Plan for Pennsylvania: Contact Tracing
Robust
surveillance, case investigation, contact tracing and isolation of
positive cases or quarantine of close contacts can slow and stop the
transmission of COVID-19. Pennsylvania's public health infrastructure of
epidemiologists, community health nurses and county and municipal
health departments are the backbone of this work. These public health
professionals are supported by surveillance and case management
technology tools to track, manage and evaluate efforts. As counties
return to work the Department of Health will conduct complete case
investigation and contact tracing of positive cases to stamp out disease
transmission. Positive cases will be isolated, and their close contacts
counseled and quarantined reducing risk of transmission in these
communities.
What are Case Investigations, Contact Tracing and Monitoring?
Case
investigations, contact tracing and monitoring are tools public health
professionals use to contain the spread of infectious diseases.
A
thorough case investigation is the key to identifying disease trends,
symptomology and risk factors. For any infectious disease, including
COVID-19, test results are required to be electronically reported by
health care providers and laboratories to Pennsylvania's National
Electronic Disease Surveillance System (PA-NEDSS). When the department
is notified of a positive test result in PA-NEDSS, community health
nurses contact the person and perform a full investigation to include
information on:
- Demographics (race, ethnicity, age, occupation, etc.);
- Symptoms and symptom onset to determine when they were infectious;
- Risk factors (occupation and workplace, travel, exposures, comorbidities, etc.);
- Hospitalization and death data; and
- Close
contacts, healthcare facilities, first responders and high-risk
congregate settings that were potentially exposed while the case was
infectious.
In addition to collecting surveillance
data/close contact information, nurses provide instructions on isolation
of the case, quarantine of close contacts and the need to contact their
healthcare provider or the department should anyone develop COVID-19
related symptoms.
Contact tracing, a core disease control measure employed
by public health personnel for decades, is a key strategy for preventing
the further spread of infectious diseases like COVID-19.
Contact tracers adhere to the Centers for Disease Control and Prevention's (CDC) core principles of contact tracing:
- Contact tracing is part of the process of supporting patients with suspected or confirmed infection.
- In
contact tracing, public health staff work with a patient to help them
recall everyone with whom they have had close contact during the
timeframe while they may have been infectious. (For Covid-19, this
infectious period is 48 hours prior to symptom onset until the case
meets isolation discontinuation criteria).
- Public health staff
then notify these exposed individuals (close contacts) of their
potential exposure as rapidly and sensitively as possible.
- To
protect patient privacy, close contacts are only informed that they may
have been exposed to a patient with the infection. They are not told the
identity of the patient who may have exposed them.
- Close
contacts are provided with education, information and support to
understand their risk. They are provided information on what they
should do to separate themselves from others who are not exposed, how to
monitor themselves for illness, and the possibility that they could
spread the infection to others even if they themselves do not feel ill.
- Close contacts are encouraged to stay home and maintain social distance from
others (at least 6 feet) until 14 days after their last exposure, in
case they also become ill. They should monitor themselves by checking
their temperature twice daily and watching for other symptoms of
COVID-19. To the extent possible, public health staff should check in,
either by direct contact or through a technologically based solution,
with contacts to make sure they are self-monitoring and have not
developed symptoms. Contacts who develop symptoms should promptly
isolate themselves and notify public health staff. They should be
promptly evaluated for infection and for the need for medical care.
Testing may be recommended. Testing may be skipped when they are already
in a household or long-term care facility with a confirmed case or
cases, then the contact may be considered a probable case without
testing.
As the commonwealth moves to loosen social distancing
restrictions, the department plans to bolster these efforts using
additional personnel, technology and improved workflows. In
order to accomplish this, the department has developed this
four-part strategy outlined below for case investigation, contact
tracing and monitoring to identify and contain localized outbreaks of
disease. This will allow Pennsylvanians to carefully move into normal
routines while ensuring that the public health system does not become
overwhelmed with people suffering from COVID-19.
Part One: Investing in an Infrastructure Focused on People
The
department's current operating budget is sufficient to fund contact
tracing in most disease outbreaks. However, in a global pandemic like
COVID-19, more funding is needed to support this effort.
The
department was awarded a federal Centers for Disease Control and
Prevention grant for $18.7 million. A portion of these funds are
earmarked by the federal government specifically for contact tracing.
The
department currently has approximately 150 staff who are part of the
team that conducts case investigations and contact tracing for any
disease outbreak. Ten county and municipal health departments also have
staff that are performing this work at the local level. However, the
majority of the state relies on the department as its local health
department.
Due to a lower disease incidence rate, community
health nurses in the Northcentral and Northwest Districts have begun to
perform contact tracing, notification and monitoring of identified case
contacts in their regions. These are the first regions identified for
reopening in the Yellow Phase of the Governor's Plan for Pennsylvania.
Additionally,
special teams of epidemiologists, epidemiology research associates,
master and doctoral students of public health and a CDC Senior Policy
Advisor have been trained and assigned to notify and provide follow-up
recommendations when a COVID-19 case and/or outbreak is identified in
large congregate settings like long-term and personal care homes; health
care facilities; correctional facilities; food processing and packaging
plants; and other large outbreak settings.
These teams will be
sufficient to provide robust contact tracing in the initial regions
identified to move into the Yellow Phase.
In counties and
districts outside of these regions, the department will partner with
county/municipal health departments, healthcare networks, academic
institutions, disease intervention specialists, displaced workers who
are trained in contact tracing workflow and other volunteer
organizations to perform this essential work. These individuals will be
trained in contact tracing and the technology involved.
Part Two: Innovate Process Through Technology Tools and Robust Case Investigations
Our
ability to track, monitor, isolate and test symptomatic contacts is
further enhanced by the use of technology applications, specifically the
MITRE-Sara Alert contact monitoring application that works alongside
our disease surveillance system, NEDSS. MITRE-Sara Alert is a web-based
monitoring tool that contact tracers will use to send daily emails,
texts and/or phone calls to cases and identified close contacts
throughout their isolation/quarantine monitoring period. This technology
enhances the contact tracer's ability to promptly respond and provide
guidance to symptomatic individuals. The MITRE-Sara Alert system also
provides valuable real-time data to the department, including the number
of symptomatic/asymptomatic contacts and cases per region.
The
department will also examine Bluetooth proximity exposure notification
technology that does not use GPS navigation data. It is a voluntary,
opt-in application which tracks other anonymous Bluetooth enabled
smartphones that have been within a critical range/time (for example:
within 10 feet for more than 10 minutes), and will send an alert to
other iOS or Android phones if a positive COVID-19 case (who has
voluntarily uploaded their COVID-19 positive status into this system)
was captured in that critical range. The technology maintains the
anonymity of all users. When fully developed, this technology will have
the capability to alert exposed individuals with instructions such as
self-quarantine, testing and other next steps.
Part Three: Partner With Established Health Care Community
Given
the magnitude of COVID-19 cases in Pennsylvania, it is estimated that
in the later phases of reopening, additional contact tracers will be
needed to accomplish case investigation, contact tracing and monitoring.
These individuals may be existing staff at the department, new staff,
partners, students and volunteers. The number needed in each region
varies depending on a number of factors including:
- Daily number of cases and burden of outbreaks in congregate settings or large workplaces;
- Number of contacts identified;
- How
quickly patients are isolated, and contacts are notified and advised to
stay home, self- monitor, and maintain social distance; and
- The public's acceptance, utilization and adherence to the automated contact tracking system.
In
the Northcentral and Northwest Health Districts, the department has
enough resources through its existing network of community health nurses
and the Erie County Health Department to begin contact tracing. These
are the regions slated to move to the Yellow Phase first under the
Governor's plan.
In the Northeast Health District, the department
will work with the Lehigh Valley Health Network to utilize its reporting
systems to reduce duplicate contact tracing efforts. LVHN's reporting
system is capturing some of the contact tracing information and
connecting with this data system will allow for a better workflow.
Additionally, the department has applied for a Dislocated Worker Grant
from the Department of Labor and Industry that will potentially enable
it to hire an additional 110 contractors dedicated to this region.
In
the Southcentral Health District, the department's community health
nurses will be supplemented with 40 volunteers from the Penn State
College of Medicine who will be trained using CDC guidelines as contact
tracers. Additionally, local health departments such as York City will
provide additional support.
In the Southeast Health District,
community health nurses in Berks, Lancaster and Schuylkill counties and
the Lancaster City Board of Health and Lancaster General Hospital will
assist with Lancaster city will be supplemented by volunteers recruited
through organizations like PennServ/AmeriCorps and ServPA. The
Department will also seek partnerships with local health leaders and
universities in the region. Additionally, federal funding will be
provided to County/Municipal Health Departments either as a pass-through
from the department or directly from the federal government.
In
the Southwest Health District, community health nurses and Disease
Intervention Specialists from the department's Bureau of Communicable
Diseases will support efforts in Armstrong, Beaver, Butler, Cambria,
Fayetteville, Greene, Indiana, Somerset, Washington and Westmoreland
counties. Allegheny County Health Department will be supported by and
work with local health leaders in that region. The Department will also
seek partnerships with local health leaders and universities in the
region.
County Health Departments (Allegheny, Bucks, Chester
(also responsible for Delaware), Erie, Montgomery, and Philadelphia
counties) and Municipal Health Departments (Allentown, Bethlehem,
Wilkes-Barre, and York) will be primarily responsible for contact
tracing in their jurisdiction. However, the department will supplement
their efforts with access to the MITRE-Sara Alert contact tracing
system, facilitate regional partnerships with health leaders and support
with additional resources as needed.
Part Four: Focus on Underserved and Vulnerable Communities
One
aspect of data collection that has been difficult to collect is
demographic data on COVID-19 patients who test negative and positive for
COVID-19. The volume of patients requiring testing has limited
providers' and laboratories' ability to report this information,
although it is required as part of disease reporting. As regions move
into the Yellow, and eventually Green Phase, this data will be collected
through the robust contact tracing, filling this gap in data and
allowing the commonwealth to target more resources to vulnerable
communities.
Pennsylvanians living and working in congregate
settings also are at greater risk of contracting COVID-19. As mentioned,
special teams of epidemiologists, epidemiology research associates,
master and doctoral students of public health and a CDC Senior Policy
Advisor have been trained and assigned to notify and provide follow-up
recommendations when a COVID-19 case and/or outbreak is identified in
large congregate settings like long-term and personal care homes; health
care facilities; correctional facilities; food processing and packaging
plants; and other large outbreak settings. To ensure a healthy
Pennsylvania for all, especially during these unprecedented times, the
Wolf Administration will only partner with organizations and entities
throughout this contact tracing strategy that have an established
commitment to non-discriminatory practices.
Reopening Pennsylvania
Reopening
Pennsylvania is not without its risks. When social distancing protocols
are relaxed, there is an increased risk of COVID-19 infection and
transmission in our communities. And with that comes the risk of
overwhelming our public health system.
Case investigation
contact tracing and monitoring are proven public health strategies to
contain the spread of diseases. These efforts worked to slow the virus'
inevitable progression to sustained community spread and will help us
identify and isolate future outbreaks.
Contact Tracing Information for Individuals and Groups