National Academies Offers Strategies to Encourage Cooperation in COVID-19 Contact Tracing | Infectious Diseases | JAMA Health Forum | JAMA Network
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National Academies Offers Strategies to Encourage Cooperation in COVID-19 Contact Tracing

  • 1Consulting Editor, JAMA Health Forum and JAMA

Although contact tracing is a cornerstone of efforts to mitigate the spread of coronavirus disease 2019 (COVID-19), many individuals who have tested positive refuse to cooperate and share information about people they may have exposed to the virus. However, new guidance for public health departments and local governments from the National Academies of Sciences, Engineering, and Medicine (NAS) outlines practices—such as working with trusted partners or offering small incentives, such as masks or hand sanitizer—that may help boost cooperation by the public.

Contact tracing, according to the Centers for Disease Control and Prevention, involves reaching out to close contacts, defined as individuals who were within 6 feet of an infected person for at least 15 minutes, starting from 2 days before illness onset (or, for asymptomatic patients, 2 days before positive specimen collection) until the patient is isolated. It works best when testing is widely available and test results are quickly in hand, especially for diseases such as COVID-19, in which many of those who are infected are asymptomatic.

But even when testing is widespread and the laboratory results for tests are rapidly available, contact tracing still hinges on whether those with positive test results cooperate with public health efforts to identify close contacts.

Many infected individuals are, in fact, refusing to participate. The news organization Politico reported in early September that contact tracing data from 14 states and New York City indicate that “more than three-quarters of people interviewed in hard-hit states like California and Louisiana refused to cooperate with efforts to identify relatives or acquaintances who may have been exposed to the disease.” Last week, New Jersey Governor Phil Murphy said that although 82% of individuals who are called by contact tracers answer the initial calls, 59% refuse cooperation.

There are a number of reasons that people who have tested positive for COVID-19 are reluctant to respond to contact tracing efforts and share information, the NAS notes, including concerns about confidentiality as well as feeling overwhelmed by a positive test result or overloaded with information about isolation and medical services. Others may be feeling ill or may be caring for a sick family member.

Some individuals may be suspicious of any government agency, the NAS guidance notes. Another factor hindering cooperation with contact tracing is exposure to conspiracy theories that circulate online—for example, false claims of government plans to install surveillance cameras outside homes to ensure that people who are advised to self-isolate or quarantine remain at home.

To help facilitate participation and cooperation in COVID-19 contact tracing, the NAS’s Societal Experts Action Network drew on lessons learned from data collection efforts in survey research to develop a rapid expert consultation to advise decision-makers in local public health departments and local governments.

“Contact tracing shares important features with the collection of survey data, as well as the taking of the US Census,” the authors noted. “Therefore, this rapid expert consultation suggests proven strategies from survey research that decision makers can use to encourage participation in and cooperation with contact tracing efforts along two fronts: encouraging individuals to respond to outreach from health department officials regarding participation in contact tracing and case investigation, and encouraging those who do participate to share information about people whom they may have exposed to COVID-19.”

For example, in survey research, providing people with advance notice that they might be contacted legitimizes the communications they subsequently receive. In the context of COVID-19 testing, sending a rapid series of notifications as soon as individuals are tested could prepare them to receive communications from the local health department and assure them that those communications are legitimate.

Partnering with trusted entities—such as local clinics and clinicians, racial and ethnic media, tribal elders, or clergy—may also increase cooperation. Research has shown that having requests for participation come from such trusted sources can double the rate of participation in surveys.

Survey response rates also rise when participants are offered prepaid incentives, even small ones. For contact tracing, incentives such as masks, hand sanitizer, groceries, or household supplies might provide a boost to participation.

The NAS consultation also advises accepting partial information from interviewees when they are uncomfortable with disclosing full names, addresses, and telephone numbers of their close connections or they cannot recall the information. In addition to providing cues to improve recall, encouraging interviewees to provide some detail, such as a cell phone number or an email address, can allow contact tracing to move forward.

Other strategies include enhancing contact tracing interviewers’ skills through such techniques as practicing and role playing with experienced interviewers. Developing messaging—using concrete terms to describe benefits of participation—can also appeal to people’s personal motivations.

“COVID-19 contact tracing is at once urgent and challenging—even for experienced and well-resourced public health departments,” the authors note. “Insights from survey research and Census taking offer a different perspective on and tested strategies for increasing participation and cooperation that could be useful as local public health departments and governments seek to address the challenges of contact tracing.”

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