Schneider JA, Pollack HA. Flipping the Script for Coronavirus Disease 2019 Contact Tracing. JAMA Health Forum. Published online September 16, 2020. doi:10.1001/jamahealthforum.2020.1129
In recent months, US public health authorities have rapidly established or expanded contact tracing to contain the coronavirus disease 2019 (COVID-19) pandemic,1 hoping that index patients could be identified, treated, and physically isolated to prevent further infections.2 Those connected to these index patients could be similarly identified through tried and true strategies used to contain local outbreaks, through readily traced contact networks.3
Some nations, such as South Korea and New Zealand, have broadly succeeded in these efforts.4 In the US, such aspirations have not been achieved. The virus has spread too rapidly and efficiently. The distrust of government among US residents has proved too deep. COVID-19 disproportionately affects populations such as immigrants without legal status, workers with low wages, and those in the criminal justice system. Political polarization,5 testing delays,6 and limited organizational infrastructure and capacity have further hindered contact-tracing efforts.
One might conclude from this experience that COVID-19 contact tracing can never work in the US. David Lakey, MD, a former Texas state health commissioner, described to The New York Times what many practitioners and researchers were surely already thinking7: “Contact tracing is the wrong tool for the wrong job at the wrong time….Back when you had 10 cases here in Texas, it might have been useful. But if you don’t have rapid testing, it’s going to be very difficult in a disease with 40% of people asymptomatic. It’s hard to see the benefit of it right now.”
We sympathize with Dr Lakey’s perspective. But our own experience suggests more optimistic lessons. One of us (J.A.S.) has helped to lead the largest contact-tracing operation in Illinois, at Chicago’s Howard Brown Health. Howard Brown Health is a federally qualified health center with 10 clinical locations across Chicago. It initiated COVID-19 contact tracing starting with the first client with a positive test result who was diagnosed at the organization, on March 13, 2020. Since then, 92 contact tracers have been trained, 3504 individuals infected with COVID-19 have been interviewed, and more than 6000 network members have been identified as individuals potentially exposed to COVID-19.
This on-the-ground experience suggests that a more pragmatic vision rooted in social determinants can advance public health. To do so, we must change the way contact tracing engages communities, change the tools contact tracing traditionally uses, and recognize that addressing social determinants of health can make the hard task of disease containment easier to achieve.
Traditional contact tracing presupposes that people can take protective actions, such as isolating from others, once they are identified as being at risk of acquiring or transmitting infection. Our COVID-19 experience suggests a critical addition to this intervention model. When someone lacks the tools to protect themselves and others, public health authorities must provide them.
Information is one such tool. Absent proper support and advice, people who learn that they are COVID-19 positive can make ostensibly reasonable decisions, which may reflect misinformation and bias. When test results are given, few individuals may have opportunities for careful conversations about transmission, isolation and quarantine, symptom duration, and their immediate networks. Contact tracing can fill these knowledge gaps. More than 70% of clients contacted by Howard Brown Health contact tracers asked basic questions about COVID-19 transmission. In answering such questions, staff can implement internal warm handoffs to address underlying anxiety, depression, and other mental health challenges often associated with COVID-19.
People also need specific resources related to food, housing, money, employment, health insurance, and access to medical care. Among nearly 1700 Black and Latinx clients with low incomes (92% of whom were COVID-19 positive), at least one-third described resource needs that hindered their ability to follow public health guidelines.
For people who cannot socially distance because they lack stable housing or are homeless, our staff provides housing assistance. For people who lack food or must choose between working low-wage survival jobs and protecting themselves against COVID-19, our staff provide food deliveries and sometimes cash aid. When people have no insurance or live with household members who are medically vulnerable, contact tracers can provide a gateway for Medicaid enrollment and mental health and addiction treatment.
Simply put, our approach to contact tracing has focused on relationships and engagement along with epidemiological surveillance and case finding. Instead of leading with “Please name the people with whom you have been in contact,” we ask, “How can we help you? What can we do right now to help you get by?” Providing needed support immediately helps individuals to avoid infecting others. Providing such help when it is most needed also advances the broader legitimacy of the public health enterprise within affected communities.
When individuals and communities with understandable distrust see contract tracing as a gateway to meet their basic needs, they become powerful allies and partners to promote protective behaviors and sound public health practice. They help to engage people at greatest risk—including immigrants without legal status and others—who otherwise perceive powerful reasons to evade traditional contact-tracing measures.
Such efforts also reflect a timeless insight. Relationships and engagement are necessary first steps in any effective public health intervention. Put another way, we must always preach the gospel of public health with supportive action. Whichever presidential candidate wins this November, the federal government must lead the way in making this vision a reality.
Corresponding Author: John Schneider, MD, MPH, Department of Medicine, University of Chicago, 5841 S Maryland Ave MC 5065, Chicago, IL 60637 (email@example.com).
Additional Contributions: We acknowledge members of the Howard Brown Health contact-tracing team, including more than 50 volunteers, for their important contributions to the program, and notably Willie Love, Erik Garcia, Beth Tadesse, Chad Hendry, Anu Hazra, Francisco Leyton, and Megan Plank.
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