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Why Contact Tracing Is an Essential Part of the Coronavirus Fight Lockdown Is a Blunt Tool. We Have a Sharper One.
(about 4 hours later)
We’ve been dealt a bad hand with the coronavirus pandemic. Until we have a vaccine or effective treatment, we have limited tools to fight it. Closing large segments of our society and having people shelter at home is a blunt tool that works, but it inflicts severe hardship on individuals and the economy.We’ve been dealt a bad hand with the coronavirus pandemic. Until we have a vaccine or effective treatment, we have limited tools to fight it. Closing large segments of our society and having people shelter at home is a blunt tool that works, but it inflicts severe hardship on individuals and the economy.
We have a sharper tool, the four-cornered Box It In strategy, to stop chains of transmission by widespread testing, isolation of cases, contact tracing and quarantine of contacts. It works, but it doesn’t work perfectly. Some say it’s hopeless to even try contact tracing on this scale. But contact tracing can work — if we do it right. Some states, like New York, Massachusetts and California, are moving quickly to expand these services.We have a sharper tool, the four-cornered Box It In strategy, to stop chains of transmission by widespread testing, isolation of cases, contact tracing and quarantine of contacts. It works, but it doesn’t work perfectly. Some say it’s hopeless to even try contact tracing on this scale. But contact tracing can work — if we do it right. Some states, like New York, Massachusetts and California, are moving quickly to expand these services.
We typically hear four doubts as we work to scale up this critical service. Let’s take each of them in turn:We typically hear four doubts as we work to scale up this critical service. Let’s take each of them in turn:
For many places right now, that’s correct. The numbers are overwhelming. But sheltering in place is working. We project that in New York City, perhaps the hardest-hit area of the world and still documenting more than a thousand new infections per day, the number of new cases will continue to decrease — if we continue to apply the blunt instrument and stay at home — to the low hundreds per day. Combined with an urgent and extensive scale-up of contact tracing capacity, we may be able to manage that number. For areas of the country and the world that haven’t yet experienced explosive spread, extensive contact tracing can help limit the need for widespread sheltering in place.For many places right now, that’s correct. The numbers are overwhelming. But sheltering in place is working. We project that in New York City, perhaps the hardest-hit area of the world and still documenting more than a thousand new infections per day, the number of new cases will continue to decrease — if we continue to apply the blunt instrument and stay at home — to the low hundreds per day. Combined with an urgent and extensive scale-up of contact tracing capacity, we may be able to manage that number. For areas of the country and the world that haven’t yet experienced explosive spread, extensive contact tracing can help limit the need for widespread sheltering in place.
Contact tracing won’t stop all spread of the coronavirus. But just because you can’t fix an entire problem doesn’t mean you shouldn’t fix some of it. Every time contact tracing results in an infected person’s being isolated or a contact’s being quarantined when that person develops infection, a web of transmission is broken. The best evidence is that most people with the coronavirus don’t spread the infection at all, but a few spread it widely in superspreading events. These events are most devastating when they occur in congregate facilities that house medically vulnerable people — in particular, nursing homes, homeless shelters and correctional facilities. Contact tracing can quickly sound the alarm so that outbreaks can be either prevented or stopped early, limiting disease spread both within and outside these places.Contact tracing won’t stop all spread of the coronavirus. But just because you can’t fix an entire problem doesn’t mean you shouldn’t fix some of it. Every time contact tracing results in an infected person’s being isolated or a contact’s being quarantined when that person develops infection, a web of transmission is broken. The best evidence is that most people with the coronavirus don’t spread the infection at all, but a few spread it widely in superspreading events. These events are most devastating when they occur in congregate facilities that house medically vulnerable people — in particular, nursing homes, homeless shelters and correctional facilities. Contact tracing can quickly sound the alarm so that outbreaks can be either prevented or stopped early, limiting disease spread both within and outside these places.
Spread by people without symptoms is a wild card that makes contact tracing harder because we have to identify and isolate infected people regardless of whether or not they have symptoms — but it doesn’t make it impossible. Many infected people eventually develop symptoms. Use of masks by all can reduce spread from people who are asymptomatic. Additional testing (for example, during an outbreak at a nursing home or a homeless shelter) can identify people with asymptomatic infection. Asymptomatic infection and transmission means that we may need to test every contact of every case for infection when first identified and also before the end of quarantine. This is the kind of operational detail that can be optimized as we conduct contact tracing more extensively.Spread by people without symptoms is a wild card that makes contact tracing harder because we have to identify and isolate infected people regardless of whether or not they have symptoms — but it doesn’t make it impossible. Many infected people eventually develop symptoms. Use of masks by all can reduce spread from people who are asymptomatic. Additional testing (for example, during an outbreak at a nursing home or a homeless shelter) can identify people with asymptomatic infection. Asymptomatic infection and transmission means that we may need to test every contact of every case for infection when first identified and also before the end of quarantine. This is the kind of operational detail that can be optimized as we conduct contact tracing more extensively.
Contact tracing is intense work, and we have underinvested in public health at the national, state and local levels for decades. So yes, this is going to be hard. But our safety and our economy depend on getting it right — so we’re optimistic that we will. Contact tracing isn’t easy. It requires effective communication to build trust, good people skills, access to resources for patient and contacts, sophisticated knowledge of health (including mental health), sensitivity to social and confidentiality concerns, and resourcefulness.Contact tracing is intense work, and we have underinvested in public health at the national, state and local levels for decades. So yes, this is going to be hard. But our safety and our economy depend on getting it right — so we’re optimistic that we will. Contact tracing isn’t easy. It requires effective communication to build trust, good people skills, access to resources for patient and contacts, sophisticated knowledge of health (including mental health), sensitivity to social and confidentiality concerns, and resourcefulness.
Effective programs treat patients and contacts as the V.I.P.s of the program and provide extensive support services — carrots and sometimes sticks — to encourage people to stay separated and stop the spread of infection. As highlighted in Centers for Disease Control and Prevention guidance, contact tracing will not be successful unless we support patients with a modernized version of historical quarantine so that they can remain separate successfully. Some people will be unable to maintain physical distancing, including nursing home residents and those living in crowded households with medically vulnerable people; we must provide these individuals with alternative housing, such as hotel rooms, for the duration of their isolation.Effective programs treat patients and contacts as the V.I.P.s of the program and provide extensive support services — carrots and sometimes sticks — to encourage people to stay separated and stop the spread of infection. As highlighted in Centers for Disease Control and Prevention guidance, contact tracing will not be successful unless we support patients with a modernized version of historical quarantine so that they can remain separate successfully. Some people will be unable to maintain physical distancing, including nursing home residents and those living in crowded households with medically vulnerable people; we must provide these individuals with alternative housing, such as hotel rooms, for the duration of their isolation.
A promising approach is the use of call centers with specially trained and supervised staff, augmented by in-person public health specialists to visit as needed, with handoff to skilled disease detectives in the case of possible outbreaks in congregate facilities. Contact tracing will require active engagement and participation by patients and their contacts. This can be increased if people throughout society understand that this is a service to patients and their contacts to support them and reduce the chance that they spread the infection to their families and others. The more readily people participate, the faster and more effective contact tracing will be.A promising approach is the use of call centers with specially trained and supervised staff, augmented by in-person public health specialists to visit as needed, with handoff to skilled disease detectives in the case of possible outbreaks in congregate facilities. Contact tracing will require active engagement and participation by patients and their contacts. This can be increased if people throughout society understand that this is a service to patients and their contacts to support them and reduce the chance that they spread the infection to their families and others. The more readily people participate, the faster and more effective contact tracing will be.
Newer technologies may help increase the efficiency and effectiveness, but person-to-person interaction will always be required. For example, technologies that help contact tracers communicate with patients and contacts and allow contacts to report their status and seek assistance can make the process more efficient. In contrast, ambitious efforts to detect contacts automatically by tracking Bluetooth connections are unproven, raise important privacy concerns and will be limited by the proportion of people participating, although they could potentially be important to contact tracing in the future.Newer technologies may help increase the efficiency and effectiveness, but person-to-person interaction will always be required. For example, technologies that help contact tracers communicate with patients and contacts and allow contacts to report their status and seek assistance can make the process more efficient. In contrast, ambitious efforts to detect contacts automatically by tracking Bluetooth connections are unproven, raise important privacy concerns and will be limited by the proportion of people participating, although they could potentially be important to contact tracing in the future.
We need to start this process in every community and scale it up so that as cases decline and capacity increases, we’re able to interview every case, provide safe isolation, warn contacts and quarantine them, and support cases, contacts and the workers who help them. We need to continue physical distancing until we reduce new cases to a manageably low number — flattening the curve so that we’re at a simmer, not a boil. This is an adaptive response — basing our actions on what pandemic stage we’re in. If cases surge, we may need to pause contact tracing and resume sheltering in place until cases again decrease to a manageable number.We need to start this process in every community and scale it up so that as cases decline and capacity increases, we’re able to interview every case, provide safe isolation, warn contacts and quarantine them, and support cases, contacts and the workers who help them. We need to continue physical distancing until we reduce new cases to a manageably low number — flattening the curve so that we’re at a simmer, not a boil. This is an adaptive response — basing our actions on what pandemic stage we’re in. If cases surge, we may need to pause contact tracing and resume sheltering in place until cases again decrease to a manageable number.
A role of government is to protect individuals and their families as well as health care workers and other essential workers. The hard, skilled work of contact tracing is akin to hurricane warnings: People are alerted so they can protect themselves and their families. Contact tracing is an essential component of our public health response to Covid-19, and we must begin it rapidly. It works, but not perfectly. But as Covid-19 shows, we don’t live in a perfect world. We need to play the hand we’ve been dealt as well as we possibly can to save lives, reduce spread and help restore our economy.A role of government is to protect individuals and their families as well as health care workers and other essential workers. The hard, skilled work of contact tracing is akin to hurricane warnings: People are alerted so they can protect themselves and their families. Contact tracing is an essential component of our public health response to Covid-19, and we must begin it rapidly. It works, but not perfectly. But as Covid-19 shows, we don’t live in a perfect world. We need to play the hand we’ve been dealt as well as we possibly can to save lives, reduce spread and help restore our economy.
Tom Frieden (@DrTomFrieden), director of the Centers for Disease Control and Prevention during the Obama administration, when he oversaw responses to the H1N1 influenza, Ebola and Zika epidemics and former New York City health commissioner, is president and chief executive of Resolve to Save Lives, a global nonprofit initiative that is part of the global public health organization Vital Strategies. Kelly Henning (@DrKellyHenning), the director of public health at Bloomberg Philanthropies, is a former professor of infectious disease at the University of Pennsylvania School of Medicine and former director of the Division of Epidemiology at the New York City Health Department.Tom Frieden (@DrTomFrieden), director of the Centers for Disease Control and Prevention during the Obama administration, when he oversaw responses to the H1N1 influenza, Ebola and Zika epidemics and former New York City health commissioner, is president and chief executive of Resolve to Save Lives, a global nonprofit initiative that is part of the global public health organization Vital Strategies. Kelly Henning (@DrKellyHenning), the director of public health at Bloomberg Philanthropies, is a former professor of infectious disease at the University of Pennsylvania School of Medicine and former director of the Division of Epidemiology at the New York City Health Department.
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