As U.S. states rollout plans to gradually reopen society, there are four essential actions that governments must commit to—and invest in—now so they can reopen society as quickly and safely as possible while preventing another explosive spread of the COVID-19. (Figure 1)
Contact tracing will be a key component of any successful suppression effort to “box in” COVID-19. In contact tracing, local and state health departments quickly identify people infected with COVID-19 using widely implemented testing programs; instruct infected people to isolate; find and notify their contacts; and support these contacts so they can quarantine for 14 days. Read about "Box it in"...
Contact tracing is a tried and true public health measure that has been successfully used to contain communicable diseases, such as HIV, sexually transmitted infections, and tuberculosis. As in all public health responses, tools must be adapted to meet the challenges of each microbe. Contact tracing for COVID-19 must be executed on a significantly larger scale, adapting to unique challenges of the virus including asymptomatic spread. Countries including China, Germany, South Korea and Singapore have all done this successfully.
It is urgent for U.S. state and local health departments to quickly prepare and implement contact tracing to box in COVID-19.
Contact tracing for COVID-19 includes four key steps:
This process continues until the end of any possible transmission chain has been reached.
A successful COVID-19 contact tracing program is comprised of ten domains:
Contact tracing protocols and forms. Effective contact tracing protocols clearly define processes around isolation for cases and quarantine for close contacts. This includes whether isolation and quarantine are legally mandated or voluntary, priority thresholds for in-person outreach (e.g., congregate settings), definition of close contacts, determination of how to manage laboratory-confirmed and probable cases, definition of the social supports package and eligibility, and arrangement of clinical linkages for contacts. The public health workforce conducting contact tracing and case investigation will rely on clear and precise forms and scripts to guide activities and communication with cases and contacts.
Public health workforce. Thousands of people will be needed to properly conduct the four contact tracing steps noted above. The approach relies on rapid and efficient recruitment, training, and deployment under the management of the state, local and/or territorial health department. Workforce training should include knowledge and skill-based exercises in order to create rapport, address concerns and barriers to contact elicitation or isolation and quarantine, and appropriately assess support needs to ensure adherence with public health recommendations.
Digital and technology solutions. Digital applications (or apps) can facilitate the massive scale-up of contact tracing that will be needed to help to box in COVID-19. Apps can augment traditional public health activities, for example by rapidly finding cases' contact information, sharing their contacts more easily, and providing isolation and quarantine support. All digital solutions must be driven by people trained in public health response, explicitly support workflows for contact tracing, and adhere to the highest privacy standards. Governance of data systems, ownership and stewardship of all case and contact-related data collected, maintained or disseminated must remain the responsibility of the applicable local public health authority. Customer Relationship Management (CRM) solutions will provide an infrastructure by which the public health workforce functions optimally.
Case reporting. The success of contact tracing to interrupt disease transmission hinges on the timeliness of case identification. The sooner a case is identified, the sooner the contacts can be elicited and notified of their exposure, thereby reducing the chances that they will further spread disease. Effective contact tracing relies on timely and complete case reporting by public and commercial laboratories and medical care providers; and linking these reports to health departments’ case management systems. COVID is a nationally notifiable disease and must be reported to public health. Electronic Lab Reporting (ELR) from commercial and clinical labs when integrated with disease management systems of the health departments would reduce the time to beginning a case investigation and subsequently identifying contacts.
Clinical consultation. Cases and contacts may require symptom management advice and clinical consultation during isolation and quarantine periods. Some people may have telephone or video access to their regular primary care provider. For those who do not have access to a regular primary care provider, health departments should establish a pool of providers for on-call clinical consultation by telemedicine.
Services to support people in isolation and quarantine. Support for contacts in quarantine and cases in isolation can improve people’s safety, comfort, and adherence to isolation and quarantine guidance. For many contacts, provision of basic resources, such as daily check-in phone calls, health education materials, masks or face coverings, thermometers, hand sanitizers and gloves, may be enough. For others, “wraparound services” (including food, laundry, pharmacy services, garbage removal services) may be necessary. Financial supports may be needed to help those in quarantine and isolation meet basic needs and to compensate for lost wages. When people who care for children, older adults or other dependents are put in isolation or quarantine, the people they care for could be left in untenable situations. Alternative caregiving services should be provided in these situations.
Facilities for out-of-home isolation and quarantine. In some situations, people with COVID-19 or their contacts may be unable to isolate safely at home. Health departments should define criteria for offering alternative housing in these instances. Out-of-home accommodation for isolation or quarantine periods may be necessary for people who live with high-risk individuals, are precariously housed, unsheltered or experiencing homelessness, live in congregate settings, or who otherwise cannot remain in their current residence. Existing facilities in the community, such as hotels, single-room dormitories, or temporary housing facilities can be contracted with to provide this service.
Public communication. For contact tracing to be successful, the public must understand that their participation and adherence to public health recommendations (including isolation and quarantine) are essential to suppress the epidemic, protect the health of people in the community, and reopen society. Health departments should establish themselves as credible and trusted information sources and managers of the crisis. Best practice communication strategies include daily press briefings by a trusted source, engaging with trusted community leaders and officials to adapt messaging to the local culture and context and to reach out to their communities, leveraging media outlets, hosting a hotline (or other way for the public to ask questions), and producing and sharing educational resources (such as FAQs and fact sheets).
Metrics and monitoring. Routine monitoring and assessment of contact tracing efforts will reveal whether the process is functioning as intended, whether the program is achieving the goal of reduced disease transmission in the community, and if not, what changes should be made. A dashboard can track key performance indicators.
Privacy and data sharing. Privacy protection is critically important, legally required and necessary to maintain the public trust, but the complexity of privacy laws can slow adoption of a contact tracing process. To both scale the process and protect privacy, consider policy simplification, proactive assessment and resolution of specific data sharing use cases and seek to design and build in privacy and security.
The COVID-19 Contact Tracing Playbook provides actionable technical guidance, including implementation checklists and tools, for each domain of a successful contact tracing program. U.S. state and local health departments can use this playbook to rapidly set up and implement contact tracing programs for successful COVID-19 containment.