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 Table of Contents  
Year : 2022  |  Volume : 3  |  Issue : 1  |  Page : 22-26

Challenges and mitigation strategies during contact tracing: Lessons learned in COVID-19-pandemic

1 Department of Community Medicine, AFMC, Pune, Maharashtra, India
2 OC, SHO, Guwahati, Assam, India
3 DADH, Amritsar, Punjab, India

Date of Submission01-Oct-2021
Date of Decision01-Feb-2022
Date of Acceptance05-Feb-2022
Date of Web Publication25-Mar-2022

Correspondence Address:
Dr. Suraj Kapoor
Department of Community Medicine, AFMC, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jphpc.jphpc_29_21

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Introduction: Contact tracing can identify potentially infected individuals before severe symptoms emerge, and if conducted sufficiently quickly can prevent onward transmission from secondary cases. This study has been conducted to find challenges and mitigation strategies in contact tracing during the COVID-19 pandemic. Methodology: A cross-sectional descriptive study was conducted among health care professionals involved in contact tracing using an online questionnaire. The participants were asked about challenges faced during contact tracing and the usefulness of mitigation strategies. Results: A total of 302 health care professionals with a mean age of 34.69 ± 5 years participated in the study. Various strategies employed by agencies during contact tracing included measures to reduce stigma, community participation, and the use of digital tools and technology. Among the most common challenges faced by the study participants, 68% felt contacts being unreachable a major challenge, while 54.3% found difficulty in contact identification. Approximately 39% of doctors, 26% of nurses, and 17% of paramedical staff faced language/communication problems. Conclusion: Training health care professionals on the key aspects of contact tracing, the use of the latest technology, mitigation of stigma by health education may help in overcoming challenges during contact tracing in the COVID-19 pandemic.

Keywords: Challenges, contact tracing, COVID-19, mitigation strategies, pandemic

How to cite this article:
Kapoor S, Anand V, Yadav AK, Bhaskar S V, Kumar S, Faujdar DS, Teli P. Challenges and mitigation strategies during contact tracing: Lessons learned in COVID-19-pandemic. J Public Health Prim Care 2022;3:22-6

How to cite this URL:
Kapoor S, Anand V, Yadav AK, Bhaskar S V, Kumar S, Faujdar DS, Teli P. Challenges and mitigation strategies during contact tracing: Lessons learned in COVID-19-pandemic. J Public Health Prim Care [serial online] 2022 [cited 2022 May 27];3:22-6. Available from: http://www.jphpc.com/text.asp?2022/3/1/22/340810

  Introduction Top

World Health Organization declared corona disease-19 (COVID-19) as a Public Health Emergency of International Concern on January 30, 2020, and later declared as pandemic on March 11, 2020.[1] Social distancing, hand hygiene, use of masks, aggressive testing with isolation and quarantine, active surveillance through effective and decentralized contact tracing plays a significant role in the prevention of the spread of disease.[2] The history of application and success of tracing and quarantine is long from smallpox to the recent SARS epidemic.[3] Contact tracing is comprised three main steps: identifying, listing, and monitoring exposed persons intending to rapidly segregate to prevent the further spread of infection. The dynamics of contact tracing are complex, and its success is related to characteristics of the disease and etiologic agent, resources, and sociopolitical factors along with the implementation of effective tracing by contact tracing team members.[4] Contact tracing also has proven hugely successful in the treatment of various sexually transmitted infections, where the definition of contact is relatively straightforward, and where the timescales of transmission are relatively slow.[5]

The scale of contact tracing needed for the prevention of SARS-CoV-2 is labor intensive. The use of various digital tools like app-based contact tracing, artificial intelligence, novel tools like the drone, CCTV, etc., may be useful in containing the outbreak in the present situation.[6] Any health-care worker including Doctors, Nurses, other paramedical staff can be utilized in the pandemic to contain the spread of infection worldwide. There are multiple challenges faced during contact tracing in the difficult scenario of COVID-19.

This study has been conducted to assess challenges faced by contact tracing teams given the recent COVID-19 pandemic. Various mitigation strategies suggested by different agencies and being applied by study participants are also highlighted in the study.

  Methodology Top

A cross-sectional descriptive study was designed to elucidate the challenges and mitigation strategies among health-care professionals. The study population included health professionals mainly doctors, nurses, other paramedical staff including lab technicians, health assistants, etc., who were involved in contact tracing while working in various institutions across India in the recent COVID-19 pandemic. An online survey was conducted from April 21, 2020, to November 30, 2020, using Google Forms. A semi-structured questionnaire was designed in English/Hindi for assessing challenges and mitigation measures with the help of experts. The same was widely distributed among peers for comments. After the questionnaire was designed it was pretested among 20 healthcare professionals using the think-aloud technique. Minor corrections were made in the questionnaire to ensure understanding and comprehension of the respondent. A snowball sampling technique was used for data collection wherein the responders were requested to further forward the forms to known ones who are involved in contact tracing. The online questionnaire was sent to 207 participants whom 167 responded, final sample size achieved was 302 through snowball sampling.

In the preamble of the questionnaire, participants were informed about the volunteer nature of the study and assured confidentiality of the data. The Google Form was designed to avoid multiple entries from the same respondent by making Google login mandatory. The researchers had no access to the login id/email of the participants. The study was approved by Institutional Ethics Committee.

Statistical analysis

The data from the Google forms were downloaded in MS Excel. The data were cleaned and coded. The continuous variable was described as mean and standard deviation. The categorical variables were described as numbers and percentages. Association between categorical variables was carried out using the Chi-square test. A P < 0.05 was taken as significant. The data were analyzed using StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC.

  Results Top

A total of 302 health care professionals aged between 20 years and 50 years with a mean age of 34.69 ± 5 years participated in the study as shown in [Table 1]. Approximately 59% of the study participants were married and 35% of the study participants were doctors, 33% belonged to the nursing profession, while the rest were other paramedical staff including health and laboratory assistants. All study participants were actively involved in the contact tracing procedure in the COVID-19 pandemic at various hospitals/institutions across the country. Women participants represented about one-fourth of the total study participants while 64.7% of the study participants were working in Government setup as compared to 35.3% working in the private sector.
Table 1: Demographic and general characteristics of study participants (n=302)

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[Table 2] lists out the perception of contacts, strategies employed, and challenges faced by the study participants during contact tracing during the ongoing COVID-19 pandemic. Study participants assessed attitude/perceptions of contacts and 78% of the study participants found Contacts had trust in Government and health authorities to curb the spread of disease. About 58% of doctors, 34% of nursing, and 46% of paramedical staff found contacts were afraid of getting isolated with the statistically significant difference in response rate between different groups with doctors perceiving fear of getting isolated among contacts more than other groups. Similarly, about half of participants reported contacts were afraid of contracting COVID-19 as well as felt contacts were much concerned about the spread of disease among their family members. More than 70% of the study participants reported the presence of stigma among contacts with statistically significant differences among doctors, nursing staff, and other paramedical staff. Approximately 60% of the study participants found contacts were receptive to the advice given by study participants during contact tracing.
Table 2: Perception of contacts and challenges and mitigation strategies adopted in contact tracing (n=302)

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On assessing useful strategies adopted in contact tracing as suggested by health authorities, most of the study participants found measures to mitigate stigma, community participation in the procedure of contact tracing, and use of digital tools like the Aarogya Setu app very useful in contact tracing. Approximately 84% of doctors, 76% of nursing, and 92% of other paramedical staff found the usefulness of dedicated contact tracing team as an important strategy with the significant difference among various groups (P-value <0.05). About 88% of study participants felt confidentiality an important mitigation measure, while 78% of study participants found IEC activities in respect to disease and risk communication useful. Majority of the study participants found technologies like the use of CCTV being useful in effective surveillance with 84% of doctors, 70% of nursing, and 51% of paramedical staff reporting. About one-third of the study participants found the role of telemedicine in contact tracing very useful with the significant difference among different groups. The younger age group (20–34 years) of the study population found digital tools, telemedicine, and technology more useful than the study participants of the age group of 35–50 years.

The most common challenges faced by study participants during contact tracing of COVID positive patients reported by more than half of the study population was contacts being unreachable and difficulty in contact identification. About half of doctors and nursing participants while about 69% of paramedical participants faced problems in contact identification. Approximately 28% of the study participants felt communication/language barrier was a challenge with significant differences between two age groups and among doctors, nursing staff, and other paramedical staff. Almost 36% of the study participants reported the problem of recall of contacts while 23% felt the large number of contacts as being a challenge during contact tracing. Other lesser challenges reported by study participants included the amount of time and effort required, compliance to quarantine and isolation guidelines by contacts, poor testing capacity in some areas, shortage of manpower, fatigue among health-care workers, and lack of will among higher authorities.

  Discussion Top

Contact tracing is a central and core public health response and epidemiological tool to control infectious disease outbreaks, especially when specific preventive and treatments are limited.[7] Effective and timely contact tracing can identify potentially infected individuals before severe symptoms emerge, and if conducted early can prevent onward transmission from secondary cases, thus helping in breaking the chain of transmission and helping in controlling the spread of disease. This study was done to assess the perception of contacts, various challenges faced and mitigation strategies adopted by health care workers during contact tracing in the COVID-19 pandemic.

On the assessment of perception of contacts during contact tracing, stigma related to the disease, fear of contracting COVID-19 for self and family members, and afraid of isolation was reported by majority of the study population. Similar issues have been reported during contact tracing employed during other diseases too like Ebola.[8] The infodemic characterized by an overabundance of news, mixing facts, rumors, and fake news is a key player in spreading stigma about the disease in the community.[9],[10] New and effective educational approaches, use of digital tools, etc., are needed to counteract the damaging effects of the infodemic during COVID-19.[11] Risk communication, health education to mitigate stigma related to disease needs to be done effectively. Training health care professionals for risk communication, effective IEC, and health education along with the role of social media channels may be a useful step.[12] Contact tracing teams while communicating with the contacts can tackle heightened risk perception of contacts by effective risk communication. As public health officials and organizations work to combat misinformation about contact tracing, they also must try to communicate effectively with the public about its goals and purpose. This study also reported that most of the contacts were receptive to advice and have trust in healthcare authorities to curb the disease transmission which is a strength in delivering effective risk communication to tackle stigma and heightened risk perception.

There were various measures employed by health care workers during contact tracing in the COVID-19 pandemic mainly; stigma reduction measures, community participation, the use of digital tools, and dedicated contact tracing team for each area. Other strategies included observance of strict confidentiality of listed contacts and positive cases, use of IEC materials, use of technology in the form of CCTV and telemedicine. These all strategies had a positive influence in the identification of contacts as per study participants and continue to be an important aspect in the present time. Community participation in the form of involvement of the general public in contact tracing was also recommended during the Nipah outbreak in Southern India.[13] Digital tools have the potential to optimize traditional contact tracing processes helping the process becoming faster and efficient, but only if they are integrated into a comprehensive public health response.[14] Training of rapid response teams deployed in contact tracing about the use of such digital tools may help in effective contact tracing. Doctors found the use of technology like CCTV and the use of Telemedicine in surveillance more useful than nursing and paramedical staff which may be due to more familiarity of doctors with newer technologies and may have used telemedicine services in the past.

Irrespective of various useful strategies used by study participants in contact tracing, there were many challenges faced which would have affected the efforts of contact tracing in combating disease transmission. The most common challenge faced by study participants was difficulty in reaching or tracing suspected contacts which may be due to stigma around the COVID-19 pandemic or fear of getting ostracized by family and friends and poor-risk communication measures employed during the pandemic. Similar finding was observed during contact tracing in the African region where stigma and misinformation were the major challenges faced by the contact tracing workforce during the COVID pandemic.[15] The difficulty in contact identification in the present study was reported by 54% of the study participants. In a study done in Botswana in the year 2015 for assessing factors influencing health-care workers' implementation of tuberculosis, about 82% of health care workers found difficulty in contact identification.[16] The disparity may be due to recent technological advancements in the field of contact identification like Artificial intelligence, digital tools like apps and the use of CCTV. A similar study done in Africa to assess challenges in contact tracing in recent pandemic found that too large contacts with the responsibility of covering the larger geographical area were a major challenge.[15] In our study also 24% of the study participants found too large contacts being a major challenge. This study also highlighted doctors faced more language/communication problems during contact tracing than nursing/paramedical study participants which can be explained by the fact that they are usually employed locally and more outreach activities are performed by paramedical/nursing staff during the pandemic leading to better acquaintance with the surrounding. However, paramedical staff faced the greater challenge of correct contact identification as compared to doctors.

The study had few limitations; first, it did not involve community grass root workers involved in contact tracing in the rural part of the country and second, no area or region-specific analysis of challenges and strategies during contact tracing was done. Further study involving these parameters may provide better insight into challenges and strategies employed in contact tracing during the COVID-19 pandemic in the country.

It is recommended that dedicated case identification and contact tracing teams to be mobilized at the local level with active community participation after proper training with an ideal composition of public health professionals (lead), health worker (nurse/paramedical), and a laboratory technician/assistant. The team with coordinated efforts may help mitigate challenges faced and will be useful in preparing for future pandemics as well. An ideal combination of dedicated contact tracing teams will not only help in better surveillance but can also overcome challenges faced by team members. Community participation in contact tracing after proper training may be a useful strategy, especially in overcoming the language/communication barrier and as capacity building in better monitoring of contacts.

  Conclusion Top

Contact tracing is an old and useful strategy that when systematically applied helps in breaking the chain of transmission of various diseases including COVID-19. Training health care professionals on the key aspects of contact tracing, use of the latest technology in contact tracing, mitigation of stigma by risk communication/health education maybe some of the useful strategies in combating the COVID-19 pandemic.

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Conflicts of interest

There are no conflicts of interest.

  References Top

WHO Timeline – COVID-19. Available from: https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19. [Last accessed on 2020 Jul 20].  Back to cited text no. 1
Gowda G, Holla R, Ramraj B, Gudegowda KS. Contact tracing and quarantine for COVID 19: Challenges in community surveillance. Indian J Community Health 2020;32 Supp 2:306-8.  Back to cited text no. 2
Klinkenberg D, Fraser C, Heesterbeek H. The effectiveness of contact tracing in emerging epidemics. PLoS One 2006;1:e12.  Back to cited text no. 3
Swanson KC, Altare C, Wesseh CS, Nyenswah T, Ahmed T, Eyal N, et al. Contact tracing performance during the Ebola epidemic in Liberia, 2014-2015. PLoS Negl Trop Dis 2018;12:e0006762.  Back to cited text no. 4
Hogben M, Collins D, Hoots B, O'Connor K. Partner services in STD prevention programs: A review. Sex Transm Dis 2016;43:S53-62.  Back to cited text no. 5
Dehal N, Krishan K, Kanchan T, Unnikrishnan B, Singh J. Integrated disease surveillance in India – Progress and pitfalls. Perspect Public Health 2015;135:290.  Back to cited text no. 6
Keeling MJ, Hollingsworth TD, Read JM. Efficacy of contact tracing for the containment of the 2019 novel coronavirus (COVID-19). J Epidemiol Community Health 2020;74:861-6.  Back to cited text no. 7
Greiner AL, Angelo KM, McCollum AM, Mirkovic K, Arthur R, Angulo FJ. Addressing contact tracing challenges – Critical to halting Ebola virus disease transmission. Int J Infect Dis 2015;41:53-5.  Back to cited text no. 8
Naeem SB, Bhatti R. The COVID-19 'infodemic': A new front for information professionals. Health Inf Libr J 2020;37:233-9.  Back to cited text no. 9
Datta R, Yadav AK, Singh A, Datta K, Bansal A. The infodemics of COVID-19 amongst healthcare professionals in India. Med J Armed Forces India 2020;76:276-83.  Back to cited text no. 10
Social Stigma Associated with the Coronavirus Disease (COVID-19). Available from: https://www.unicef.org/documents/social-stigma- associated-coronavirus-disease-covid-19. [Last accessed on 2021 Apr 20].  Back to cited text no. 11
Abrams EM, Greenhawt M. Risk communication during COVID-19. J Allergy Clin Immunol Pract 2020;8:1791-4.  Back to cited text no. 12
Wilson A, Warrier A, Rathish B. Contact tracing: A lesson from the Nipah virus in the time of COVID-19. Trop Doct 2020;50:174-5.  Back to cited text no. 13
Tracking COVID-19: Contact Tracing in the Digital Age. Available from: https://www.who.int/news-room/feature-stories/detail/tracking- covid-19-contact-tracing-in-the-digital-age. [Last accessed on 2021 Apr 20].  Back to cited text no. 14
Nachega JB, Atteh R, Ihekweazu C, Sam-Agudu NA, Adejumo P, Nsanzimana S, et al. Contact tracing and the COVID-19 response in Africa: Best practices, key challenges, and lessons learned from Nigeria, Rwanda, South Africa, and Uganda. Am J Trop Med Hyg 2021;104:1179-87.  Back to cited text no. 15
Tlale L, Frasso R, Kgosiesele O, Selemogo M, Mothei Q, Habte D, et al. Factors influencing health care workers' implementation of tuberculosis contact tracing in Kweneng, Botswana. Pan Afr Med J 2016;24:229.  Back to cited text no. 16


  [Table 1], [Table 2]


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