|Year : 2022 | Volume
| Issue : 2 | Page : 27-29
Contact tracing in the hospital setting for COVID-19: An experience from AIIMS, New Delhi
Devashish Desai1, Anivita Aggarwal1, Komal Singh1, Shivdas Rajaram Naik1, Arvind Kumar1, Ravneet Kaur2, Naveet Wig1
1 Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Department of Community Medicine, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||20-Mar-2021|
|Date of Decision||01-May-2021|
|Date of Acceptance||05-May-2021|
|Date of Web Publication||16-May-2022|
Dr. Arvind Kumar
Department of Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
In this commentary, we relate our experience with contact tracing within the setting of a tertiary care institute and how it evolved over the course of the pandemic. The need for a contact tracing mechanism arose when the hospital's first COVID-19 positive employee emerged at the end of March 2020. The central contact tracing team (CCTT) was subsequently established to perform this essential function. We describe the methodology followed by the CCTT as well as the practical hurdles encountered during contact tracing. The benefits of setting up an institutional contact tracing mechanism cannot be overemphasized. We strongly recommend setting up such a mechanism in all health-care institutes, not just for the COVID-19 pandemic but also for future respiratory disease outbreaks as well.
Keywords: Contact tracing, COVID-19, health worker, hospital, severe acute respiratory syndrome coronavirus 2
|How to cite this article:|
Desai D, Aggarwal A, Singh K, Naik SR, Kumar A, Kaur R, Wig N. Contact tracing in the hospital setting for COVID-19: An experience from AIIMS, New Delhi. J Public Health Prim Care 2022;3:27-9
|How to cite this URL:|
Desai D, Aggarwal A, Singh K, Naik SR, Kumar A, Kaur R, Wig N. Contact tracing in the hospital setting for COVID-19: An experience from AIIMS, New Delhi. J Public Health Prim Care [serial online] 2022 [cited 2022 Jul 4];3:27-9. Available from: http://www.jphpc.com/text.asp?2022/3/2/27/345278
In this short report, we relate our experience with institutional contact tracing and how it evolved over the course of the pandemic. While there are several guidelines available regarding contact tracing in the setting of hospitals,,,, accounts of their practical implementation are lacking in the literature. India's first confirmed COVID-19 case was reported at the end of January 2020. However, our institute's first COVID-19-positive employee emerged only by the end of March. The subsequent panic that ensued among this person's perceived contacts and the disruption it caused at the workplace revealed an unmet need for an institutional contact tracing mechanism. The logistics of this was complicated by the fact that ours is one of India's largest multispecialty tertiary care institutes spread across several campuses in the states of Delhi and Haryana.
Overburdened government teams were already performing contact tracing for the rest of the country. However, doing the same within the complex environment of a hospital was a different matter for those unfamiliar with its inner workings. Thus, the central contact tracing team (CCTT) was established by the institutional COVID-19 task force under the leadership of faculty from the department of community medicine and staffed with residents from multiple clinical and nonclinical specialties. Its aim was to perform institutional contact tracing in the event that an employee or a patient admitted to a non-COVID-19 ward tested positive for COVID-19. While it was initially assisted by infectious disease residents, it quickly evolved to become an independent and capable body with formidable experience and expertise.
The CCTT methodology [Figure 1] involved preparing an initial list of all possible contacts beginning 2 days before the onset of symptoms or date of testing (whichever was earlier) followed by telephonic interview of every contact to determine the exact nature of exposure including duration, proximity, and details of personal protective equipment (PPE) worn. With these details, contacts were risk stratified as high versus low risk [Table 1]. All high-risk contacts were tested for COVID-19 by the reverse transcription polymerase chain reaction after day 5 of exposure and had to complete a mandatory 14 days quarantine period. Low risk was tested only if they subsequently became symptomatic and could continue to work with all precautions.
The criteria used for risk stratification were ever evolving. Initial guidance was taken from the recommendations of the WHO, the United States Centers for the Disease Control and Prevention (US-CDC), the Indian National Center for Disease Control, and other guidelines for contact tracing. Most guidelines were plagued with arbitrary exposure time cut-offs, generalizations regarding what was considered adequate PPE without accounting for the infectiousness of the patient (asymptomatic versus coughing versus ventilated patient), and other such inconsistencies. The WHO criteria were far too sensitive and would have resulted in the unnecessary quarantine of contacts with very minimal or transient exposure. Overall, the US-CDC criteria were found to be the most sensible, as it considered much more elaborately the wide spectrum of exposures in a health-care setting, which was ironic considering the CDC document was accompanied by a nihilistic disclaimer regarding the futility of contact tracing within hospitals. Ultimately, however, the risk assessment was best done on a case-to-case basis using available criteria as a general guidance and not as a substitute for common sense.
By the middle of May, the daily number of employees testing positive increased to more than 50. It was becoming impractical for the already augmented CCTT to trace contacts for such a large number of people daily. In order to upgrade the contact tracing mechanism to effectively handle the increasing case load in an orderly fashion, it was decided to decentralize the task of contact tracing to the level of individual departments. One faculty from each department was appointed the contact tracing nodal officer and tasked with setting up a departmental contact tracing team (DCTT) with representatives from all cadres including residents, nurses, technicians, sanitary workers, etc. Similar nodal officers were appointed for security staff and employees working in administrative areas. The DCTTs reported to and were guided by the CCTT. They performed the task of contact tracing for employees within their purview or patients admitted under their own departments. A final list of risk stratified contacts was sent daily to the CCTT for revision and approval. After a week of initial hiccups, the nodal officer network began functioning smoothly, and just in time as the case load continued to increase further. While departments have now become self-sufficient, the CCTT continues to play a supervisory role.
Apart from the subjectivity of risk stratification of contacts, the CCTT faced several other problems along the road. Recall during interview of contacts was often flawed. Potential contacts were sometimes missed while others were occasionally erroneously risk stratified, although this was inevitable as contact tracing is inherently an imperfect process. The possibility of employees malingering to get 14 days quarantine could not be ruled out, and benefit of doubt was given to all contacts. There was additional pressure on the risk stratification process due to the looming workforce shortage. The idea of abandoning contact tracing entirely always remained within the realm of possibility as community transmission had begun. However, the CCTT was able to adapt to all of this and emerge more capable every time.
The benefits of setting up an institutional contact tracing mechanism cannot be overemphasized. The CCTT brought order to the hospital when panic and chaos threatened to destabilize it. It prevented entire wards and departments from being unnecessarily quarantined out of panic while at the same time ensuring that those who were exposed were not missed. The hospital infection control committee was able to re-educate employees in infection control measures in a targeted fashion according to the findings of the CCTT. The efforts of the CCTT quantitatively brought down the Rt of the hospital, thus saving the lives of our most vulnerable employees in the process. The data generated by their efforts helped uncover local outbreaks within the institute, identified new hotspots in the community and informed the institute's subsequent COVID-19 policies. We strongly recommend setting up such a mechanism in all health-care institutes, not just for the COVID-19 pandemic but also for future respiratory disease outbreaks as well.
| Summary and Recommendations|| |
An organized approach toward intra-hospital contact tracing is a useful strategy for ensuring employee safety during the COVID-19 pandemic. The early identification and quarantining of probable spreaders may limit the ultimate size of a hospital's outbreak and thus protect the rest of the workforce. A dedicated team of institute employees would be best suited to perform this task due to familiarity with the complex internal environment that is unique to each hospital. Upscaling of this mechanism by decentralization is required to tackle large outbreaks efficiently.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Risk Assessment and Management of Exposure of Health Care Workers in the Context of COVID-19: Interim Guidance, 19 March 2020. World Health Organization. Available from: https://apps.who.int/iris/handle/10665/331496
. [Last accessed on 2020 Oct 05].