key: cord-1040566-zpbeq1rg
authors: Pelton, Matt; Medina, Daniela; Sood, Natasha; Bogale, Kaleb; Buzzelli, Lindsay; Blaker, Joshua; Nye, Derek; Nguyen, Paul D.H.; Giglio, Marisa; Smiley, Catherine; Michalak, Nathan; Legro, Nicole R.; Connolly, Mary; Dishong, Rachel A.; Nunez, Johnathan; Du, Ping; Exten, Cara
title: Efficacy of a Student-Led Community Contact Tracing Program Partnered with an Academic Medical Center during the COVID-19 Pandemic.
date: 2020-10-22
journal: Ann Epidemiol
DOI: 10.1016/j.annepidem.2020.10.004
sha: d7083b8d9c1142f0ea2de9757b55846ee0468071
doc_id: 1040566
cord_uid: zpbeq1rg

PURPOSE: Contact tracing has proven successful at controlling COVID-19 globally and the Center for Health Security has recommended that the United States add 100,000 contact tracers to the current workforce. METHODS: To address gaps in local contact tracing, health professional students partnered with their academic institution to conduct contact tracing for all COVID-19 cases diagnosed on site, which included identifying and reaching their contacts, educating participants and providing social resources to support effective quarantine and isolation. RESULTS: From March 24(th) to May 28(th), 536 laboratory-confirmed COVID-19 cases were contacted and reported an average of 2.6 contacts. Contacts were informed of their exposure, asked to quarantine and monitored for the onset of symptoms. Callers reached 94% of cases and 84% of contacts. 74% of cases reported at least 1 contact. Household members had higher rates of reporting symptoms (OR 1.65, 95% CI 1.19:2.28). The average test turnaround time decreased from 21.8 days for the first patients of this program to 2.3 days on the eleventh week. CONCLUSIONS: This provides evidence for the untapped potential of community contact tracing to respond to regional needs, confront barriers to effective quarantine and mitigate the spread of COVID-19.

Purpose Contact tracing has proven successful at controlling COVID-19 globally and the Center for Health Security has recommended that the United States add 100,000 contact tracers to the current workforce.

To address gaps in local contact tracing, health professional students partnered with their academic institution to conduct contact tracing for all COVID-19 cases diagnosed on site, which included identifying and reaching their contacts, educating participants and providing social resources to support effective quarantine and isolation.

From March 24 th to May 28 th , 536 laboratory-confirmed COVID-19 cases were contacted and reported an average of 2.6 contacts. Contacts were informed of their exposure, asked to quarantine and monitored for the onset of symptoms. Callers reached 94% of cases and 84% of contacts. 74% of cases reported at least 1 contact. Household members had higher rates of

The novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) caused a respiratory infection (coronavirus disease 2019, to spread rapidly throughout the world 1 While effective, contact tracing requires comprehensive and coordinated public health resources to reach and monitor all contacts. Tracing contacts of confirmed and presumed cases prevents transmission of the virus before symptom onset 6 . Effective contact tracing involves minimizing the delay between symptom onset and isolation to ensure that cases are removed from the community to interrupt transmission 6, 7 . However, self-imposed isolation presents numerous challenges for individuals to obtain essential supplies such as food, medication, and cleaning supplies, particularly for those within socially vulnerable populations and those lacking education on infectious disease transmission 8, 9 . Cultivating resources to address these needs and educate community members is essential to maximize ability to comply with isolation and quarantine.

Given the urgent need for contact tracing in central Pennsylvania, health professional students from an academic medical center began a contact tracing program on March 16, 2020, J o u r n a l P r e -p r o o f under the guidance of public health professionals 10 . Our goals were to 1) conduct contact tracing and 2) identify socially vulnerable individuals and connect them to resources to enhance effective quarantining. The program leveraged health professional students pulled out of traditional courses at the outset of the COVID-19 pandemic within the United States. We used standard key performance indicators (KPIs) in the field of contact tracing to evaluate the efficacy of our program: contact to case ratio, percentage of contacts testing positive, time to initial call, exposure awareness, among others 11 . Here, we provide preliminary results to demonstrate the performance of a student-led contact tracing program affiliated with a tertiary care center, characterize the population served, and illustrate the value of locally-curated social resources for overcoming barriers to isolation/quarantine.

Our team consisted of 150 medical, physician assistant, nurse practitioner, and graduate public health students (tracers) operating as part-time (averaging 8-11 hours) volunteers. This equates to approximately 36 full time workers (30 hours weekly). We were notified of all reverse-transcription polymerase-chain reaction (RT-PCR) COVID-19 positive cases (confirmed cases) diagnosed at our institution, a tertiary care and designated regional COVID-19 testing site, every 24 hours. Tracers called all confirmed cases to identify their exposed contacts (within six feet for at least 15 minutes) and evaluate social needs. Tracers called all contacts to (1) notify them that they had been exposed to a confirmed or presumed case (2) monitor for emergent symptoms for 14 days following the last exposure to the case 12 , (3) educate the contacts about self-quarantining measures and (4) identify unmet social needs while maintaining the confidentiality of the original case per HIPAA guidelines 13 . Contacts were monitored with a J o u r n a l P r e -p r o o f daily secure electronic survey or phone call. If a contact exhibited symptoms (1) as reported by the case, (2) on initial contact call or (3) on a follow-up survey or call, they were offered COVID-19 testing, treated as a "presumptive case" and their contacts were collected. All calls were made through our institution's operator, with a third-party translator service as needed. If a participant (case or contact) was unavailable, a voicemail with contact information was left.

Participants were called once a day for the three consecutive days, often at different times, until they answered or were deemed "unable to contact".

All data was managed in the HIPAA-compliant Research Electronic Data Capture (REDCap) and each case or contact was assigned an unique REDCap identification numbers (RCID) 14 . Latencies from symptom onset to COVID-19 test, test to obtaining result, result to RCID creation, RCID creation to call were KPIs used to monitor program timeliness. Contact-tocase ratio, number of cases reporting no contacts, number of contacts reporting symptoms, percent of contacts that test positive and percent of contacts unaware of exposure were used to evaluate efficacy. This project was reviewed by the Penn State College of Medicine Human Subjects Protection Office and determined to be consistent with quality improvement and not research.

We aimed to elicit participants' understandings of isolation and quarantine and identify barriers that prevented effective isolation and quarantining, while educating participants about COVID-19. We created a COVID-19 information sheet based on Harvard University's COVID- 19 Health Literacy Project, and recommendations from the CDC and the WHO with supplemental links to local resources addressing food and medication delivery, financial J o u r n a l P r e -p r o o f assistance, and mental health [15] [16] [17] . These documents were distributed to all participants in their preferred language via follow-up email.

We addressed food insecurity by sorting participants into one of three groups: (1) unable to travel for food (due to transportation barriers or household members being quarantined), (2) inability to afford food, or (3) both. To address these we, (1) emailed a list of local food and prescription delivery services, (2) referred to local food pantries, and (3) referred to an affiliate non-profit that offered food delivery services directly from a food pantry. When we identified complex social needs beyond the scope of this project, such as wage loss and child-care issues, individuals were referred to the hospital's social work department. If an email address had been collected by the tracer, an automated email would be sent to participants at the end of the call asking for suggestions and feedback about the program (Supplemental Table 1 ).

We compared the ages for confirmed cases, presumed cases and asymptomatic contacts using a Kruskal-Wallis test to confirm a relationship followed by a Mann-Whitney U test with a Bonferroni adjustment, because the ages of contacts were not normally distributed. We performed the Chi-squared test to compare household to non-household contacts becoming symptomatic and reported odds ratio and its 95% confidence interval. Additional information regarding statistical analysis is included in respective figure legends. Graphs were constructed using R Studio and GraphPad Prism 8. Figures were created using Adobe Illustrator.

From March 24th to May 28th, the team called 1489 individuals. 536 were RT-PCRconfirmed cases of COVID-19. 953 were contacts exposed to people with COVID-19, 261 of J o u r n a l P r e -p r o o f which were treated as presumptive cases ( Figure 1A) . The average age of confirmed cases, presumptive cases and asymptomatic contacts was 44.7, 33.7 and 29.6, respectively, and decreased across groups (p<0.001) ( Table 1) reported an average of 3.6 symptoms (Figure 2A) .

Of the 692 contacts that did not develop symptoms, 460 (66.5%) were household contacts Table 2 ).

Throughout the COVID-19 pandemic, contact tracing has been coordinated at the national, state, and local levels utilizing a wide variety of nontraditional employees and volunteers 8 . Here, we summarize the KPIs and early results of a novel volunteer-based, health professional student-led contact tracing program partnered with a tertiary medical center. Our results illustrate the efficacy of community-based contact tracing efforts in quickly reaching cases, identifying their contacts, and supporting their efforts to self-quarantine. We also highlight how access to unique local resources enhances contact tracing efforts.

Our cases have identified an average of 2.6 close contacts that they exposed to COVID-19, which is lower than the 4.4 contacts/case reported in Shenzhen, China 18 . This may reflect the population characteristics in our service catchment area, a nine-county area that includes a small urban center as well as suburban and rural areas that has an 80-fold lower population density than Shenzhen, a metropolitan area 19, 20 . Alternatively, this may provide evidence that J o u r n a l P r e -p r o o f community members adhered to the stay-at-home order and social distancing guidelines recommended by Pennsylvania's Governor Wolf from April 1 st to June 4 th 2020 2,21 . It is important to note that while cases may voluntarily disclose the information of their close contacts; we are unable to mandate any individual to disclose contact information. Further, after the stay-at-home order was implemented, individuals may have been less likely to report contacts out of shame or fear of consequences. Therefore, our contact:case ratio could reflect the realworld challenge of collecting contacts and our average contacts per case of 2.6 may underestimate the true number of contacts of our cases.

Compared to contact tracing programs across the United States, our program has excelled at reaching participants and eliciting their contacts. We have reached 94% of cases and 84% of contacts, while other programs are only reaching 50-60% 22 . Additionally, 74.1% of our presumed or confirmed cases reported at least 1 close contact which is markedly higher than New York City's value of 35-42% 22 . This may be explained by our health system's operator;

community members may be more likely to respond to a recognizable caller ID from a reputable healthcare institution. These findings support the efficacy of local community-led contact tracing.

Further, the Center for Health Security has recommended that the US add 100,000

contact tracers to the current workforce 23 21 2) cases may be less likely to report contacts outside of the house, possibly due to stigma associated with COVID-19 25 . We found that household contacts were 1.65 times more likely to become symptomatic than non-household contacts, which is much lower than other reported household transmission (+6.3x) 18 . However, given that our presumed cases are not laboratory confirmed, this number may be skewed; household contacts may report symptoms at different rates than non-household contacts.

Modeling suggests that the efficacy of contact tracing is maximized when contacts are reached quickly, many are identified, and pre-symptomatic transmission is limited 6 Contact tracing primarily slows the spread of disease by asking those who have been exposed to self-quarantine. It is ineffective if contacts did not have the means to self-isolate.

Resources and incentives are an essential tool for encouraging quarantine for contacts, 8 especially when 85% of exposed adult household contacts become infected 33 . Participants most frequently reported difficulty obtaining food, cleaning supplies, medications. They reported leaving the house during their quarantine to obtain these items as well as attending doctor appointments. While we met many of these needs with online delivery services, food pantries and other resources, we were least able to adequately provide cleaning products and personal protective equipment.

We primarily received positive feedback about interactions with our contact tracing team.

Many of the suggestions provided were inoperable; lack of knowledge of efficacy of treatment options, previous awareness of exposure, and mixed opinions about call length were common areas of suggestion. There was feedback that we deemed operable, including expanding the resources we had available to offer to our participants, increasing clarity about the reason of the call and increasing our knowledge base about quarantining strategies.

J o u r n a l P r e -p r o o f

This work has several limitations that must be noted. Test turnaround hinders the timeliness of our contact tracing program. Ideally in contact tracing, every contact is tested 31 .

We tested all presumptive cases that wanted a test, but were unable to test all contacts due to institutional limitations. Therefore, we were largely unable to confirm if many of our presumptive cases were truly COVID-19 positive and all our asymptomatic contacts were truly COVID-19 negative. Participation in our program was entirely voluntary, which likely reduced the number of contacts elicited from cases. Our database is incomplete -some participants do not answer all questions, and we do not attempt to retroactively enter data once all contact information is collected. Finally, our data set is limited by iterative script changes that accumulated based on feedback and barriers to efficiency.

Our findings in the context of these limitations leave many questions unanswered. Future work may incorporate mathematical modeling to determine the impact of community-led contact tracing on local case burden and spread of disease. Further work should characterize which contacts are at risk of developing disease and the efficacy of these interventions in supporting quarantine and decreasing transmission. To continue to improve this program, we are prioritizing testing all contacts, decreasing the latency to reaching contacts and continuously evaluating and improving the resources we provide.

Here, we outline the preliminary results of a volunteer student-led contact tracing program partnered with an academic healthcare institution. These data validate the efficacy of a student-led volunteer contact tracing program to respond to regional contact tracing needs, providing evidence for the untapped potential of community contact tracing. Finally, we J o u r n a l P r e -p r o o f highlight barriers to effective quarantine experienced by Pennsylvanians and propose interventions to enhance quarantine capabilities. Further work should characterize the underlying forces that limit the efficacy of contact tracing such as refusal to participate, barriers to effective isolation and quarantine and limited testing capacity. Appreciate advice and concern (2), thorough information (1) .

None/it was fine (54) No suggestions (6)

Continue to follow up (2), less follow-up (1), personalize follow-up (1), follow up with employers (1), send follow-up information/up-to-date content about COVID to patients (1); Patient still waiting for test (1) Faster follow-up (1)

Provide personal protective equipment (1), groceries, work notes (1), antibody testing (1) get more COVID tests (1), provide treatment for COVID (2) Want more COVID tests (1), had difficulty obtaining work note (2)

Want to know what happens post-quarantine (1) , inform what medications they should use (1), want more information (1), explain contact tracing better (1), explain antibody testing (1) Want better explanation of contract tracing program at initiation of call (2), give more information on antibody testing/donating plasma (1)

Gathering information already gathered by another caller (2) Already aware exposed (1)

Inadequate explanation in voicemail (1) Better connection/phone service (2) Want quicker response to voicemails (1) want increased consistency between callers (1), confused about when to return to work (1). Call not completed (1) 

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None to disclose.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.