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A Qualitative Analysis of Local Health Departments' Experiences With Contact-Tracing Tools in Response to COVID-19

Clements, Layné MHS, CPH; Baum, Christina MPH

Author Information
Journal of Public Health Management and Practice: January/February 2022 - Volume 28 - Issue 1 - p 101-103
doi: 10.1097/PHH.0000000000001465
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In March of 2020, the World Health Organization declared a pandemic in response to COVID-19, the respiratory illness caused by the SARS-CoV-2 virus. In the United States, there have been about 40 million individuals infected with COVID-19, almost 645000 COVID-19-related deaths, and these figures continue to rise.1 The pandemic response has necessitated engagement at the federal, state, and local levels of public health (as well as from health care and community partners), and local health departments (LHDs), as the chief health strategists in their communities, have played a vital and diverse role in COVID-19 prevention and response. Responding to COVID-19 has required many strategies, including aggressive testing, vaccination, and extensive contact tracing.

Contact tracing has long been an LHD practice to interrupt the spread of and contain infectious diseases such as tuberculosis and sexually transmitted infections. It involves activities such as notifying those exposed to a disease, assisting with testing, monitoring for symptoms, and requesting self-quarantine or self-isolation.2 Despite routinely performing contact tracing prior to the pandemic, the transmissibility and severity of COVID-19 infections and resulting massive explosion of cases and contacts meant that LHDs were rapidly inundated, and many sought to implement an enhanced contact-tracing tool for improved case management. While quantitative analysis and reports regarding the tools adopted at the state and local level exist, qualitative inquiry into better understanding the impact and usefulness of these tools has not yet been reported. As a result, beginning in 2021, the National Association of County and City Health Officials (NACCHO) conducted a qualitative study to better understand the extent to which LHDs implemented and used COVID-19 contact-tracing tools.

Methods

The study employed a cross-sectional qualitative design using a purposive sampling technique resulting in 6 interviews with 6 different LHDs, although one of the interviews involved a contracted agency for an LHD (LHD 1 in the Table) and not the LHD itself. NACCHO developed the interview guide that consisted of 10 open-ended questions seeking to better understand LHDs' responses to the pandemic, specifically focusing on the use and adoption of COVID-19 contact-tracing tools. NACCHO distributed recruitment posts from March to April 2021 and interviews were conducted in May 2021. Respondent characteristics are detailed in the Table. Each interview was transcribed, and qualitative analysis was conducted using line-by-line coding as well as open coding to later inform the broader categories and emerging themes for all interviews.

TABLE - Respondent Characteristics
Characteristic LHD 1 LHD 2 LHD 3 LHD 4 LHD 5 LHD 6
Jurisdiction population size
Small: <50 000 X
Medium: 50 000-499 999 X X
Large: >500 000 X X X
Governance
Local X X X X X
Shared X
Region
Northeast X
West X
South X
Midwest X X X
Abbreviation: LHD, local health department.

Findings and Discussion

Infrastructure: data collection

Understanding the existing infrastructure for data collection, including the systems, tools, and programs, to support contact-tracing activities is crucial. COVID-19 infection data, such as confirmed positive cases and close contacts, are needed to implement effective contact-tracing strategies. At the beginning of the pandemic, all the LHDs (100%) used established contact-tracing tools in response to the pandemic, including handwritten forms and spreadsheets such as Google Sheets or Microsoft Excel. Most respondents (66.7%) also reported using online fillable forms such as the one developed by the Centers for Disease Control and Prevention. This initial infrastructure posed challenges for data collection. Of the respondents, 66.7% reported difficulty following up with individuals in quarantine due to not only the technical challenges of potentially misspelled names and indiscernible handwriting but also because of the LHD's telephone number being possibly viewed as spam and personal reluctance due to the frequency of and medium for contact tracing (ie, as it is a daily activity that can be viewed as redundant, individuals in quarantine did not answer telephone calls from contact tracers and contact tracers felt hesitant to follow up). Contact tracers were reported to also be hesitant about asking individuals sensitive questions such as sexual orientation and gender expression and employment inquiries. Each of the LHDs (100%) expressed feeling overwhelmed. Most (83.3%) felt frustrated with this method of data collection and as COVID-19 cases in their jurisdiction began to rise, there was a distinctly perceived need for a more comprehensive, user-friendly tool.

Most of the LHDs (83.3%) adopted a new contact-tracing tool in response to the pandemic (notably, one [16.6%] did not). Of the LHDs that implemented a new tool, only 33.3% reported that their tool was state-sponsored while most of the respondents (66.7%) reported that they were responsible for identifying the best tool to address COVID-19 within their jurisdiction. While 40% of respondents stated that their tool was chosen as it was a requirement for grant funding and 20% stated that it was provided by their state, 40% of respondents chose tools due to cost (free), ease of implementation, how well the tool generated useful data, and the applicability of the tool's integrated systems. As such, there was a wide variety of contact-tracing tools selected by the interviewed LHDs. Salesforce and REDCap were the most used tools among the respondents that implemented a new contact-tracing tool (40%); the others (each adopted by 1 LHD, some LHDs used multiple tools) were Dimagi, Cal-Connect, Microsoft Teams, Sara Alert, online fillable forms, DocuSign, CLEAR, Cisco Jabber, Kiteworks, Twilio, Calabrio, and (Apache) Maven.

Despite the diversity of tools chosen, 100% reported improved data collection, extended capacity for contact tracing, and improved COVID-19 responses with the use of the new tool. Eighty percent of the LHDs that implemented a new tool stated that the tool aided in streamlining data and automating follow-up calls/messages while 80% also noted the benefit of using the same tool as used in another state and the transferability of COVID-19 cases with travel. Sixty percent of respondents recalled the benefit of having an interconnected, seamless integration of systems. Implementing a new tool was not without its own difficulties, however, as 40% of respondents stated it was a challenge to learn to use their ever-changing tools.

Infrastructure: workforce

Examining the connections between the LHD workforce and its adoption and utilization of COVID-19 contact-tracing tools is also critical for understanding the tools' utility and impact. Interestingly, 66.7% of large jurisdictions reported that they feel that their LHDs' responses were immediate and swift while this was not reported by any other LHDs. One hundred percent of LHDs reported repurposing staff to address the growing need for the COVID-19 response. Each of the LHDs (100%) faced the challenge of keeping staff safe within the workplace while determining a method of effectively working remotely. Once the new contact-tracing tool was implemented in the LHDs, remote work was enabled to a higher capacity. There was also a reported improvement in the oversight of the contact-tracing process in 60% of the LHDs. Despite the overwhelmingly positive perceptions regarding implementation of new contact-tracing tools, the process was not without challenges within the workforce. One hundred percent of the LHDs reported staff experiencing a period of adjustment after implementing the tools and specific challenges such as the tool not being originally designed with a public health focus (40%) or not meeting specific needs (ie, language translation) (20%). Even so, 80% of LHDs stated that they worked closely with their tool's company to help shape and request certain updates to the tool, which would help better assist the LHD's contact-tracing efforts (Figure).

FIGURE
FIGURE:
Most LHDs Identified Multiple Benefits After Adopting New COVID-19 Contact-Tracing ToolsAbbreviation: LHDs, local health departments. This figure is available in color online (www.JPHMP.com).

Recommendations for next steps

In addition to reporting that there was a point during the pandemic response that there were overwhelming case numbers to contact trace, the majority of LHDs (80%) reported wishing the tool that was eventually adopted had been implemented at the beginning of the response. It is worth noting that 33.3% of the LHDs wish there had been a state-sponsored tool implemented to increase cohesive statewide response. All LHDs (100%) would recommend to other LHDs to optimize the usefulness of their current contact-tracing tool and of the LHDs that implemented a new contact-tracing tool in response to the pandemic, 100% would recommend fully utilizing the integrated systems technology of the tools.

Limitations

The findings may be limited by the small sample size of 6 interviews. The majority of the LHDs had large jurisdiction sizes (50%), local governance (83.3%), and were in the Midwest region (50%). Since the study lacks adequate sampling of LHDs that could potentially be more severely impacted and have less access to COVID-19 contact-tracing tools (eg, very small, rural LHDs), the findings could also be limited in their broad applicability.

Conclusion

Given their critical role in communicable disease prevention and response, LHDs have strong foundations to support contact-tracing work, including solid data collection and workforce infrastructures, resourcefulness, and community partnerships. The most reported benefits of implementing new contact-tracing tools during the COVID-19 pandemic were improvements to data collection, extending capacity for contact tracing, and improving overall response efforts with the majority of respondents expressing the need for maintaining their newly implemented tools for future pandemic responses. Pandemic preparedness includes the adoption of scalable contact-tracing tools, with emphasis on systems that can be integrated with other data sources within and across jurisdictions. LHD access to these systems makes contact tracing more streamlined, enhances data collection and sharing, expands staff capacity, and overall strengthens response capacity.

References

1. Centers for Disease Control and Prevention. CDC COVID Data Tracker. Atlanta, GA: Centers for Disease Control and Prevention. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Published 2021. Accessed September 1, 2021.
2. Centers for Disease Control and Prevention. Coronavirus (COVID-19) Frequently Asked Questions. Atlanta, GA: Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/faq.html#:∼:text=Contact%20tracing%20has%20been%20used,information%20%2D%20Credit%20card%20numbers. Published 2021. Accessed September 1, 2021.
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