen and increase the need for outbreak cluster investigations.

PERFORMING COVID-19 CONTACT TRACING

At a macro level, an important balance between local contact tracing efforts and testing and community engagement should be achieved. Local organizations performing COVID-19 testing can minimize the delay from the test to initiation of contact tracing, possibly the most important variable in COVID-19 contact tracing success. If larger organizations, including health departments, are to minimize delays, they will have to match local organizations in providing up-to-date information on testing sites and availability, supportive resources, and a process for obtaining said resources.

At HBH, more than 30% of individuals testing positive for COVID-19 report food insecurity, housing instability, and a need for health insurance or employment (HBH, unpublished data, 2020). HBH offers many of these services internally, providing a seamless referral process that can have the secondary benefit of promoting collaborative trust within existing COVID-19 transmission networks. However, local contact tracing efforts are often underresourced and serving at their maximum capacity, limiting their reach and impact in high-prevalence communities.¹² Federally qualified health centers in affected communities in Chicago have been underresourced for decades and usually do not have prior contact tracing experience. As a result, these centers have been late adopters of the basic prerequisites required for contact tracing (e.g., provision of COVID-19 testing).

HBH has moved quickly to hire temporary workers and transition sexual health contact tracers (35 full-time tracers and 60 volunteer tracers) to COVID-19 contact tracing, ensuring that the organization has the capacity to appropriately engage the 2900 positive index clients and associated 5100 network members in contact tracing (HBH, unpublished data, 2020). In addition, HBH has trained more than 50 bilingual contact tracers, including individuals from the Latino Medical Student Association, foreign medical graduates, and temporary employees through a local hiring firm (HBH, unpublished data, 2020).

One of the strengths of larger health department entities is their authority and ability to mobilize resources during large outbreaks and engage in active monitoring of outbreak investigations.²³ Local organizations could complement these efforts by gaining trust from the public, particularly in cases in which communities have experienced marginalization and harm from governmental or affiliated institutions.

As shown in Figure 1, social services are a critical component of contact tracing efforts and mitigation of long-term effects on patients. Social services can offer a variety of types of support (e.g., meal delivery, child care, general health services), but services in the communities most affected by COVID-19 are often not sufficiently funded or resourced to manage demands.¹⁵ According to the Nonprofit Finance Fund, 60% of social service organizations are facing long-term financial hardship, 56% report limited staff availability, and beginning in March 2020 their demand for service increased by 25%.¹⁴ Crucial social service organizations are struggling to keep their doors open because of rapid increases in need.^14,24 Contact tracing efforts cannot exist without concurrent delivery of social services to help mitigate the impact of transmission; funders of social service organizations need to consider awarding less restrictive funds to allow for organizations to pay employee salaries, rent, and other overhead costs so that they can keep their necessary services running.²⁴

INNOVATING WITH ADVANCED SMARTPHONE TECHNOLOGY

In a highly publicized joint venture, Apple and Google have proposed a tracking app, Proximity, that will “combat the virus and save lives.”²⁵ This comes on the heels of South Korea and Singapore’s TraceTogether, a GPS-based app that notifies community members when they are in proximity to a case patient.²⁶ Reports on TraceTogether’s efficacy have been of great interest to the Western world given the app’s capacity to alert community members to a COVID-19 exposure through cutting-edge Bluetooth technology.²⁶ Although these 2 app programs are well intentioned, there are several fundamental barriers to their bending the curve relative to COVID-19 contact tracing as described here.

First, it is challenging to achieve the correct balance of sensitivity and specificity to drive health behaviors. High sensitivity could generate more noise and limit behavior change such as social distancing or self-isolation. This, combined with limited specificity, can create an atmosphere that generates more anxiety, which could be counterproductive and spread misinformation.^7,11 Second, and most important, it is unclear what sort of penetration these 2 apps, which require voluntary self-reports, would achieve across affected communities. At HBH, the majority of individuals reporting stigma as a result of COVID-19 are Black and Latinx (HBH, unpublished data, 2020). High levels of medical and government mistrust attributable to national policies, particularly among undocumented clients, would be an important concern to address; concerns about state surveillance would limit engagement in such tracking interventions.^12,15–17

Finally, Singapore and South Korea have robust national health care programs that are equipped with key health data systems and can quickly adapt to local conditions and merge with other available data sources in real time.²⁷ In addition, variations in cultural norms and expectations between the United States and Singapore and South Korea should be considered. Both Eastern countries value collectivism and prioritize the health and safety of the community, such as maintaining herd immunity, over personal desires.^27–29 The United States could benefit not from increasing technology to address COVID-19 but by first ensuring the prioritization of the public health system and of scientifically driven COVID-19 prevention and treatment approaches.

POTENTIAL IMPACT

Although challenging to evaluate, contact tracing has been found to be effective in limiting onward transmission of COVID-19 in early reports.³⁰ Successful contact tracing is elicitation of relevant network members including household members and those who bridge to other households or networks. In network transmission by visualization, infectious diseases are often assumed to be linear such that spread will have occurred several steps away by the time an intervention is deployed.³¹ Rather, transmission often resembles clusters of individuals and includes multiple triads.³² It is crucial to stay ahead of transmission through identifying and intervening with bridging network members. Intervening with one member of a triad can have an impact on the other members as well as other connections linked to the triad.^6,7

When contact tracing is conducted rapidly (Figure 1), HBH has found that 70% of close contacts are either positive or have symptoms consistent with COVID-19 (HBH, unpublished data, 2020). This leaves an opportunity to prevent 30% of potential infections and, with a case fatality rate of 1% in the case of HBH, equates to a potential saving of at least 18 lives from initiating tracing for 2000 individuals (HBH, unpublished data, 2020). The challenge is the first step in the contact tracing continuum, eliciting partners, with only 50% of index clients having at least one partner elicited. However, reaching contacts of index case patients has proven difficult (HBH, unpublished data, 2020). Contact tracers who penetrate networks to the second and third degrees, of course, would have a greater chance of limiting onward transmission.⁷

HBH has interrupted many potential transmission events, including an asymptomatic household member about to be sent to another household, a relative about to visit a positive network member who experienced stigma and did not want to disclose, and an asymptomatic but positive person attending a large gathering of older adults (HBH, unpublished data, 2020). HBH has also provided corrective advice on merging family networks during holiday weekends (HBH, unpublished data, 2020). Communicating appropriately tailored health messages that correct misinformation and affirm community are necessary to complement any COVID-19 testing intervention. The World Health Organization declared the pandemic an “infodemic,” defining misinformation as “cases in which people’s beliefs about factual matters are not supported by clear evidence and expert opinion.”^33,34 Engaging at-risk networks through contact tracing allows for individuals to receive accurate and up-to-date information from reliable health organizations.

These COVID-19 contact tracing lessons from the frontlines, ongoing professional guidance, and prevention of misinformation will be key to reopening schools, large events, and even a robust meat packing industry. Contact tracing can help us understand when protective measures should be reinitiated in the context of relaxation as well as when public health systems should intervene with respect to social distancing and other measures related to personal protection.^5–7 Contact tracing can be applied in all phases of an epidemic: early on to halt the epidemic before generalized community spread can occur, during a surge to help flatten the curve by having contacts isolate and quarantine, and as the epidemic declines to mitigate sporadic outbreaks that may occur. Finally, we again emphasize the importance of local contact tracing efforts. In addition to their primary focus, these efforts have indirect benefits in terms of limiting onward transmission such as increasing testing rates, offering life-saving resources, and providing access to crucial social support.