by Terry Rogers
During press conferences, Governor John Carney and the Director of Public Health, Dr. Karyl Rattay, often talk about the need for contact tracing in the fight against COVID-19. Currently, the Delaware National Guard is assisting the state with this important tool in battling the virus and more than 130 Delawareans will be hired over the next few months to continue contact tracing in the state.
“To protect the citizens of Delaware, we must prevent the spread of COVID-19,” Dr. Kara Odem Walker, Delaware Director of Health and Human Services, said. “The average person infected with this virus can transmit it to two or three more people. We need to bring that reinfection rate to about one in order to dramatically slow the transmission until we have a vaccine or cure. As a practicing family physician, it is important to me to talk to my patients about their risk for any disease and to use testing results as a way to inform next steps. With COVID-19, testing results are absolutely critical.”
Dr. Walker explained that it is important that anyone who is diagnosed with COVID-19 to isolate and for their close contacts to quarantine until they learn if they are positive as well. In an effort to promote both of these aspects, contact tracing will be used by public health to help them connect test results to critical next step. Dr. Walker explained that the CDC recommends “closing the loop” using testing, isolating, quarantining and finding the virus.
“Closing the loop means that with each wave of infection, there are fewer and fewer secondary infections,” Dr. Walker explained. “This allows more and more people to move about and proceed beyond a new normal but back to actual normal. The goals of contact tracing falls into four separate goals which include isolation, quarantine, monitoring and resource coordination.”
In Delaware, anyone who tests positive or is believed to be positive are asked to isolate for 14 days based on symptoms to help prevent the spread of the virus. These individuals are interviewed to determine who they may have come into contact with over the past two weeks in order to ask those individuals to quarantine for 14 days.
“We want to monitor both the index cases and contacts during their isolation and self-quarantine to make sure they are cleared,” Dr. Walker said. “Finally, we want to provide resources so those who are in isolation and quarantine have what they need to stay safe, make sure they have food, safe housing, prescription, etc. This is the challenge in front of us. The essence of community tracing is that it helps us connect contacts with the care and resources they need to prevent further transmission of the virus.”
In Delaware, contact tracing began with individuals who will reach out to those who may have come in contact with someone who tested positive for the virus by telephone. In addition, there are field contact tracers who will visit the homes of those who may have come in contact with a positive person, providing them with resources and conducting interviews. Case investigators who make the initial contact with the newly diagnosed COVID-1 individual will explain what a diagnosis means and collect details on anyone the person came into close contact with over the previous two weeks. That information is then entered into a database to be used by contact tracers.
“There may be instances where we do not have a phone number or someone is not answering the calls,” Dr. Walker said. “In these cases, field case investigators will use other methods to reach out to those who may have been in contact with a positive individual. This may be an address or workplace. Once we either reach them by phone, at their home or a workplace, we will provide them with information on testing and the need to quarantine. For those who need assistance, we will provide resources for them to get food, safe housing, prescriptions and more. Our goal is to reach anyone who is positive within 48 hours and to refer any contacts to testing sites within 48 hours. We want to also be sure we reach out to those who are not tested within 48 hours to be sure they do so. We also want to refer any contacts who are socially vulnerable to the Department of Health and Social Services for resources.”
Dr. Tolbert Nyenswah, a Senior Research Associate with Johns Hopkins Bloomberg School of Public Health, confirmed Dr. Walker’s assessment that contract tracing is critical in minimizing the spread of COVID-19. Dr. Nyenswah worked with contact tracing in Africa during the Ebola outbreak.
“Contact tracing is a very important element of public health practice and has been around for a couple of years as a major public health tool,” Dr. Nyenswah said. “We have used contact tracing for diseases like smallpox, something we eradicated almost a century ago, we used it to deal with the H1N1 avian Spanish flu and we still use it to deal with tuberculosis. If someone gets tuberculosis and they are unable to take their medication, public health sends someone to do community tracing to encourage them to take their medication. Syphilis and HIV, even vaccine-preventable diseases like measles, we use contact tracing to deal with that. Contact tracing is not new.”
According to Dr. Nyenswah, contact tracing is critical for the reopening of the country and it has been used successfully to break the chain of transmission for other diseases. He also suggested that anyone who wanted to know exactly how contact tracing works, the legalities of the system and other details take the contact tracing course available to anyone on Coursera.
One of the issues Dr. Nyenswah faced when dealing with the Ebola outbreak was the stigma of the illness which had a very high mortality rate. Although the mortality rate for COVID-19 is significantly lower than Ebola, people are still not willing to be tested and many feel they can just recover from the illness on their own, not seeking medical assistance until they are very sick.
“It is important to get the information out about how important contact tracing is in a disease such as COVID-19,” Dr. Nyenswah said. “It can be difficult to get information about contacts because people are afraid to provide that information, but it is absolutely necessary to stem the spread of this illness.”
Edy Morales-Yoc, a licensed practical nurse at the Department of Public Health Adams Center in Georgetown who is working as a contact tracer, explained the information that a contact tracer will ask when they interview people.
“When we either call or visit you, we will first provide you with our name and the reason for our call,” Morales-Yoc said. “We will verify your name and birthdate, but we will not ask for any other information. We will provide information about isolation, self-quarantine as well as resources if you need them. For example, food assistance or if you need a thermometer, we will provide that.”
David Cotton, the Vice President of Public Health Response and Evaluation with NORC at the University of Chicago, explained that his company will not receive any information entered into the database. NORC is organizing the hiring of all contact tracers in Delaware and assisting with the creation of technology that will be used. In addition, those who contact the COVID-19 positive people are different contact tracers than those who reach out to those who came in contact with that person. This further limits the ability for a contact tracer to share confidential information.
“All information will be kept on state servers and in state databases,” Cotton explained. “Our staff has no access to any records stored on those servers. All contact tracers will be trained on confidentiality and protecting privacy rights as well as data.” Dr. Walker explained that all information collected is protected under HIPAA and state privacy laws so people should not be concerned their information will be released to anyone if they are contacted. Contact tracers will not reach out to primary care physicians even if the physician ordered the test.
There have been concerns that children or members of a household who contract the virus will be removed from the home during the contact tracing process.
“Single parents should not be concerned that they or their children will be removed from the home if they test positive for the virus,” Martinez-Yoc said. “We actually encourage you and the family to stay together and, of course, maintaining good, safe-practice hand washing, keeping your distance. The risk of exposure is there but if you take the precautions necessary, the risk is minimized. I have known people in the community where both parents have been sick with the virus and the kids have not contracted the virus. But it is always good to have a plan. If you become very ill and cannot take care of your children, you need to have a plan. I do understand that should that happen, childcare will be provided if necessary, but your children will not be taken away.”
Dr. Walker explained that there are concerns about job security and the need to quarantine even when someone is not sick. She explained that the state is developing systems that would allow them to work with employers should someone need to be quarantined for two weeks after they have returned to work.