key: cord-0724296-nt1qupg8 authors: Bruno, Denise M.; Afable, Aimee; Pervil-Ulysse, Mona; Putman, Jeffrey S.; Demissie, Kitaw title: Implementation of a Case Investigation and Contact Tracing Program at an Academic Medical Center in New York City date: 2022-02-08 journal: Acad Med DOI: 10.1097/acm.0000000000004624 sha: 994dc62763c6c15a9aa5fe5c0a15733cb955c0bc doc_id: 724296 cord_uid: nt1qupg8 In the spring of 2020, New York City was an epicenter of COVID-19 infections, hospitalizations, and mortality. One of the hardest hit areas in New York City was central Brooklyn, where State University of New York (SUNY) Downstate is located. As the severity of the initial wave of the COVID-19 pandemic waned in New York City, SUNY Downstate Health Sciences University planned to institute COVID-19 surveillance on campus to limit its spread among employees and students. APPROACH: In collaboration with university leadership and students across schools, the SUNY Downstate Contact Tracing Corps was established in July 2020. Using guidance from the Centers for Disease Control and Prevention and the New York State Department of Health, protocols for case and contact investigations, including scripts, were developed. Students were recruited and trained in remote and confidential case and contact investigations. OUTCOMES: From August 1, 2020, to March 23, 2021, there were 185 COVID-19 cases referred to the contact tracing program; of these, 180 were successfully investigated and isolated (97%). Case investigations identified 111 Downstate close contacts; 105 were investigated and quarantined (94.5%). There were 122 exposure-only investigations referred to the program, and 121 were successfully investigated and quarantined (99%). NEXT STEPS: The SUNY Downstate Contact Tracing Corps transitioned to a core group of tracers in January 2021 and has been maintained at 4 to 6 tracers since that time. With the emergence of COVID-19 variants, the threat of new variants, and variable COVID-19 vaccination rates across Brooklyn, Downstate employees and students remain vulnerable to COVID-19 transmission. Given this, the SUNY Downstate Contact Tracing Corps will continue to conduct case and contact investigations. From August 1, 2020, to March 23, 2021, there were 185 COVID-19 cases referred to the contact tracing program; of these, 180 were successfully investigated and isolated (97%). Case investigations identified 111 Downstate close contacts; 105 were investigated and quarantined (94.5%). There were 122 exposure-only investigations referred to the program, and 121 were successfully investigated and quarantined (99%). The SUNY Downstate Contact Tracing Corps transitioned to a core group of tracers in January 2021 and has been maintained at 4 to 6 tracers since that time. With the emergence of COVID-19 variants, the threat of new variants, and variable COVID-19 vaccination rates across Brooklyn, Downstate employees and students remain vulnerable to COVID-19 transmission. Given this, the SUNY Downstate Contact Tracing Corps will continue to conduct case and contact investigations. In early spring 2020, New York state was affected by the COVID-19 pandemic more severely than other states in the United States. 1 One of the hardest hit areas in New York City (NYC) was Central Brooklyn, where the State University of New York (SUNY) Downstate Health Sciences University, the only academic medical center in Brooklyn, is located. Central Brooklyn has a high proportion of African American, Caribbean American, and immigrant residents, and its neighborhoods have some of the highest rates of poverty, chronic disease, and premature mortality in NYC. 2 Many social determinants of health, including poverty, the physical environment, and race/ethnicity, have been associated with increased severity of COVID-19 infection. 3 In addition, populations of color disproportionately represent lower-paid, often frontline workers, with limited ability to social distance or work remotely. 4 On March 28, 2020, Downstate's University Hospital of Brooklyn was designated by the state to be a COVID-19-only facility. As mitigation measures effectively reduced transmission during the first wave of the pandemic, mechanisms to monitor community spread increasingly relied on contact tracing. 5, 6 As an academic medical center, Downstate Health Sciences University provides clinical services for patients in the community, educates the health care workforce, and conducts research. To assure a rapid response for case investigations and contact tracing in a community that had been disproportionately affected by the pandemic's first wave, SUNY Downstate established its own contact tracing corps in July 2020. This effort was coordinated with the New York City Department of Health (NYCDOH) to focus on the prevention of COVID-19 transmission on campus. Case investigation is the identification, investigation, isolation, and support of subjects with confirmed or probable infection of COVID-19, and contact tracing is the subsequent identification, interviewing, monitoring, quarantining, and support of their contacts who have been exposed to, and possibly infected with, the virus. 7 Because COVID-19 may be transmitted before symptoms develop, case investigation and contact tracing must be conducted as soon as possible. 8 The Recruitment of student tracers was completed on a voluntary basis and capped at a total of 60. Staffing was based on a predicted number of identified cases and contacts, understanding that a surge in cases would require an expansion of the contact tracing team. Students were required to complete an online Coursera course developed by Johns Hopkins University, 9 COVID-19 Contact Tracing, and attend a 4-hour video orientation and training developed by SPH and School of Health Professions faculty. Tracers were also required to complete training in the Health Insurance Portability and Accountability Act (HIPAA) and demonstrate proficiency in the HIPAAcompliant REDCap data entry program. After January 1, 2021, a core group of 6 tracers was selected to continue case investigations and contact tracing. The campus safety officer held daily meetings with the campus surveillance officer, SPH lead tracer, director of employee/student health, and the vice president for academic and student affairs. This daily meeting addressed concerns; reviewed protocols; and assured consistent daily communication for students, faculty, and employees. Senior members of the Contact Tracing Corps were also in regular communication with key university leadership, program directors, and stakeholders, and frequently attended campus-wide COVID-19 committees. The Downstate Contact Tracing Corps coordinated its efforts with the NYCDOH and the NYC Test and Trace Corps to assure a rapid response to positive cases and potential contacts. The Downstate Contact Tracing Corps conducted initial investigations for Downstate students and employees. The NYCDOH conducted investigations for non-Downstate cases and contacts since the Downstate program did not have the resources for community tracing. Downstate tracers continued daily monitoring of Downstate cases and close contacts until there was confirmation that the NYCDOH had initiated contact. Lead tracers reported case information to the NYCDOH if cases were not contacted by the NYCDOH or the NYC Test and Trace Corps. With guidance from the Centers for Disease Control and Prevention (CDC), SUNY Downstate's Contact Tracing Corps developed protocols and scripts for case investigations and contact tracing. 7 As additional information about the transmission of COVID-19 infection became known, protocols and scripts were updated to be consistent with CDC and New York State Department of Health guidelines ( Table 1 ). The Downstate Contact Tracing Corps received notification about cases and exposures through the daily COVID-19 lab testing report, from the director of student/employee health, the campus safety officer, and through Downstate's pooled saliva surveillance testing program. A dedicated case investigation and contact tracing email account was established on December 15, 2020, to centralize reporting of COVID-19 cases and exposures. This account received referrals with positive test results and potential close contact exposures directly from students, employees, and supervisors, in addition to those sources already described. For the first 3 months of the program, tracers were assigned investigations based on a voluntary schedule with a minimum of 3 tracers scheduled per day. The campus surveillance officer and lead tracers assigned investigations on a rotating basis after conducting an initial assessment of the case or exposure. Tracers were required to acknowledge receipt of their investigation request within 2 hours of the email notification, or the investigation was reassigned to another tracer. All investigations were to be completed as soon as possible, with most completed in less than 24 hours. All investigations were done via remote communication. To maintain tracers' privacy and to have uniformity in the area code of phone numbers for the tracing team, tracers were instructed to obtain a designated phone number through Google Voice, using the area code 518 (Albany), for all investigations rather than using their personal cell phone numbers. During surge periods with increased cases and exposures, volunteers from the group of tracers were asked to support the scheduled tracers and conduct additional investigations. At the end of the isolation and quarantine period, students, faculty, and staff were required to obtain clearance from student/employee health before returning to campus. Demographic information, assessment of symptoms, and challenges to isolation/quarantine were recorded in REDCap, a secure HIPAA-compliant web application. Each case and contact were provided with information about resources to support any identified isolation or quarantine challenges. The database was modified periodically to streamline data entry, incorporate changes in quarantine guidelines, and add additional fields, including information about employment area, job description, vaccine receipt, and vaccine manufacturer. From August 1, 2020, to March 23, 2021, there were 185 COVID-19 cases referred to the Contact Tracing Corps; of these, 180 were successfully investigated and isolated (97%). Case investigations identified 111 Downstate close contacts, and 105 were investigated and quarantined (94.5%). There were 122 exposure-only investigations referred to the program, and 121 were successfully investigated and quarantined (99%). Of note, there were 11 cluster investigations during this period. The Downstate Contact Tracing Corps also assessed many reported exposures that did not meet the CDC criteria for being considered a close contact. The NYCDOH and the NYC Test and Trace Corps supported the Downstate Contact Tracing Corps' efforts and provided resources for cases and exposures, such as care kits that included hand sanitizer, masks, a pulse oximeter, and home COVID-19 testing kits. The Downstate Contact Tracing Corps also referred several cases and contacts to Innovation Report the NYC Take Care Hotels program, which offers a free hotel room for the few situations where students or employees required a separate place to isolate or quarantine safely. As demonstrated by the number and percentage of successfully completed investigations, the Downstate Contact Tracing Corps team was effective at reaching members of the Downstate community who tested positive for COVID-19 or were exposed to someone who tested positive. Although the program was effective at tracing Downstate cases and contacts, the program faced multiple challenges. Initially, tracers had difficulty contacting cases and exposures quickly. Employees and students were sometimes difficult to reach, and phone calls from the tracers were unanswered or went to voicemail. To avoid delay and the need for multiple calls, the protocol was revised to instruct tracers to send an initial text message to alert the case or exposed individual that a member of the contact tracing team would be contacting them via phone. The text message was effective in improving the success of the initial calls. In addition, campus-wide emails were sent periodically to remind students, faculty, and staff to answer phone calls from the 518 area code since it might be a call from the Downstate Contact Tracing Corps. Overall, compliance was very high, with more than 97% of cases and 94% of contacts investigated. Another challenge encountered by the contact tracing team involved staff and students who worked off-site or rotated through outside clinical institutions. Quarantine guidelines at several institutions differed from Downstate's protocols, with shorter quarantine periods or different requirements for COVID-19 testing post-exposure. Downstate program directors and administrators worked with key individuals at these sites to communicate guidance on isolation and quarantine periods and testing requirements for Downstate students, faculty, and staff. During the pandemic, information evolved quickly, which required rapid and effective communication. Changing information required frequent campuswide bulletins, emails, and website updates as well as changes to the protocols. One limitation to the effectiveness of the Downstate Contact Tracing Corps was the reliance on voluntary reporting to Employee/Student Health or to the Contact Tracing Corps. It is likely that some students and employees who tested positive for COVID-19 outside of Downstate or who were exposed to someone with COVID-19 failed to notify the program. There were several instances 10/21/2020 The CDC definition of a "close contact" was modified to include someone who has been within 6 feet of an infected person (laboratory-confirmed or a clinically compatible illness) for a cumulative total of 15 minutes or more over a 24-hour period (for example, 3 individual 5-minute exposures for a total of 15 minutes in one day where the Contact Tracing Corps became aware of a case or exposure after the isolation or quarantine period had ended. The number of unreported cases or exposures is unknown. The essential elements that contributed to SUNY Downstate's ability to provide a rapid response to COVID-19 included clear and consistent messaging from leadership outlining expectations for reporting infections and exposures as well as timely replies to all Contact Tracing Corps communications. The large cadre of student volunteers allowed flexibility in case assignments and rapid rotation among the volunteers. Daily communication among core leadership allowed real-time protocol adjustments following the evolving local and public health guidance. The rapport and trust the Contact Tracing Corps had as SUNY Downstate colleagues of those people who were investigated facilitated tracers' success in making contact. The dedicated email account allowed centralized reporting for the entire campus. Finally, the dedication of the tracers and the commitment of the entire Downstate community were integral to the program's success. The Downstate campus safety monitor and the core leadership team continue to monitor COVID-19 cases and exposures on the Downstate campus daily. The Contact Tracing Corps transitioned to 6 core contact tracers in January 2021 and has been maintained at 4 to 6 tracers since that time. With the emergence of COVID-19 variants, the potential threat of future variants, and local geographic variation in COVID-19 vaccination rates, SUNY Downstate students and employees will continue to be vulnerable to COVID-19 infection. Given this, there is no plan to discontinue the program and the SUNY Downstate Contact Tracing Corps will continue to conduct case and contact investigations, continuing to adapt to evolving state and federal guidelines. the Northwell COVID-19 Research Consortium. Presenting characteristics, comorbidities, and outcomes among 5,700 patients hospitalized with COVID-19 in the New York City area COVID-19 and the impact of social determinants of health COVID-19 outbreak Centre for the Mathematical Modelling of Infectious Diseases COVID-19 Working Group. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts Contact Tracing in the Context of COVID-19: Interim Guidance Centers for Disease Control and Prevention. 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