Contact tracing

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).

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 preventative 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.[1] 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.[2]

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.[3]

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.[4]

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.[5] Development of better guidelines and strategies for pandemic contact tracing continues.

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.[2]

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.[2]

References
  1. Scutchfield, F. Douglas (2003). Principles of public health practice. Clifton Park, NY: Delmar Learning. p. 71. ISBN 0766828433.
  2. Ontario Provincial Infectious Diseases Advisory Committee (2009). Sexually transmitted infections best practices and contact tracing best practice recommendations. Toronto: Ontario Ministry of Health and Long-Term Care. ISBN 9781424979462.
  3. Australasian Contact Tracing Manual. Darlinghurst, NSW: Australasian Society for HIV Medicine. 2010. ISBN 978-1-920773-95-3.
  4. WHO. "Severe Acute Respiratory Syndrome (SARS) - multi-country outbreak - Update 26". Global Alert and Response. WHO. Retrieved 28 May 2013.
  5. Swaan, Corien M.; Appels, Rolf; Kretzschmar, Mirjam EE; van Steenbergen, Jim E. (2011-12-28). "Timeliness of contact tracing among flight passengers for influenza A/H1N1 2009". BMC Infectious Diseases. 11 (1): 355. doi:10.1186/1471-2334-11-355. ISSN 1471-2334. PMC 3265549. PMID 22204494.
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