Contact tracing

Contact tracing
Contact tracing attempts to find all contacts of a confirmed case, in order to test or monitor them for infection. The goal is to stop the spread of a disease by finding and isolating cases.

In public health, contact tracing is the process of identification of persons who may have come into contact with an infected person ("contacts") and subsequent collection of further information about these contacts. By tracing the contacts of infected individuals, testing them for infection, treating the infected and tracing their contacts in turn, public health aims to reduce infections in the population. Diseases for which contact tracing is commonly performed for include tuberculosis, vaccine-preventable infections like measles, sexually transmitted infections (including HIV), blood-borne infections, some serious bacterial infections, and novel infections (e.g. SARS-CoV and SARS-CoV-2). The goals of contact tracing are:

• To interrupt ongoing transmission and reduce spread of an infection
• To alert contacts to the possibility of infection and offer preventive counseling or prophylactic care
• To offer diagnosis, counseling and treatment to already infected individuals
• If the infection is treatable, to help prevent reinfection of the originally infected patient
• To learn about the epidemiology of a disease in a particular population

Contact tracing has been a pillar of communicable disease control in public health for decades. The eradication of smallpox, for example, was achieved not by universal immunization, but by exhaustive contact tracing to find all infected persons. This was followed by isolation of infected individuals and immunization of the surrounding community and contacts at-risk of contracting smallpox.

In cases of diseases of uncertain infectious potential, contact tracing is also sometimes performed to learn about disease characteristics, including infectiousness. Contact tracing is not always the most efficient method of addressing infectious disease. In areas of high disease prevalence, screening or focused testing may be more cost-effective.

Partner notification, also called partner care, is a subset of contact tracing aimed specifically at informing sexual partners of an infected person and addressing their health needs.

Steps in contact tracing

Contact tracing generally involves the following steps:

• An individual is identified as having a communicable disease (often called the index case). This case may be reported to public health or managed by the primary health care provider.
• The index case is interviewed to learn about their movements, whom they have been in close contact with or who their sexual partners have been.
• Depending on the disease and the context of the infection, family members, health care providers, and anyone else who may have knowledge of the case's contacts may also be interviewed.
• Once contacts are identified, public health workers contact them to offer counseling, screening, prophylaxis, and/or treatment.
• Contacts may be isolated (e.g. required to remain at home) or excluded (e.g. prohibited from attending a particular location, like a school) if deemed necessary for disease control.
• If contacts are not individually identifiable (e.g. members of the public who attended the same location), broader communications may be issued, like media advisories.

Although contact tracing can be enhanced by letting patients provide information, medication, and referrals to their contacts, evidence demonstrates that direct public health involvement in notification is most effective.

Relevance of contacts

The types of contacts that are relevant for public health management vary with the communicable disease because of differing modes of transmission. For sexually transmitted infections, sexual contacts of the index case are relevant, as well as any babies born to the index case. For blood-borne infections, blood transfusion recipients, contacts who shared a needle, and anyone else who could have been exposed to blood of the index case are relevant. For pulmonary tuberculosis, people living in the same household or spending a significant amount of time in the same room as the index case are relevant.

Use in novel diseases and outbreaks

Although contact tracing is most commonly used for control of endemic diseases, it is also a critical tool for investigating new diseases or unusual outbreaks. For example, as was the case with SARS, contact tracing can be used to determine if probable cases are linked to known cases of the disease, and to determine if secondary transmission is taking place in a particular community.

Contact tracing has also been initiated among flight passengers during the containment phase of larger pandemics, such as the 2009 pandemic H1NI influenza. However, there continue to be large challenges in achieving the goals of contact tracing during such chaotic events. Development of better guidelines and strategies for pandemic contact tracing continues.

On 10 April 2020, Apple and Google, which, combined, account for most of the world's smartphones, announced coronavirus tracking technology for iOS and Android. Relying on Bluetooth Low Energy (BLE) wireless radio signals for contact tracing, the new tools would warn people about others they'd been in contact with who are infected by SARS-CoV-2. Various protocols, such as Pan-European Privacy-Preserving Proximity Tracing (PEPP-PT), Decentralized Privacy-Preserving Proximity Tracing (DP-PPT/DP-3T), Contact Event Numbers (CEN), Privacy Sensitive Protocols And Mechanisms for Mobile Contact Tracing (PACT) and others, are being discussed to preserve user privacy. Corresponding coronavirus apps will be released in May and enhanced later in 2020.

Ethical and legal issues

Privacy and duty to warn

Challenges with contact tracing can arise around issues around privacy and confidentiality. Public health practitioners often have legal requirements to act to contain a communicable disease within a broader population and also cite an ethical duty to warn individuals of their exposure. Simultaneously, infected individuals have a recognized right to medical confidentiality. Public health teams typically disclose the minimum amount of information required to achieve the objectives of contact tracing. For example, contacts are only told that they have been exposed to a particular infection, but not informed of the person who was the source of the exposure.

Confidentiality and risk of stigma

Some activists and health care providers have expressed concerns that contact tracing may discourage persons from seeking medical treatment for fear of loss of confidentiality and subsequent stigma, discrimination, or abuse. This has been of particular concern regarding contact tracing for HIV. Public health officials have recognized that the goals of contact tracing must be balanced with maintenance of trust with vulnerable populations and sensitivity to individual situations.

See also

• Mathematical modelling of infectious disease
• Transmission (medicine)
• Government by algorithm
• Disease surveillance

External links

• Transmission Network Analysis to Complement Routine Tuberculosis Contact Investigations (PDF)
• The Doctor's World; Sex, Privacy And Tracking H.I.V. Infections
• Development of a Contact Tracing System for Ebola Virus Disease — Kambia District, Sierra Leone, January–February 2015