Contact tracing is essential to preventing the spread of COVID-19. I previously wrote a blog post about the release of an O’Neill Institute brief, Quick Take: HIV Lessons for COVID-19 Contact Tracing. While the brief provides recommendations for what to do and not to do in responding to the COVID-19 crisis, I thought it would be helpful provide some additional reflections on the history of contact tracing.
Contemporary contact tracing in the United States dates back to the early 20th century response to syphilis and later expanded to include other sexually transmitted infections (STIs). Since its origin, contact tracing generated debate about the right to confidentiality of the infected person (i.e., the index case) and the right of the infected person’s partners (i.e., the contact) to be informed about exposure. With the emergence of HIV and the absence of effective HIV treatment in the 1980s and early 1990s, the right to privacy of the index patient was emphasized. Contact tracing was also renamed “partner notification”. When applied to HIV infection, the word partner includes not only sexual partners but also intravenous drug-using partners who share needles. Although some states tried to establish mandatory partner notification programs, programs and state educational initiatives centered on people with HIV and other STIs notifying partners, and they were and still are voluntary. The primary models of partner notification include (1) patient referral, (2) provider referral, or (3) a combination of the two.
In the late 1990s, programs began to be named “partner counseling and referral services (PCRS)” to reflect the range of services offered. The current guidelines from the Centers for Disease Control and Prevention (CDC) refer to “partner services”. Partner services is a broad term that includes partner notification as a critical component, but also includes prevention counseling, testing services, treatment or linkage to medical care, and linkage or referral to other services (e.g., reproductive health services, prenatal care, substance abuse treatment, social support, housing assistance, legal services, and mental health services).
CDC provides funding to state and local health departments to perform HIV and STI testing and partner services. As a condition of funding eligibility, health departments are required to implement partner services according to CDC guidelines. Although CDC provides recommendations outlining the basic elements of partner services, health department implementation varies. Health departments use different methods and models for partner services that depend on local legislation and regulations, local service delivery systems, and available resources.
Traditionally, health departments provide partner services to respond to HIV and STI cases through trained health department-employed disease intervention specialists (DIS). To this day, health department-employed DIS play viral roles in case investigation and contact tracing and have supervisory roles. There are health departments that have been very effective at using their own DIS, even as other health departments have faced challenges. Some challenges that impede the success of health department partner services include delays in reporting cases to the health department, delays in interviewing original cases, many reported anonymous partners from cases, and other factors such as distrust of health departments and concerns about confidentiality. In an effort to improve partner services, some jurisdictions have deployed Community-Embedded Disease Intervention Specialists (CEDIS). CEDIS may be stationed at clinics or community-based organizations. When CEDIS are stationed in these settings rather than at health departments, they can more readily have access to medical records and, in many instances, are able to interview newly identified cases in person, either at initial diagnosis or when they returned to the clinic for treatment. In numerous instances, the use of CEDIS has allowed for greater participation in partner services and improved disease interruption and linkage to care. Generally, CEDIS are trained by the health department, and health department-employed DIS meet with CEDIS on a regular basis, provide technical guidance on difficult cases, and review case completion and monthly activity reports. Some benefits of CEDIS are that CEDIS staff reflect the communities they serve and have cultural competency, there are fewer interactions for the patient, people can be linked to care faster, and the model is integrated into existing service delivery (either medical care or support services).
It is important to remember that contact tracing is not a new tool. Contact tracing has been used to help control HIV, STIs, and other infectious diseases. Its history may be important for policymakers and health departments to understand as they consider various options for deploying contact tracing in different parts of the country.