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Overview of States’ Case Investigation and Contact Tracing Strategies during the COVID-19 Pandemic
Learn about key approaches states used when designing and adjusting contact tracing programs during the COVID-19 pandemic.
The post <strong>Overview…
As states quickly stood up contact tracing and case investigation (CI/CT) programs during the COVID-19 pandemic — and modified strategies during case surges and waves of new variants — different approaches emerged that reflected unique state and local contexts.
Some strategies aimed to reach as many exposed individuals as possible via phone call, text, or in-person visit, while some relied more heavily on technology and automated exposure notification. Others turned to self-reporting or asked individuals to notify their own close contacts. Many states used a combination of these approaches, shifting resources around as needed to meet changing needs.
In partnership with Mathematica, NASHP tracked the changing landscape of state CI/CT approaches between May 2020 and August 2022. Here, we’ll go over some key approaches states used when designing and adjusting CI/CT programs over the course of the COVID-19 pandemic, along with lessons learned.
What Is Case Investigation and Contact Tracing?
- Individuals with COVID-19 are asked to identify close contacts (generally defined as any individual within six feet for at least 15 minutes) from the previous two weeks.
- Trained staff and volunteers reach out to identified contacts by phone or electronically, confidentially inform them of exposure, and provide information on next steps.
- Contacts may be encouraged to quarantine (or directed to a place to quarantine in some cases) and get tested if they can. They may be offered health care, food, and housing assistance if needed. Individuals are instructed to isolate for a period of time until they are no longer contagious — typically based on Centers for Disease Control and Prevention isolation guidance.
State CI/CT Methods
States employed a variety of CI/CT methods to reach COVID-19 cases and close contacts. For much of the pandemic, one of the most common methods of outreach was via a manual phone call to the phone number listed on the laboratory reports for cases. In August 2020, 39 states reported mostly using manual phone calls to conduct CI/CT. Case investigators and contact tracers called cases and contacts, respectively, to let them know they had tested positive for, or had been exposed to, the virus that causes COVID-19. Staff followed a script to walk people through key information, including how to isolate or quarantine, signs that medical attention was necessary, and opportunities to access helpful resources.
As the pandemic progressed, CI/CT methods evolved to meet emerging needs. For example, jurisdictions found alternative ways to conduct CI/CT when staffing was a challenge or developed more effective approaches to CI/CT for populations that are disproportionately affected by COVID-19. Electronic notification via text message or email replaced phone calls when reaching out to those at lower risk for serious illness. This trend grew as jurisdictions experienced staffing shortages and case rates rose. By December 2021, seven states were reportedly using predominantly electronic notification to conduct CI/CT, with 23 states still relying mostly on manual phone calls and 18 using a combination of these strategies.
New CI/CT partnerships grew increasingly important as residents returned to work and school. Many jurisdictions relied on schools and businesses to conduct CI/CT. In school settings, nurses and administrators acted as contact tracers and communicated with parents and caretakers about quarantine and isolation. Some states required restaurants and other businesses to collect contact information for customers if CI/CT needed to be conducted.
Some jurisdictions intentionally focused approaches to address health disparities that were heightened by the pandemic. In August 2020, Washington, DC, added in-person home visits to the city’s contact tracing program, allowing investigators to better connect with individuals from marginalized communities who might be difficult to reach due to their work hours, housing instability, or other factors. Similarly, Illinois deployed staff to communities through the states’ Pandemic Health Navigator Program.
How the Shifting Dynamics of COVID-19 Affected CI/CT
During the case surges driven by the delta and omicron variants (see figure below), many CI/CT programs became overwhelmed with the number of cases and contacts that required outreach. These surges drove changes in how states used their workforce and technology solutions and even the length of the interview scripts contact tracers and case investigators used. Many states that initially conducted population-wide CI/CT to reach all cases and contacts via phone shifted to focus on clusters and outbreaks or other forms of prioritization.
Source: https://covid.cdc.gov/covid-data-tracker/#trends_dailycases_select_00
Due to the CI/CT backlog during the omicron wave, some states encouraged cases to notify close contacts themselves. This approach freed up contact tracing staff to focus on specific populations at high risk of serious illness and those in congregate living facilities.
Workforce Strategies for CI/CT
One consistent challenge state officials faced as case numbers rose and fell was the need for a flexible and “right-sized” workforce that could carry out effective CI/CT. As case numbers increased and health departments needed to staff up quickly to meet demand for CI/CT, a variety of strategies emerged. Some states contracted with other organizations or companies that had enough staff to take on the large influx of cases and their close contacts. In Massachusetts, for example, the state contracted with Partners In Health to conduct much of the state’s contact tracing. The organization has deep international experience responding to infectious disease outbreaks as well as the staff to take on CI/CT. Indiana contracted with Maximus, a company that ran call centers and conducted CI/CT programs for several states.
Some states kept CI/CT in-house, drawing on existing state or local government employees who could shift from their typical responsibilities and be trained to conduct CI/CT. During the spring and summer of 2020, for example, the local health departments leading the Kansas CI/CT response retrained employees to carry out CI/CT programs. This was often a temporary measure while the state worked to directly hire more employees to support CI/CT efforts. In August 2020, Kansas announced that there were 52 contact tracers on staff and that efforts were underway to hire and train a total of 100. Over the course of the pandemic, states’ reported contact tracing numbers fluctuated widely during different phases of the pandemic and changing disease burden.
There were also states that partnered with universities or volunteer organizations to share the burden of CI/CT and to help train contact tracers and case investigators to enter the workforce. In Wisconsin, the state used its State Emergency Operations Center to organize and train contact tracers and coordinate volunteers from the Emergency Assistance Volunteer Registry. States also augmented their workforce with support from other government entities such as the National Guard or the Centers for Disease Control and Prevention (CDC) Foundation.
As the pandemic progressed and new variants emerged, most states moved between these different approaches and combined the varied strategies to find what could work and what would be most sustainable. Individual cities and counties often implemented their own approach, built separately from the state approach. Chicago, for example, funded community-based organizations to create a COVID Contact Tracing Corps and COVID Resource Coordination Hub that could reach more people through trusted organizations.
Prioritization in CI/CT Programs
In November 2020, the CDC issued guidance to states about how to prioritize CI/CT for specific populations to maximize the effectiveness of programs overwhelmed by high caseloads. Prioritization remained a tool for states over the course of the pandemic as case numbers ebbed and surged, but prioritization criteria varied. Most states prioritized people in congregate living facilities, such as long-term care facilities. Some states focused on those with preexisting health conditions at higher risk for serious illness. Others prioritized people who were incarcerated, those involved in an outbreak or cluster of cases, people in certain age groups, people from some racial and ethnic groups, and those in higher risk jobs such as health care providers or other essential workers.
While prioritization was implemented with the intent to decrease the burden on CI/CT programs, investigators were often provided with very limited demographic data from electronic laboratory reports. Oftentimes, laboratory reports only included a patient’s name and telephone number, therefore requiring investigators to contact individuals to determine if they fell within a prioritized group and undermining the attempt to streamline CI/CT efforts.
Technology Solutions
States deployed a variety of technological supports to enhance CI/CT programs. Some were used internally to manage and report case data. Exposure notification apps put the tools of contact tracing into the hands of the public. Standard systems such as Situational Awareness Response Assistant Alert allowed states to manage cases and close contacts, see who needed to be contacted, and manage ongoing symptom reports.
Some states, as well as some colleges and universities, opted to develop their own exposure notification apps for residents, while other states used Google/Apple/Microsoft technology and ultimately joined the National Key Server that allowed different apps to function across state lines. A 2021 report from the U.S. Government Accountability Office highlighted some of the benefits and challenges of these apps. Benefits included that the apps could help speed up the process of CI/CT for the public and offer individuals more information about exposures. Challenges included privacy concerns and inadequate rates of adoption for maximizing the effectiveness of these tools.
Other Considerations
Other changes were driven by school reopenings, which added a layer of complexity to CI/CT approaches. Because many schools had gone remote for a period in 2020, the return to classroom learning presented a new CI/CT challenge for states to navigate. States approached school reopenings in a number of ways, with some offering state-wide requirements or mandates and others offering districts more flexibility in choosing their approach to the pandemic response. In February 2022 — late in the pandemic — 14 states reported adherence to CDC guidance exempting children from quarantining if masked during their potential exposure to COVID-19.
As COVID-19 vaccines rolled out and became available to the public, CI/CT programs shifted to include questions about people’s vaccination status, to offer information about how to get vaccinated and, in some cases, updated requirements for quarantine or isolation periods based on vaccination status. States also began to shift COVID-19 response resources toward vaccination. In Georgia, for example, local health departments stopped contact tracing in January 2021 to focus on the vaccine rollout.
Key Themes and Lessons
Across the varied approaches that states took to CI/CT during the COVID-19 pandemic, there were some common themes that may inform future responses to public health emergencies:
- Flexibility to maintain a right-size workforce. As the number of cases and contacts shifted during and following surges, it was often difficult to adjust the number of contact tracers and case investigators to the necessary level. And then, when case numbers declined, it was also difficult to decrease the CI/CT workforce while avoiding layoffs and retaining those with training for future surges. Two approaches may inform future efforts:
- Strategic partnerships with non-state entities with expertise in public health response can augment needed workforce nimbly.
- Recruiting and training state employees in other departments in CI/CT could create a bench that could be called on during a public health emergency.
- Emphasis on culturally informed outreach to historically marginalized communities. CI/CT programs present an opportunity to build trust and effectively disseminate public health information to residents. As in other components of COVID-19 response, intentional partnerships with community health workers and community-based organizations to communicate effectively with, and provide support for, residents in their respective communities was a key state strategy.
- Flexibility to shift resources to maximize impact. As the pandemic response has evolved, jurisdictions have had to quickly shift efforts and resources to meet the need at the given time. Widespread CI/CT can inform resource needs, while using electronic communications can make CI/CT programs more efficient when caseloads are high. CI/CT can inform and support vaccination efforts as vaccines become available. Shifting resources to where they are most needed is critical for ensuring better outcomes.
- Understanding the role of educational institutions, long-term care facilities, and businesses. The COVID-19 response sparked new partnerships with academic institutions and private businesses, catalyzing cross-sector action. K–12 schools conducted contact tracing, as did colleges and universities while often also playing a role in training the CI/CT workforce. Long-term care facilities were often prioritized for CI/CT and provided cluster and outbreak data to the state. Restaurants and other businesses collected names and contact information to aid in contact tracing. Understanding and leveraging the unique role that all these partners can play will be important to future public health responses.
- Data that inform a cohesive response. There is a critical need to update systems that support data collection, analytics, sharing, and the timely exchange of information. Longstanding data-sharing issues crystallized during pandemic response and shed light on gaps and innovations. Efforts to improve data completeness, reliability, and relevance and efforts to facilitate data sharing among public health and education agencies, hospitals, labs, and local, state, and federal entities have highlighted key policy and practice issues informing national, state, and local reforms.
- Ensuring opportunities for the use of available funding. States and local jurisdictions were flooded with millions and, in some cases, billions of dollars in federal COVID-19 relief funds over short funding periods. State procurement processes often hampered the ability to put contracts into place rapidly, negatively affecting the ability of community-based organizations to quickly engage in activities that worked to improve equity. Organizations eager to address disparities in their communities waited months before state contracts were executed, which limited their ability to create change. State agencies may want to consider surge planning so that administrative and procurement tasks do not slow the ability to respond to the next public health crisis.
The post <strong>Overview of States’ Case Investigation and Contact Tracing Strategies during the COVID-19 Pandemic</strong> appeared first on NASHP.
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