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3 lessons for COVID-19 contact tracing

July 31, 2020 by PATH

Contact tracing is a decades-old public health tool that has helped contain the spread of tuberculosis, HIV, and other infectious diseases. Now, we must apply the lessons from that work to the COVID-19 pandemic—one person at a time.

A community outreach worker conducts a follow-up visit at the home of a person living with tuberculosis in in Mumbai, India. Photo: PATH/Prashanth Vishwanathan.

A community outreach worker conducts a follow-up visit at the home of a person living with tuberculosis in in Mumbai, India. Photo: PATH/Prashanth Vishwanathan.

Receiving any diagnosis of disease can come as a shock. When the illness is infectious—such as tuberculosis, HIV, or COVID-19—the news often leaves a patient reeling. “It’s a lot to take in. It can be a very emotional time,” says Dr. Kimberly Green, PATH’s global director for HIV and tuberculosis. “Every person will process the results differently.”

Contact tracing is part of a sound follow-up plan for care, and it is fundamental to public health. With the patient’s consent and cooperation, health workers —working with or without the client herself—attempt to identify and contact everyone who may have been exposed to the disease. They, in turn, can be tested. The ultimate goal: provide care and curtail the spread of infection.

  1. Build trust from the beginning

For these efforts to be effective, they must be client-centered and address persistent underlying barriers to health care—racism, poverty, and fear of stigma. Health workers and providers must respond to the needs of the newly diagnosed individual before introducing contact-tracing options. A compassionate and culturally sensitive approach is key to building trust.

Contact tracing can happen with a provider’s assistance, in a facilitated conversation. It can also unfold anonymously, through online public health portals. For instance, a person who had condom less sex with a newly diagnosed HIV patient might receive an alert suggesting that now's a good time to test for the virus. Ditto for injecting partners. The identity of the originally diagnosed person need never be revealed.

Tracing can also happen with in-person or phone support from health workers or peer providers. “Ideally, providers engaged in contact tracing will come from the same community as the client,”says Dr. Green. This is crucial for Black, Indigenous, and other communities of color, many of whom have had negative experiences with health systems. When contact tracers hail from the same communities as patients, it goes a long way toward building trust.

Regardless of approach, confidentiality is paramount. People’s data must be anonymized and secured. The rise of contact-tracing apps especially triggers concerns about privacy. To address these, we need strong data governance policies that maintain confidentiality and help build confidence in contact tracing.

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2. Protect people from stigma and violence

When a person receives a diagnosis—especially for a highly stigmatized disease such as HIV—their reactions might include fear and shame. For others, an HIV diagnosis can trigger intimate partner violence, rejection from family, and job loss. Over the years, contact-tracing strategies have evolved to protect clients and minimize these dangers.

Dr. Cyprien Tendo-Bugondo, PATH’s regional differentiated HIV services advisor in the Democratic Republic of the Congo, has seen this shift firsthand. In the early days of HIV contact tracing, he says, the standard approach involved contacting all the people in an HIV-positive patient’s family tree. But that risked confidentiality and exposed the patient to potential backlash, including intimate partner violence.

Today, says Dr. Tendo-Bugondo, patients in the DRC have choices. For instance, when a married woman learns she is HIV-positive, she may fear a violent reaction from her husband. Health workers don’t demand or coerce information from the patient. Rather than informing her husband directly, they might invite him to a screening for non-communicable illness such as diabetes. While at the clinic, they can discuss HIV and offer testing. Throughout this process, the woman’s confidentiality is protected.

“We can reach the patients’ contacts and maintain respect,” says Dr. Tendo-Bugondo. “With dignity, without judgments, without disclosing identities.” This approach depends on consistent training and support for peer providers and health workers. They are the linchpins of successful contact tracing—steeped in community knowledge, active in informal networks, and working in close contact with clinical care providers.

Done right, contact tracing can uncover chains of infection. “If contacts are identified and people are tested,” says Dr.Tendo-Bugondo, “there’s a greater chance to identify those who are infected and link them to long-term antiretroviral therapy, which can reduce the transmission risk over the long run. Contact tracing is really an efficient first step to prevent the spread of HIV.”

A nurse at the Kasumbalesa Referral Health Center in the Democratic Republic of the Congo counsels clients in an antiretroviral therapy. Photo: PATH/Stella Kamena

A nurse at the Kasumbalesa Referral Health Center in the Democratic Republic of Congo counsels clients in an HIV antiretroviral therapy clinic. Photo: PATH/Stella Kamena.

3. Use data to measure success

When it comes to containing a pandemic, random self-directed testing alone is inefficient. “Opt-in testing strategies need to be coupled with contact tracing or social network testing to best focus available resources,” says Dr. Green. “We need to get the balance right.”

Contact tracing for HIV has proven effective, typically finding that 15 to 40 percent of the group is testing positive for HIV. These figures are reflected in the DRC, where Dr. Tendo-Bugondo reports that contact tracing helps to identify 20 to 30 percent of HIV-positive individuals. By tracking data, health workers can also adapt their methods to be more effective.

Despite the proven effectiveness of contract tracing, many countries have not fully rolled it out for COVID-19. “As COVID-19 continues to escalate around the world, contact tracing—where it is confidential, humane, and data-driven, combined with universal masking and physical distancing—is essential for breaking the chain of SARS-CoV-2 transmission,” says Dr. Green. “It can dramatically reduce death, chronic post-recovery complications, and economic hardship that much of the world is experiencing”.

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