LIVING DOCUMENT This playbook is a dynamic, “living” document. Global knowledge pertaining to COVID-19 is rapidly evolving. Feedback and suggestions can be sent to [email protected].

Date of last update: December 21, 2020

COVID-19 Contact Tracing Playbook

Published by Resolve to Save Lives, an initiative of Vital Strategies

As U.S. states roll out 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.

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.

4 STEPS

Contact tracing for COVID-19 includes four key steps:

This process continues until the end of any possible transmission chain has been reached.

10 DOMAINS

A successful COVID-19 contact tracing program is comprised of ten domains:

1. 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.

2. 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.

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.

Checklist

1. Case reporting

CASE Refers to a person with probable or confirmed COVID-19 infection.

CONFIRMED CASE Meets confirmatory laboratory evidence.

PROBABLE CASE

• Meets clinical criteria AND epidemiologic evidence with no confirmatory laboratory testing performed for COVID-19; or

• Meets presumptive laboratory evidence AND either clinical criteria OR epidemiologic evidence; or

• Meets vital records criteria with no confirmatory laboratory testing performed for COVID-19 (Source: )

COVID-19 The name of the disease caused by the novel coronavirus, SARS-CoV-2, and is short for “Coronavirus Disease 2019.” (Source: )

CONTACT or CLOSE CONTACT A person who may be at risk for a contagious disease because of their proximity or exposure to a known case. Exact definition of close contact differs by disease; for COVID-19, CDC defines a close contact as someone who was within 6 feet of an infected person for at least 15 minutes starting from 48 hours before illness onset until the time the patient is isolated. Data are limited to precisely define the “prolonged exposure” to determine “close contact”, however 15 minutes of close exposure can be used as an operational definition for contact investigation. Factors to consider when defining close contact include proximity, the duration of exposure (e.g., longer exposure time likely increases exposure risk), whether the individual has symptoms (e.g., coughing likely increases exposure risk) and whether either the case patient or contact were wearing an N95 respirator (which can efficiently block respiratory secretions from contaminating others and the environment). At this time, differential determination of close contact for those using fabric face coverings is not recommended. (Source: )

CONTAINMENT Preventing the spread of disease in early stages of transmission through measures such as early detection and isolation of cases, and contact tracing and quarantine. (Source: )

EPIDEMIOLOGIST When disease outbreaks or other threats emerge, epidemiologists are on the scene to investigate. Often called “Disease Detectives”, epidemiologists search for the cause of disease, identify people who are at risk, determine how to control or stop the spread or prevent it from happening again. Physicians, veterinarians, scientists, and other health professionals often train to be “Disease Detectives”. (Source: )

HIGH-RISK INDIVIDUALS People at higher risk for severe illness from COVID-19. Based on the current evidence, high-risk individuals include:

• People 65 years and older

• People of all ages with underlying medical conditions, particularly if not well controlled, including: people with chronic lung disease or moderate to severe asthma; people who have serious heart conditions; people who are immunocompromised due to causes including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS or prolonged use of corticosteroids or other immune weakening medications; people with severe obesity (body mass index [BMI] of 40 or higher); people with diabetes; people with chronic kidney disease undergoing dialysis; and people with liver disease (Source: )

INFECTIOUS PERIOD The onset and duration of viral shedding; not yet known for COVID-19. (Source: )

ISOLATION Used to separate people infected with the virus (those who are sick with COVID-19 and those with no symptoms) from people who are not infected. (Source: )

PROXIMITY TRACING or EXPOSURE NOTIFICATION Digital tools that automatically track the proximity of individuals and can notify people who were in close proximity to a positive case, using Bluetooth technology or GPS coordinates.

QUARANTINE Used to keep someone who might have been exposed to COVID-19 away from others. Quarantine helps prevent spread of disease that can occur before a person knows they are sick or if they are infected with the virus without feeling symptoms. (Source: )

SUPPRESSION Reducing and maintaining low levels of disease transmission through intermittent loosening and tightening of public health and social measures (PHSMs); detection and isolation of cases, and contact tracing and quarantine.

TELEMEDICINE The delivery of health care services and information via electronic information and telecommunication technologies.

The COVID-19 pandemic has presented the United States. (and the world) with the most severe public health tragedy and challenge in over a century. While public health agencies in the U.S. are well-practiced and have systems in place for detecting and responding to infectious disease outbreaks, novel coronavirus came with unique challenges, requiring public health agencies to rapidly adapt and respond at unprecedented scale.

Effective public health epidemic response measures are implemented according to the phase of an epidemic, with contact tracing as essential measure during the containment and suppression phases. In the U.S., contact tracing is primarily being used as a suppression strategy, after wide implementation of physical distancing measures.

The contact tracing systems and practices being put into place now must be evaluated, refined to incorporate lessons learned, and institutionalized so that they can be rapidly activated during subsequent outbreaks. When the next epidemic comes, contact tracing during the early containment phase can stop the spread of disease before it becomes a large outbreak—and prevent this from ever happening again.

Adaptive response timeline for future epidemics

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Checklist

1. Policies for telemedicine

• 1.a Provide a telemedicine safety net for cases and contacts who do not already have access to virtual health care for the duration of isolation and quarantine.

  • Cases and contacts will receive basic resources to support symptom monitoring, such as a digital thermometer. Some people may require symptom management advice and clinical consultation services during the isolation and quarantine periods.

• 1.b Determine eligibility for telemedicine services. (See )

  • The telemedicine service should be available to cases and contacts without medical insurance or who do not have a regular primary care provider offering telephone or video access during the time of isolation or quarantine. Public health should not pay for telemedicine services for individuals who already have access to this type of service through their health insurance (e.g., Medicaid, Veteran’s, commercial insurance).

2. Telemedicine service provider

• Contract with a local medical care provider to provide telemedicine services for eligible COVID-19 cases and contacts. (See )

  • Depending on the number of individuals needing and qualifying for this service, contracts with multiple medical care providers may be needed.

  • Some jurisdictions may have infrastructure already in place to provide telemedicine consult via a nurse triage line, for example using public health nurses with health assistants and others doing contact elicitation.

3. Linkage for cases and contacts

• Ensure the link to telemedicine services is made for contacts and cases, as appropriate.

  • Train contact tracing staff to assess a person’s eligibility for telemedicine services.

  • Contact tracing staff should provide instructions to people on accessing telemedicine based on their eligibility.

Implementation Tools

• Massachusetts Medical Society:

Checklist

1. Budget

Checklist

1. Process indicators

• Identify key process indicators: (*key indicators)

  • Speed of contact tracing

    • *Percentage of new cases reported within 24 hours of specimen collection

    • *Percentage of cases interviewed and isolated within 24 hours of case report

2. Outcome indicators

• Identify key outcome indicators: (*key indicators)

  • Overall

    • *Percentage of new cases arising among contacts identified by program and under quarantine at the time of onset of their symptoms or, if asymptomatic, at first positive test with immediate initiation of isolation. i.e., as proportion increases, it means we’re getting better at capturing and containing exposure before it spreads further

3. Quality improvement and quality assurance indicators

• Identify key QI and QA indicators: (See )

  • Data validity and completeness

  • Workforce recruitment, training and retention

4. Equity considerations in reporting

• Collect data for tracking and reporting on program equity. Ensure data is collected from cases and contacts in the contact tracing system to be able to stratify by relevant variables, such as:

  • Geography (county, city, neighborhood, ZIP code, or other meaningful geographic category)

  • Race/ethnicity

5. Dashboard

• Develop a dashboard aligned with IT system and consider how to align the dashboard with case reporting and case surveillance systems:

  • Key outcome and process indicators

  • Total and current cases by status (awaiting outreach; outreach underway; monitoring and support; closed)

6. Targets

• Set targets for key indicators, including timeliness of case and contact notification and quarantine, in order to guide adjustments to policies and protocols. (See )

Implementation tools

Checklist

1. Existing workflows and infrastructure

Checklist

1. Budget

Checklist

1. Assess the overall process

• 1.a Consider conducting an initial privacy assessment by asking, for example:

  • who are the people/roles involved in the process,

  • who are the entities,

  • what is the technology,
• 1.b With appropriate advice, consider documenting or amending existing policies, in light of the program maturity and the needs of the local jurisdiction.

• See

2. Assess policy simplification

• Assess policy simplification. Consider the costs and benefits of policies that default to treating information as sensitive, even if not legally required.

  • Sample: Your information is confidential and will be used only for public health purposes. We will collect, use, and share the minimum necessary information appropriate for these purposes and we will not release the name of someone who tests positive to anyone with whom that person has been in contact.

  • See

3. Privacy / Communications to contacts

• In the tracing process, Contacts, who are informed that they may have been exposed, are not told the names or identities of the Cases who may have exposed them.

4. Notification

• Publish a privacy policy that explains how information is collected, used, shared, and retained in connection with the contact tracing process. Even in the absence of a legal requirement for such a policy, publishing one improves the transparency of the process.

5. Data sharing plan/framework

• It is important to proactively define data sharing use cases and rules. Consider, with appropriate advice, creating a data sharing plan for your state and local jurisdiction that specifically addresses what data can be shared and with whom. Consider the following questions:

  • What is the data that’s being considered for sharing? Define and map data flows and explain what happens to the data in the privacy notice.

  • How sensitive is the data? Classify data sets into categories, such as: Protected Health Information (PHI), Personally Identifiable Information (PII), Public Health data and Public data.

6. Technology

• When considering technology to enhance a contact tracing process, ensure privacy and security standards, including under HIPAA, are met.

  • The 2 general categories of tracing technologies are (i) “case management” tools to automate the efficiency of case investigation, management, and communications within a human-based tracing process and (ii) “proximity tracking” (by cell phones) which can help automate the identification and follow up communications with contacts.

  • Consider communicating privacy policies to your technology teams to promote cross-functional discussion.

7. Assess and ensure proper data security policies, standards and controls are in place

• Such policies should reflect applicable legal standards and the public trust.

8. Assess and document data retention, access, deletion, & de-identification policies

• Such data policies should reflect at least the “minimum necessary” and other applicable legal standards, respect for individuals and the reasonable capabilities of the technology.

9. Train staff

• Train employees on privacy and security policies, as well as the reasons for the policies (including to build public trust in a process that relies on voluntary community cooperation).

  • Consider written privacy agreements and certifications.

  • Enforce the policy, including with transparent investigations of data breaches and appropriate consequences for policy violations.

10. Remote working rules

• If employees work from home, consider implementing controls such as prohibitions on saving information to personal devices and steps to ensure that private conversations are not overheard.

11. Agility

• Review, revise, iterate, and simplify policies and the process framework based on experience, best practices, and technology developments.

HIPAA and privacy compliance are highly fact-specific. This checklist is not intended as, and should not be treated as, legal advice concerning any particular course of action.

Implementation tools

• Criteria for evaluating contact tracing apps to ensure privacy

  • CDC:

  • Access Now:

Checklist

1. Risk communication and community engagement

Checklist

1. Governance

• Establish governance structure and relevant government agencies' and organizations' roles in contact tracing.

  • Consider federal, state, county, and local agencies.

  • Consider potential roles for the private sector. To address the large number of COVID-19 cases in some areas, authorities are assembling many partners in contact tracing efforts, including from the private sector.

    • Private companies can provide specialized capabilities around the use of technology to support contact tracing.

2. Legal authority over isolation and quarantine

• Determine whether and how isolation/quarantine orders can be mandated by law or remain voluntary:

  • Work with lawyers to understand which officials have the legal authority to impose mandatory quarantine or isolation and under what conditions. States and cities may have different approaches. Confirm which authority has jurisdiction to issue an order depending on where the case or contact is found, resides, or need to be isolated/quarantined.

  • If contact tracers lack authority to issue mandatory quarantine or isolation orders, there should be provisions to refer appropriate civil authorities to issue formal orders to cases and contacts who refuse voluntary requests.

3. Cases for interview and contact elicitation

• 3.a Interview and elicit contacts on all confirmed and probable cases. If public health resources are limited, prioritize confirmed cases. (See CDC's s)

  • See

  • See on Case Investigation Hierarchy

4. Staffing and workforce strategy

• Identify staffing/workforce strategy, within public health department or outsourced and managed by public health department. (See ; See for more information.)

5. Technology-enabled processes

• 5.a Determine if contact tracing processes will be supported by a digital app; integrate the app into the disease surveillance system workflow. (See checklist for more information.)

  • Data security and data privacy protections need to be built into all technologies and processes.

• 5.b Identify which points in the contact tracing workflow can be efficiently automated and which workflows will be conducted by staff:

6. Contact tracing protocols

• 6.a Develop contact tracing protocols.

  • Determine if contacts will be prioritized for follow-up, including when outreach will be automated vs. done in-person.

    • Ideally, health departments should collect information on all close contacts. Those that do not have the capacity to monitor and test all contacts promptly can use a risk prioritization guide. (See on Close Contact Evaluation and Monitoring Hierarchy)

7. Confidentiality protocols

• Identify and document protocols for maintaining confidentiality during contact tracing, e.g., any requirements for storage of notes and data, and special considerations when conducting contact tracing from home. Follow HIPAA regulations.

8. Notification and communication protocols

• Identify which communication with contacts can be passive only (e.g. by web, email, text, or app interface), or, if resources allow, if all contacts will receive a phone call.

  • Determine protocols for cases and contacts who do not respond to texts or phone calls (by risk level). Try alternative methods of locating and communicating with cases and contacts, such as Facebook Messenger ().

  • Consider campaigns to ask people to answer their phones and to engage honestly with contact tracers.

9. Cross-jurisdictional protocol

• Determine protocol for locating and notifying contacts outside of the jurisdiction in cooperation with the jurisdiction where the contact resides.

10. Ports of entry protocol

• Determine protocol for testing and tracing cases at ports of entry.

  • If border agents identify a case, identify which jurisdiction will be responsible for care and tracing.

11. Social support protocol

• Define wrap-around services to support individuals in isolation and quarantine and determine eligibility criteria for the provision of wrap-around services. (See for more information)

  • What criteria are used to determine eligibility?

  • Who assesses for eligibility, e.g. link to Department of Human Services to conduct?

12. Out-of-home isolation

• 12.a Determine which cases will be offered isolation out of home, and if any will be mandated.

• 12.b Determine which contacts will be offered quarantine out of home, and if any will be mandated.

13. Telemedicine protocols

• Arrange clinical linkage including telemedicine support. (See for more information)

Implementation Tools

• CDC:

• CDC:

• CDC:

Checklist

1. Staffing needs and resources

• Estimate staffing needs and resources for scaled contact tracing.

• 1.a Core contact tracing staff

  • Case Investigators

  • Contact Tracers

  • Contact Tracing Team Leads

• 1.b Additional workforce needs

  • Program Director

  • Cluster Outbreak Investigators/Field Epidemiologists

2. Current workforce assessment

• 2.a Assess the current workforce available to fill contact tracing roles.

  • Understanding the human resources already available to support the surge contact tracing workforce will inform hiring needs.

  • The workforce can come from a variety of existing sources and will depend on available budget and hiring authority. Consider:

3. Organizational chart

• Determine who will be responsible for supervising staff by job title, and organize core contact tracing staff into teams, as appropriate.

  • A maximum of eight team members plus a team leader is suggested.

  • Include epidemiologists (or staff responsible for complex investigations) in each unit.

4. Recruitment

• 4.a Identify the best personnel mechanism and recruitment processes to use for filling each type of position (e.g., permanent employee, part-time employee, contractor, volunteer).

  • Partnering with a private organization, such as a local university or non-profit organization, to manage hiring and/or workforce operations may be quicker and easier than doing this through health department mechanisms.

  • Consider communities and populations disproportionately impacted by COVID-19 and hiring from within these communities. Consult with community-based organizations and community leaders who have earned local community trust.

5. Workforce onboarding and training

• 5.a Identify or develop materials and processes for contact tracing staff orientation.

  • Include orientation to the organization, contact tracing in general, and to the contact tracing program.

  • Consider different training needs for existing staff and new hires. For example, existing staff may need a refresher on the Incident Command System (ICS) or preparedness activities within their agency.

6. Workforce management system

• Establish a management system for contact tracing staff.

• 6.a. Identify or develop protocols for each type of contact tracing position.

• 6.b. Identify or establish criteria, measures, and expectations for evaluation of workers in each type of contact tracing position.

7. Ongoing staff development

• 7.a. Plan ways in which contact tracing staff can grow, improve their knowledge, and refine their skillset. (See )

  • Possible modes of ongoing staff development include:

    • Educational/training components of a daily or weekly team meeting

8. Liability protections

• Confirm that contact tracing staff have protections of civil servants including liability protections, insurance and/or indemnity clauses.

  • Confirm staff have completed sufficient training to be competent and qualified for job responsibilities

9. Incentives and retention strategies.

• Develop a strategy for staff retention.

  • Consider financial incentives for completing so many months of service, provision of extra paid time off, process for rotating off the response for breaks.

  • Consider strategies to prevent burnout and promote mental health.

Implementation Tools

• CDC: (See Section 2: Contact Tracing Implementation Guides and Tools for the Public Health Workforce)

• Workforce calculators

  • CDC: