Millions of Americans across the country have been practicing social distancing and following “shelter in place” orders, all united in an attempt to slow the spread of COVID-19. These efforts have not been in vain as many cities are experiencing a much-anticipated “flattening of the curve”. Leaders are now developing plans to loosen restrictions and re-open local economies, however exactly when that can happen is yet to be determined. The U.S. Federal Government has outlined a three-phased approach to Open Up America Again that should not commence until gating criteria has been met and state governments have the appropriate processes in place to ensure they are adequately prepared to prevent further transmission of the virus.

According to White House experts, before states begin to ease restrictions, the following gating criteria should be met: 1. Downward trend in influenza-like illnesses (ILI) as well as COVID-like cases reported within a 14-day period; 2. Downward trend in documented COVID-19 cases within a 14-day period or downward trend of positive tests (as a percent of total tests) within a 14-day period; and 3. Hospitals are capable of treating patients without crisis care in addition to a vigorous testing program for at-risk healthcare workers, including antibody testing (Whitehouse.gov, 2020). At the time of this writing, Governors are expected to secure adequate personal protective equipment (PPE) and other medical equipment to handle a significant increase in demand as well as a surge in intensive care unit capacity. Protecting individuals employed in critical industries, high-risk facilities, and mass transportation remains a priority. States should encourage sustained social distancing and advise people to wear face masks in public. Continued surveillance is imperative as any upswing in the number of new COVID-19 cases should trigger a reinstatement of earlier restrictions to mitigate a second wave of infection.

Contact Tracing

Two key processes that should be established before entering Phase One are testing and contact tracing. Testing has been a controversial issue due to a shortage of appropriate supplies and chemical reagents as well as a lack in reliability of the tests themselves. Once dependable testing is achieved, contact tracing and isolation should follow. While this methodology has not received as much attention in the media, the Federal Government has recommended that states establish safe and efficient screening and testing sites for symptomatic individuals and trace contacts of COVID-19 positive individuals (Whitehouse.gov, 2020).

What is contact tracing and can it really help combat COVID-19?
Contact tracing or contact investigation is a public health approach that has been utilized to contain pathogens including tuberculosis, polio, Ebola virus, and the first 2003 severe acute respiratory syndrome (SARS) epidemic (Cates et al., 2016; Shuaib et al., 2017). The goal of contact tracing is to identify, treat and isolate current and potential cases of an infectious disease in order to control and prevent further human-to-human transmission. Countries such as South Korea, China, Singapore, Germany and New Zealand have employed contact tracing with varying degrees of success to hinder the spread of COVID-19 and re-open their economies.

Contact tracing involves the following steps (Centers for Disease Control and Prevention, 2020a; World Health Organization, 2017):

1. Identification: Once an individual is confirmed to be infected with COVID-19 by way of a positive diagnostic test, request that they self-quarantine at home if they do not require hospitalization. Interview them about their activities and with whom they have been in close contact such as family, work colleagues, friends, etc.
2. Notification:A public health worker will call every potential contact and notify them of their exposure. They will request that the contact isolate themselves at home and monitor for potential symptoms. Length of quarantine may vary based on the level of risk and duration of exposure.
3. Isolation: Support the safe, sustainable and effective quarantine of contacts to prevent additional transmission.
4. Follow-up: Conduct follow-up calls with all contacts to monitor for symptoms and to test for infection if symptoms do develop.

Challenges
As mentioned earlier, reliable testing is required in order for contact tracing to be effective. However, priority testing targets hospitalized patients, health care workers with symptoms, patients in long-term care facilities, the elderly, individuals with underlying conditions with symptoms, first responders with symptoms, and critical infrastructure workers with symptoms (CDC, 2020b). Not everyone with symptoms can be or will be tested at this time. In addition, a high percentage of COVID-19 positive individuals are asymptomatic and do not have access to testing. The inability to identify those carrying the virus will impede efforts to halt person-to-person transmission, leaving current shelter-in-place orders an unfortunate but critical necessity in many areas.

Contact tracing is labor and resource intensive, requiring a sizable army of knowledgeable individuals to coordinate and carry out this undertaking. Under the circumstances, it is not feasible to conduct contact tracing interviews with the hundreds of thousands of individuals with the disease, let alone their contacts. It may be achieved in smaller populations, as the infection curve flattens, and the number of new cases decreases. While several states have ramped up their hiring of contact tracers, there’s no guarantee that a tracer will be able to track down each and every contact. If they do reach them, those contacts may not comply with recommendations to self-quarantine. Digital tools such as mobile applications are being utilized in other countries to augment and automate this process. Here in the U.S. however, privacy is a major concern and until confidentiality can be protected, this technology will likely not be adopted.

Experts warn that a rush to re-open the economy could backfire and send us tumbling into a second-wave of infection. Finding the right balance between loosening restrictions and safeguarding those at greatest risk will be difficult. For now, a cautious, moderate approach is our best bet.

References
Cates, J., Trieu, L., Proops, D., Ahuja, S.D. (2016). Contact Investigations Around Mycobacterium tuberculosis Patients Without Positive Respiratory Culture. Journal of Public Health Management Practice. 22(3), 275-282. DOI: 10.1097/PHH.0000000000000261

Centers for Disease Control and Prevention (2020a). Contact Tracing: Get and keep America open: supporting states, tribes, localities, and territories. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/php/open-america/contact-tracing.html

Centers for Disease Control and Prevention (2020b). Priorities for testing patients with suspected COVID-19 infection. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/downloads/priority-testing-patients.pdf

Shuaib, F.M., Musa, P.F., Muhammad, A., Musa, E., Nyanti, S., Mkanda, P., Mahoney, F., Corkum, M., Durojaiye, M., Nganda, G.W., Sani, S.U., Dieng, B., Banda, R., and Ali Pate, M. (2017). Containment of Ebola and Polio in low resource settings using principles and practices of Emergency operations centers in public health. Journal of Public Health Management Practice. 23(1), 3 – 10. DOI: 10.1097/PHH.0000000000000447

Whitehouse.gov & Centers for Disease Control and Prevention (2020). Guidelines - Opening Up America Again. Retrieved from https://www.whitehouse.gov/openingamerica/#criteria

World Health Organization (2017). Contact Tracing. Retrieved from https://www.who.int/news-room/q-a-detail/contact-tracing

More Reading and Resources
The 3 Buckets of Prevention Still Need the Public Health Protective Net
Contact Investigations Around Mycobacterium tuberculosis Patients Without Positive Respiratory Culture
Containment of Ebola and Polio in Low-Resource Settings Using Principles and Practices of Emergency Operations Centers in Public Health