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 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 (PDF)