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Design, Implementation, and Outcomes of a Volunteer-Staffed Case Investigation and Contact Tracing Initiative at an Urban Academic Medical Center

This case series evaluates the design, implementation, and outcomes of a volunteer-staffed contract tracing program at a large academic health center.


Introduction
In the US, most public health functions, including case investigation and contact tracing (CI and CT), are the purview of state and local health departments (LHDs). In the years leading up to the COVID-19 pandemic, regular budget cuts and frequent employee departures resulted in a public health system often under-resourced to perform even routine duties. [1][2][3] From 2010 to 2020, spending among state and LHDs decreased by nearly 20% per capita and the US public health workforce lost nearly 55 000 jobs. 1,3 Furthermore, as little as 1.5% of the US government's $3.6 trillion annual health budget is directed toward population-level public health activities. 4 For comparison, the annual Centers for Disease Control and Prevention (CDC) budget in fiscal year 2022 was $15.4 billion, comparable to the posted 2021 operating costs of a single large private health system. 5,6 During the COVID-19 pandemic, private institutions experienced the consequences of public health disinvestment, including the necessity to engage in activities that had traditionally been the province of public health authorities. [7][8][9][10] For example, schools, colleges, and universities implemented a suite of mitigation measures, including hybrid learning models, symptomatic testing and asymptomatic screening, and CI and CT. 7,8 Hollywood production crews created detailed testing plans, and many completed their own CI and CT. 9,10 Health systems also leveraged existing infection control infrastructure and expanded their operations to investigate transmission in health care settings and sometimes in the community. 7 This study describes a volunteer-staffed CI and CT initiative at the Perelman School of Medicine run in collaboration with the Philadelphia Department of Public Health (PDPH) that served University of Pennsylvania Health System (UPHS) patients with COVID-19 and their close contacts. We report on program design, implementation, and outcomes, as well as how the program addressed unmet social needs to facilitate isolation and quarantine. This study also identifies challenges and opportunities for private health system collaborations with LHDs.

Methods
All program activities in this case series were approved as quality improvement by the University of Pennsylvania's Institutional Review Board. CI and CT volunteers obtained verbal consent from all cases and contacts to participate in interviews. This study followed the relevant elements of the reporting guidelines for case series.

Program Implementation
Team members (RFS and CCC) met with PDPH officials on March 25, 2020, and identified the need for CI and CT support (eFigure 1 in the Supplement). Initially, PDPH sought 10 volunteers to augment their in-house CI and CT capacity. Instead, due to rapidly increasing pandemic demands, our team recognized the need to build a parallel CI and CT capacity so that we could flexibly respond and integrate members into the city's workflow as needed. Ultimately, we trained a stand-alone team to work in collaboration with PDPH with a focus on supporting patients tested within UPHS.

Volunteer Recruitment and Screening
Between March 2020 and May 2020, volunteers were recruited through university email listservs.
We offered fieldwork opportunities for students whose academic programs had been disrupted by the pandemic. Team members also received unsolicited offers to volunteer from alumni, personal contacts, and concerned community members. Candidates completed a screening survey regarding demographics, qualifications, mental health status and distress, and motivations. From March 28 to June 1, 2020, 324 interested candidates completed the survey (eFigure 2 in the Supplement).
Accompanied by social workers, team members conducted telephone interviews with select candidates to identify candidates who would work well in stressful pandemic circumstances. From March 2020 to May 2021, 160 people served as volunteers.

Team Structure
Volunteers were assigned to clearly delineated roles (Figure 1). In addition to CI and CT teams, specific teams addressed cases from high-risk work sites (eg, nursing homes and prisons), communications (eg, sending frequently asked question lists and employer letters) (eFigure 3 in the Supplement), and operations (eg, volunteer case and contact assignments). Team management designed, implemented, and managed the program, including supporting recruitment efforts, creating and deploying the training, coordinating with the university and local departments of public health, reporting to local and state officials, and overseeing all volunteer leaders, among other tasks.
The case investigation team was responsible for investigating cases positive for SARS-CoV-2, identifying their close contacts, and delivering up-to-date isolation guidance. The contact tracing team was responsible for notifying close contacts of cases regarding their possible exposure and delivering up-to-date quarantine and testing guidance. The operations team uploaded to REDCap case information and contact details derived from case investigations and assigned calls to case investigators and contact tracers. The reporting team for high exposure risk cases reported to the relevant LHD cases who were positive and were likely unable to maintain physical distancing, or high exposure risk cases (HERCs). These included individuals living or working in congregate care settings (eg, nursing homes or shelters) or working in occupations with high likelihood of transmission to other people (eg, meat processing plants). The communications team provided follow-up guidance on safe isolation and quarantine (eFigure 3 in the Supplement) and employer letters for any case or contact who requested one. The social needs response team was an external team that connected patients to a range of services, including food delivery, rent assistance, medical transportation, and assistance identifying a primary care physician. See eMethods in the Supplement for a detailed description of team roles and responsibilities.

Training
The team developed and led an initial synchronous virtual 2-hour training session to prepare volunteers for CI and CT, incorporating concepts and materials from US and international health departments and colleague input. 1 Training modules included background on COVID-19 and CDC guidelines, CI and CT processes, the workflow and data collection system, and consent and interview techniques. Although volunteers received training for CI and CT, they were later divided into teams dedicated to 1 role. Volunteers who spoke with contacts had no access to names of index cases, to prevent unwitting disclosure of patient information. All volunteers completed asynchronous training on protection of human participants. 11

Workflow and Interview Guide
Based on a daily case log generated by UPHS personnel, CI volunteers reached out to patients who tested positive for SARS-CoV-2 at any UPHS testing location. Through structured prompts regarding activity during the infectious period, interviewers sought to identify anyone with whom patients had close contact, initially defined as being within 6 feet for more than 15 minutes. CI volunteers also delivered isolation guidance and recommendations for keeping household members safe. other were combined as other because there were 0 to very few responses for these categories.
Other categories were combined for unmet social needs analysis to facilitate statistical analysis due to low numbers reported. Race and ethnicity were assessed as part of a standard demographic questionnaire.
All data were collected using research electronic data capture (REDCap), a secure web-based platform, 14 via tools that incorporated a consent script, specific questions, interview technique reminders, and isolation and quarantine guidance. REDCap tools were routinely updated to reflect continuous quality improvement and evolving public health guidance. The program incorporated safeguards to protect patient privacy, including training, continuing instruction, and restriction of data access via REDCap system design. When communicating via unsecured platforms, volunteers were cautioned not to share identifying information. CI and CT teams maintained separate REDCap projects to protect against inadvertent disclosure of patient information to contacts.
Daily, UPHS administrators securely shared with team management a list of patients who tested positive via polymerase chain reaction (PCR) for SARS-CoV-2 in the prior 24 hours at any UPHS site (eg, emergency departments or testing sites). The operations team then assigned patients to CI and CT volunteers, with caseloads determined by volunteer availability and daily case rates. Pediatric cases and hospital inpatients were excluded because of anticipated challenges with making contact, obtaining consent, and gathering information. During surges, the team called only cases residing in Philadelphia County, although contacts were notified regardless of home address. See Figure 2 for a workflow diagram.
All team members used a mobile application that identified their outgoing calls as originating from the health system. Team members also each obtained a unique online telephone service number via Google Voice with a Philadelphia area code for return calls. On the recommendation of other programs, volunteers called each individual multiple times in rapid succession (signaling the importance of the call) at 3 different times of day over 2 days. In April 2020, UPHS faculty created a student-staffed social needs response team (SNRT) to address unmet social needs among patients, as well as to support safe isolation and quarantine. CI and CT volunteers screened all cases and contacts for unmet social needs (eg, housing and food) and referred to the SNRT anyone who reported at least 1 unmet need and consented to referral. The

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REDCap form included an automated pop-up to prompt volunteers to complete a social needs referral when participants reported unmet social needs.

PDPH Collaboration
Our team closely communicated with PDPH throughout the program. To prevent duplication of efforts, we securely shared a daily list of patients assigned to our CI volunteers. PDPH staff removed from their queue those cases who were assigned to our CI and CT volunteers. If case volume exceeded our capacity, unassigned UPHS cases were by default added to PDPH's queue for case investigation. Information regarding contacts was not shared with PDPH unless those contacts later tested positive via PCR at a UPHS site. We also sent weekly briefing memos with programmatic updates and case and contact call summary statistics (eg, call numbers, response rates, and unmet social needs).

Qualitative Data
Qualitative results were based on team documentation from March 2020 to May 2021, including emails, calendars, progress memos, messaging channel (Slack, Slack Technologies) conversation, and volunteer recruitment surveys. Team members reviewed these documents to synthesize programmatic challenges and successes.

Statistical Analysis
We report outcomes of CI and CT interviews using participant data from REDCap. Descriptive statistics and odds ratios (ORs) of the likelihood of reporting social needs are reported, based on analyses conducted in R statistical software version 8.9.0 (R Project for Statistical Computing). 15 Statistical tests were 2-sided and reported at the 95% CI.      . Despite these exposures and the likelihood that many index cases likely exposed many people, the reported number of contacts per case was low, often because cases did not have names and contact information for people they had encountered in public spaces. In addition, many cases asked us not to call exposed household members who were already infected or already quarantined.  Table 2).

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Black participants were more likely than participants of other self-reported races to experience unmet social needs. Among 1501 Black participants with data on unmet social needs, 540 individuals refusing to isolate because when they were sick…with COVID, they weren't paid for 3 weeks and couldn't make bills. They work at a nursing home…they can't miss work and will lose their house." When faced with such fundamental threats, cases and contacts often had to make difficult decisions that conflicted with isolation and quarantine guidance (eg, going to work while infectious).
Throughout the program, our team met to discuss quality improvement and operational challenges. We noted and responded to shortcomings in initial program design, particularly as they related to coordination of efforts between our health system-based team and PDPH. For example, we developed systems for rapidly identifying and referring to the appropriate LHDs cases that had a high likelihood of onward transmission or potential for generating outbreaks in high-risk populations.
Such HERCs were directed to the immediate attention of an outbreak investigations professional at PDPH, as described in this April 18, 2020, memo from our team to University of Penn and PDPH leadership: "Our team will send PDPH's report form for severe/high-risk setting cases via secure email…HERCs may be identified during CI interviews, in which case they will be reported to PDPH using the same form/email…we will have a dedicated Reporting Team that will exclusively be responsible for reporting HERCs to PDPH." We also grappled with a second example related to interjurisdictional CI and CT challenges To foster communication with LHDs and streamline data sharing, we attempted multiple strategies, including the purchase of a site license for the CI and CT software used by PDPH and many (but not all) neighboring health departments. However, the private company that developed this software responded that it was unable to fulfill our request, because it, too, was understaffed to meet pandemic demands for its services (recorded in an email dated August 4, 2020).

Discussion
In this case series, we described the design, implementation, and accomplishments of a 15-month volunteer-staffed CI and CT program run within a large academic health system in collaboration with the LHD. At multiple points throughout the pandemic, caseloads have outstripped the capacity of health departments to conduct CI and CT. In response, many institutions established stopgap CI and CT teams to augment health department capacity. [7][8][9][10][16][17][18][19] This study's findings suggest the acceptability of a health system conducting COVID-19 CI and CT within its patient population, as well as the role that CI and CT volunteers may play in addressing a range of unmet needs.
During the COVID-19 pandemic, a prevailing narrative emerged that individuals in the US were unwilling to participate in CI or CT. 20 In contrast, we found that most cases and contacts responded to our calls, similar to reports from a large study 21 of health departments, which reported an interview rate of 59%. It is well documented that contact tracing is associated with prevention of transmission of infectious diseases like Ebola and tuberculosis, 22,23 as well as COVID-19 when implemented with other mitigation measures. [24][25][26][27][28] There is also good evidence that CI and CT are highly cost-effective, but the US has not yet built the necessary infrastructure or invested in optimizing the process or its implementation. 29,30 A key question highlighted by our experience is how to achieve optimal staffing for CI and CT efforts given the highly fragmented, localized approach to public health in the US. In this program, most staff effort was donated by volunteers, with philanthropic and in-kind university support for program management. In the context of a waxing and waning pandemic and limited resources, it is neither financially nor operationally reasonable for LHDs to maintain staffing for peak cases;

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however, without surge staffing readily available, jurisdictions would need to ration CI and CT when case numbers increase. A potential solution is to establish state, regional, or national CI and CT corps as a shared resource to provide support remotely, integrating services across geographic lines and responding promptly to stamp out incipient outbreaks. Having sufficient capacity at a regional and national level may be the only way to provide a buffer against swings in local needs, much like a national PPE stockpile. 31 This study's results also suggest that CI and CT teams are important conduits of health information, filling critical gaps in health care and public health services. We provided verbal and written guidance, and sometimes this was the only guidance participants received regarding their diagnosis or ex-  34 In the absence of a primary care physician, CI and CT programs address fundamental questions, such as when to safely return to work and when to seek emergency care. Additionally, CI and CT programs provide letters to employers to excuse work absence. Thus, the dissolution of CI and CT programs is especially harmful to people without primary care access.
Finally, this study suggests that CI and CT programs may facilitate quarantine and isolation, especially for low-resource populations, which is essential to an equity-focused pandemic response.
Nearly 30% of our participants reported at least 1 unmet social need, which CI and CT volunteers addressed through referral to the SNRT, which linked people to services like food delivery.
Furthermore, more than half of our participants were Black, and Black participants were more likely than White participants to report unmet social needs that interfered with isolation or quarantine.
Systemic racism has created these inequities, which can be exacerbated by disinvestment in prevention strategies like CI and CT. [35][36][37] Limitations This work had several limitations, chiefly that the data were collected for emergency pandemic response and not for research. Additionally, REDCap is typically used for research data collection rather than for case investigation and documentation of close contacts. A system designed for CI and CT should automate routine tasks, such as notifying relevant health departments of close contacts and sharing written guidance. These tasks were instead conducted manually. A challenge that must be remedied is the lack of a universal data-sharing platform for conducting CI and CT that enables interinstitution and crossjurisdiction communication and provides sufficient customization to address variation in policies and procedures.

Conclusions
This case series demonstrated the role of a health system-based CI and CT initiative in coaching patients through public health guidance and linking them to vital social resources. CI and CT programs across the country, including our own, were implemented rapidly to address a global catastrophe and were largely disbanded midpandemic, thus eliminating a mitigation strategy and a potential health support, especially for high-risk communities. In the absence of robust, adequately resourced public health infrastructure, health systems should consider their role in the nonclinical