Contact Tracing in Hospitals Falls Off As
COVID-19 Cases Rise

Sheila Mulrooney Eldred

December 16, 2020

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Like most healthcare workers at his hospital in Lafayette, Indiana, Ramesh Adhikari, MD, occasionally gets an email noting that a patient he saw later tested positive for COVID-19. He's reminded to self-monitor for symptoms. But 10 months into the pandemic, it has become increasingly unlikely for contact tracing investigations to result in clinicians quarantining.

The very act of working in the hospital, Adhikari says, means being likely to see COVID-19 every day, whether in a known patient or an asymptomatic person who tests positive later. If hospitalists had to quarantine after every interaction with a COVID-positive person, there wouldn't be anyone left to do their jobs, Adhikari says.

"It's really hard to do [contact tracing] in healthcare workers thoroughly because of the way we work," Adhikari said. "It's impossible to do it absolutely."

In a recently updated guidance, the Centers for Disease Control and Prevention (CDC) extended more leeway in contact tracing when community rates of COVID-19 surge, even allowing that contact tracing "may not be possible" in certain situations. And by defining an exposure more narrowly — healthcare workers are only considered "exposed" if their contact was more than 15 minutes or lacking in some form of PPE — the guidelines suggest that hospitals can rely more on universal PPE and screening protocols, as Adhikari's hospital does, and less on extensive contact tracing to curtail viral spread.

Accordingly, while contact tracing has gotten more lax, doctors say, universal precautions — including full PPE and screening of symptoms for patients and healthcare workers — have become more stringent.

It's a shift from the beginning of the pandemic. At first, the CDC recommended wearing masks only during aerosol-producing procedures. Exposures were frequently reported and healthcare workers sent home. With more evidence in favor of stricter PPE requirements, hospitals including the one where Shyam Odeti, MD, works in Johnson City, Tennessee, have adopted a universal precaution strategy — requiring masks everywhere and a gown, face shield, gloves, and N95 to enter a COVID-positive patient's room. Thus, most exposures fall into that low-risk category.

"If I get it and am symptomatic, I don't think my colleagues would be exposed by any means because of these stringent policies being enforced," said Odeti, a hospitalist who often wears a surgical mask on top of his N95 all day. "And US healthcare is not in a state that can afford to quarantine healthcare workers for 14 days."

Can Universal PPE Precautions Supplant Contact Tracing?

The extent of contact tracing varies by hospital. Larger university and community hospitals often have infection control and occupational health teams that can do their own contact tracing, while smaller institutions can't always spare staff. And some state health departments get involved with contact tracing of healthcare workers while others do not.

"I would venture to say that most hospitals are doing something in terms of contact tracing," said Pam Falk, MPH, CIC, a member of the Association for Professionals in Infection Control and Epidemiology's COVID-19 task force and an infection control consultant. "It kind of depends on their bandwidth."

But there's no longer a norm. Outside of a pandemic, with ample staffing and far fewer instances that need to be investigated, standards for contact tracing are higher, Falk said: When a patient is found to have an airborne disease such as tuberculosis, measles, mumps or chickenpox, a hospital's infection prevention team should investigate, confirm the diagnosis and identify everyone who was exposed. The hospital's occupational health team assists in deciding who will likely need prophylactic treatment and if employees should be furloughed. The thoroughness of such measures has always depended on a hospital's bandwidth, she said.

Because PPE seems to be able to contain COVID-19 better than some of the older diseases targeted by contact tracing, universal protections may be a reasonable alternative in current circumstances, doctors said — if PPE is available.

"At the end of the day, universal source control with surgical masks — and ideally eye protection for clinicians as well — should prevent most transmissions," said Aaron Richterman, MD, from the Division of Infectious Diseases at the Hospital of the University of Pennsylvania, Philadelphia, who coauthored a JAMA commentary on decreased transmission rates in hospitals.

Contact tracing is still useful, though, to identify weaknesses in universal protection measures, he said.

"I don't think it's worth abandoning. It's like a tool in the toolbox. All are imperfect, and none work 100% of the time," Richterman said, but using all of them can achieve a fairly high measure of safety. Of the tools, universal masking likely works the best, he contends, so it should be the top pick for hospitals without resources to use all of the tools.

A recent incident at Brigham and Women's Hospital in Boston is a case study in how contact tracing can work together with universal protections to identify cracks in the system, said Richterman, who worked at the hospital earlier in the pandemic.

Mass General Brigham adopted a universal masking policy for staff and patients in March. Then, when the system experienced an outbreak in September, the hospital did "a very detailed public evaluation that included contact tracing and universal testing," Richterman said. Testing even included genetic analysis of the virus to confirm which cases were hospital acquired. In the end, the hospital identified weaknesses in infection control that could be rectified, such as clinicians eating too close together.

"The approach is not to point fingers, but to say, ‘What's wrong with the system and how do we improve?'" Richterman said. "To ask, why did that maskless transmission happen? Is there not enough space to eat? Are people working too many hours? It's useful for systems to understand where transmissions are happening."

Amith Skandhan, MD, a hospitalist in Dothan, Alabama, is comfortable without much contact tracing as long as there is universal PPE use. His hospital informs clinicians of exposures, but "basically we're trained to treat every patient as if they had COVID," he said, so "I feel more secure in the hospital than in the community." Masks have become so habitual they're like part of your regular clothing, he says — you feel incomplete if you don't have one.

While ad-hoc approaches to contact tracing may be useful in the current stage of the pandemic, they are likely to be short-lived: Once a community's positivity rate falls, the CDC's guidance suggests how hospitals can return to full contact tracing.

Sheila Eldred is a freelance health journalist in Minneapolis. Find her on Twitter @MilepostMedia .

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