Maximizing the Impact of Contact Tracing for COVID-19: The Importance of Human-Centered and Equity-Driven Programming

Emily B. Wroe & Shefali B. Oza

Introduction

When we train new contact tracers joining the Community Tracing Collaborative in Massachusetts, we share data, such as what proportion of people we are reaching, as well as individual stories. We want them to contemplate: how do we help people confront the enormous complexities they face daily, especially in a pandemic? We do this to reinforce that contact tracing is human-centered, and that its effectiveness depends as much on the individual interactions as it does on more quantifiable metrics like reach and speed.

Sadly, this COVID-19 pandemic acts like every other, brutally exploiting and worsening structural inequities in society. Livelihoods, especially of the most vulnerable, are further impacted by the essential but disruptive control strategies of isolation and quarantine. An effective contact tracing program should be designed to link people to the support they need to successfully self-isolate/quarantine. Massachusetts does this through a Care Resource Coordination program. After all, a program to stop community transmission will not achieve its intended impact if people are unable to isolate/quarantine.

Contact tracing as a tool in pandemic response: what are the goals?

From the moment COVID-19 began widely impacting society, contact tracing has been central to an evolving discussion of how public health systems can effectively respond.^1-8 In fact, contact tracing is a fundamental part of pandemic response. A multipurpose tool, it is part data collection/surveillance and part action. The data surveillance component is often the primary focus: who are the cases, what are their symptoms, where were they infected, and who have they exposed?^9,10 These epidemiologic data allow us to learn about virus behavior, including how the virus is moving through society, and how to inform policy to stop further transmission (i.e. are weddings or restaurants more dangerous? Church services or sports teams?). Programs, policy makers, and the media prioritize such epidemiologic questions — proposed metrics exist, states display dashboards, comparisons are frequently cobbled together.^9,11,12 While essential, this singular data focus leaves a blind spot for one of the most important, but challenging, aspects of contact tracing: making sure that people can actually isolate/quarantine.

Temporarily separating the cases and contacts from societal interactions through isolation/quarantine is one of our best non-pharmaceutical ways of stopping transmission chains. This is particularly important for this tricky virus when people are highly infectious before symptoms start (if symptoms arrive at all).^13-15 But a request to isolate and quarantine has a disruptive impact on people’s lives. Especially in a pandemic coursing its way through poor communities, racial and ethnic minorities, and vulnerable populations, contact tracing programs must be actively and deliberately designed to address the material support people need to achieve isolation and quarantine.

Positioning Care Resource Coordination as an integral component of contact tracing programs

Care Resource Coordination (CRC) programs aim to address these issues. A CRC program acts as a bridge between the public health program and the larger systems and safety nets in communities that exist to support people. These programs acknowledge the increasing insight that many people need support to isolate when diagnosed with COVID-19.^16,17 The dearth of resources for such support often results in staff having to connect people to resources themselves or even rely on their powers of persuasion.¹⁷

In Massachusetts, the CRC program is a core part of the Community Tracing Collaborative – the state’s contact tracing program founded in April to support the local health system through the pandemic.¹⁸ Here, the work of contact tracing and the CRC program is intertwined. Contact tracers determine if there are social support needs while talking to cases and contacts, through a brief home assessment. They then refer individuals to Care Resource Coordinators who work to link those in need to broader societal programs.

The contact tracers call people, often at times of exquisite vulnerability and fear, asking them to do something that is inherently counterintuitive to our social nature and potentially damaging to their livelihoods: to stay home by themselves. They are taught to ask: what would you need right now to stay home for two weeks without leaving your house? Is there food in your kitchen? Do you have money to pay the rent and heating bills? Could you lose your job if you have to quarantine? Do you have your prescription medications in hand? The examples feel endless.

The Massachusetts CRC program sees a myriad of challenges, with food insecurity consistently topping the list. Housing issues include rental assistance, threatened eviction and persecution by landlords, difficulty paying utilities, and crowded multigenerational homes which make separation difficult. Some need basic supplies like diapers, infant formula, and masks; others need prescription medications, access to medical and mental health care, transportation to appointments, and health insurance. Immigrant communities and non-English speakers face additional barriers to navigating complex, siloed systems and accessing services.

In a country with a fragmented social safety net like the United States, CRCs are a way to connect specific programs to broader social assistance systems. CRCs navigate this patchwork quilt of services, connecting cases and contacts with wide-ranging needs to what is available in their communities.

The CRC experience offers two opportunities. First, to deliberately incorporate care resource coordination within broader public health systems so programs can achieve intended goals. As public health asks people to participate in societal impact – isolate, quarantine, vaccinate, social distance – this is an opportunity to incorporate a functional connection to social services within the public health system. The short-term example here is of CRCs within a pandemic contact tracing program, but this model could be well-suited for expansion into various longer-term public health programs, where impact frequently relies on broader socioeconomic circumstances otherwise beyond the normal reach of the program.

Second, this COVID-19 pressure test of our societal safety net offers a learning opportunity. CRCs bear witness daily to the reality of people’s lives, the acute-on-chronic needs that exist, and the biggest challenges and structural barriers people are facing. We could develop the scaffolding for more comprehensive approaches to social services in the future if we systematically evaluate these barriers to safe isolation and quarantine, the gaps in services, and the solutions offered by organizations and at the national, state, and community levels.

Conclusion

The extensive discourse about contact tracing programs has largely focused on epidemiologic surveillance. However, over the course of the COVID-19 pandemic, inquiring about material needs as part of contact tracing has become increasingly common.¹⁹ Critical to programmatic success is empowering and enabling cases and contacts to do what we are asking of them. Otherwise, we cannot stop chains of transmission. This requires acknowledging structural inequities, deliberately designing programs to address them, and fitting solutions within broader support systems. We have an opportunity to learn from contact tracing programs about gaps in social services and to incorporate resource coordination in public health systems going forward.

About the Authors

Dr. Emily Wroe, MD MPH, is a global health specialist, Associate Physician at Brigham & Women’s, and Instructor in Medicine at Harvard Medical School. As Partners In Health’s Director of Implementation & Design for the Massachusetts Community Tracing Collaborative, she oversaw data systems, protocols, training, and the Care Resource Coordinators. She is currently a Senior Advisor for PIH’s U.S. COVID response and the Associate Director of Policy & Implementation with the NCD Synergies Project.

Dr. Shefali Oza, PhD, is an epidemiologist with research and implementation experience. As Deputy Director of Data and Design for PIH’s Massachusetts COVID-19 work, she oversaw system design, the Data Team, and the Epidemic Intelligence Unit. She is currently a Senior Advisor for PIH’s COVID response and a Research Fellow at LSHTM.

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