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Interim Roadmap for Contact Tracing Prioritization

Background

Systematic testing, contact tracing, and supported isolation and quarantine remain cornerstones of an effective public health response to the COVID-19 pandemic. Contact tracing is much more effective when performed soon after case symptom onset when their contacts are in the early phase of possible infection if they do become infected. However, immediate contact tracing measures are often less feasible when hundreds or thousands of cases are identified a day in each community. It is critical that efforts to contact trace reflect a wholistic understanding of community challenges and such efforts may require a more targeted approach to contact tracing in which the emphasis is placed upon priority cases and settings where there are high levels of community transmission.

During times when transmission is low or moderate, the goal for contact tracing and symptom monitoring programs should be identifying and reaching 100% of confirmed and probable COVID-19 cases for interview, providing isolation guidance, and identifying a comprehensive list of individuals in close contact with the case during their infectious period. In turn, under ideal circumstances, all identified contacts are notified, asked to actively monitor symptoms, and asked to remain in quarantine following their last exposure to a COVID-19 case per local health department guidance.

Summary

Recognizing the need to significantly increase contact tracing capacity, the Illinois Department of Public Health (IDPH) provided Local Health Departments (LHDs) with additional funding from the Federal Coronavirus Aid, Relief, and Economic Security (CARES) Act to conduct disease and contact investigations and daily symptom monitoring for those in isolation and quarantine. IDPH also hired an auxiliary contact tracing workforce to provide surge and supplemental support to LHDs. LHDs have increased the number of contact tracing staff, and both IDPH and LHDs continue to recruit staff to enhance the existing workforce who are meeting this arduous challenge. Nonetheless, the high level of community transmission makes effective contact tracing challenging and necessitates an immediate need to prioritize those at highest risk of serious illness from COVID-19. Refining the approach to contact tracing, as outlined in this guidance, bolsters the ability of LHDs to meet critical contact tracing needs while continuing to boost staffing capacity to reach the highest proportion of infected and exposed individuals who are at risk of furthering disease transmission.

IDPH and LHDs have collaboratively identified several activities related to disease investigation, contact notification, and symptom monitoring that may be modified or suspended during periods of increased community transmission in order to meet the current demands in a sustainable way. In periods of high community transmission, LHDs are encouraged to adopt flexible strategies to meet the goals of contact tracing and monitoring as best they can within their capacity.

This document outlines modified practices and considerations for appropriate adjustments in contact tracing practices, serving as an interim roadmap for a more targeted and efficacious approach. Adapted from the Centers for Disease Control (CDC) recommendations for high-burden jurisdictions, the modified contact tracing practices will allow LHDs to prioritize public health interventions during situations of increased community spread by prioritizing: 1) vulnerable populations; 2) congregate settings (including long-term care facilities): 3) high exposure contacts; and 4) high-density indoor settings.

Refining the approach to contact tracing, as outlined in this guidance, bolsters the ability to meet critical contact tracing needs while continuing to boost staffing capacity to reach the highest proportion of infected and exposed individuals who are at risk of furthering disease transmission. IDPH will continue to update this roadmap, in partnership with LHDs, as the pandemic and contact tracing evolve.

Recommendations

In areas of substantial or high COVID-19 transmission, LHDs should adopt targeted strategies to meet the goals of contact tracing and monitoring as outlined below in the prioritization scheme (Figure 1) and contact tracing modifications (Figure 2).[1]   

LHDs may consider implementing these modifications to contact tracing practices when county-level transmission of COVID-19 is substantial or high[2]

Information on exposure locations, occupation, outbreak, and other epidemiologic information should continue to be collected from all cases when they are investigated and entered in the Salesforce case record. Resource coordination to address structural barriers to safely isolate and/or recover should continue as is to ensure equity in the disease response for every case/close contact.

Figure 1 describes a suggested prioritization scheme for case investigation for appropriate notification and monitoring of close contacts when having to perform the work during periods of substantial and high-level disease transmission.

Figure 2 describes potential modifications to case investigation and contact tracing practices. These modifications should only be implemented during periods of substantial and high transmission when standard operating procedures for contact tracing are no longer sustainable. LHDS are not required to use these modifications if they have capacity to sufficiently investigate all cases and identify all close contacts during periods of substantial and high transmission.

The recommended modifications identified below are not intended to be an exhaustive list of available options. LHDs may consider additional modifications to their contact tracing programs where necessary, provided that those modifications are consistent with existing state guidelines. LHDs should notify IDPH of any additional modifications using contact information provided below.

Prioritization scheme for case investigation and contact tracing

Systematic testing, contact tracing, and supported isolation and quarantine remain cornerstones of an effective public health response to the COVID-19 pandemic. Contact tracing is much more effective when performed soon after case symptom onset when their contacts are in the early phase of possible infection if they do become infected. However, immediate contact tracing measures are often less feasible when hundreds or thousands of cases are identified a day in each community. It is critical that efforts to contact trace reflect a wholistic understanding of community challenges and such efforts may require a more targeted approach to contact tracing in which the emphasis is placed upon priority cases and settings where there are high levels of community transmission.

During times when transmission is low or moderate, the goal for contact tracing and symptom monitoring programs should be identifying and reaching 100% of confirmed and probable COVID-19 cases for interview, providing isolation guidance, and identifying a comprehensive list of individuals in close contact with the case during their infectious period. In turn, under ideal circumstances, all identified contacts are notified, asked to actively monitor symptoms, and asked to remain in quarantine following their last exposure to a COVID-19 case per local health department guidance.

Priority 1

  • Residents of acute care, long-term care, and congregate living facilities (if facility does not have an internal outbreak investigation policy) regardless of vaccine status​​
  • Unvaccinated Immunosuppressed individuals (Individual at higher risk of medical illness
  • Household and close contacts​ of priority 1 cases that are themselves high risk for complications of COVID-19 (Immunosuppressed etc.) ​
  • Intimate Partner contacts outside of the household​ of priority 1 cases that are high risk for complications of COVID-19 (e.g. boyfriend, girlfriend, partner, this does not include school exposures).  ​

Positive cases may choose to notify intimate partner contacts in place of LHD calls. ​​

Priority 2

Persons in high density indoor settings in which physical distancing or face covering is limited (examples could include but may not be limited to bars, factories, gym, salons)

  • LHD should work with workplace management to implement COVID-19 mitigation measures and identify workplace contacts.   LHD will determine if contacts should be notified by letter/mail or via individual notifications depending on the circumstances. ​​

Activities such as school sports, youth activities, team sports​​ and school lunchroom settings

  • LHD should coordinate with school, nurse, coach, league director, etc. to notify contacts of exposure with a letter/mail and information on self-monitoring. Nothing in this guidance modifies the obligations and authority of schools to identify and exclude close contacts in schools (see Executive Order 2021-25)

Large indoor gatherings and events​/outdoor events with no physical distance observed (family reunions, graduation parties, weddings, festivals).  ​

  • LHD should notify the event coordinator and ask them to share with attendees.   If LHD has no contact information for event coordinator, they may consider other options such as a press release for notifying the public as necessary​.

Public Places (Restaurants, taverns, grocery stores, etc.) ​​

  • Notify owner to implement mitigation measures of masking, social distance, and hand sanitizing
  • Notify if there is an individual that can be identified as someone who had significant exposure.

Others not in priority 1 or 2

LHD should notify all. LHD should further investigate if they have the capacity.

Potential modifications to case investigation and contact tracing processes

Suspend investigation of contacts in low-priority categories as necessary to maintain timeliness of response to confirmed cases and high-priority contacts.

Prioritize cases (priority 1 and 2) less than 6 days from symptom onset or specimen collection datealls. ​​

Process efficiency

Group together cases with the same addresses in salesforce case list

Prioritize those 65 years and older from salesforce case list

LHD should send information to another jurisdiction as appropriate for cases and contacts

Use case fields de-prioritization in Salesforce.

Do not fill isolation location if same as case address

Leave out transport location if it’s a non-extended travel

Do not fill symptoms if not applicable

Make fewer attempts to contact individuals who test positive before classifying them as unreachable.

Consider reducing the number of attempts to reach each client, using a combination of phone calls and text messages.

Consider foregoing contact investigations if 14 days or more have elapsed since a person was identified to have exposure to a person with COVID-19 except a known hospitalized case.

If case patients demonstrate interest and capability, health departments may request that the case communicate key messages to their household or other close contacts abouttesting and quarantine.

If case patients demonstrate interest and capability, health departments may request cases to communicate key messages to their household contacts.

Rely on electronic symptom monitoring as the default method for monitoring individuals under quarantine.

Reserve monitoring phone calls for individuals with special needs or those who “opt-in” for more intensive monitoring.

Reduce frequency of phone contacts to 2 days for monitoring, such as at day 7 and day 14 of the quarantine period for these cases.

In crisis situations, suspend monitoring for selected contacts, in favor of providing instructions to call their primary care provider if symptomatic

Suspend certain data collection and data entry requirements.

Enter household contacts into Salesforce, but only create a contact Investigation if the household contact requires a separate notification phone call.

Share responsibility for contact tracing activities with other qualified organizations.

Collaborate with universities, school systems, and large employers to facilitate, develop, and implement contact tracing plans.

Send a single letter to organizers of events or gatherings, rather than to individuals known to attend events where they were exposed.

Use press releases for large events