Preventive medicine specialists
Laura E. Breeher, M.D., M.P.H., and Caitlin M. Hainy, C.N.P., D.N.P., R.N., share the core concepts of contract tracing and the risk assessment and key steps necessary in the challenging framework of exposure investigation.
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Welcome to Mayo Clinic Cove in 19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with a C CMI guidelines. It's a pleasure to present on contact. Tracing in case investigation is part of the Cove, it 19 Siri's I'm More ABRIR and Service medical director for Occupational Health Services in Rochester, Minnesota, and I'm joined by my colleague Dr Caitlin. Pay me from Occupational Health Services. We have no relevant disclosures at the end of the presentation today. Our objectives are for the audience to understand the purpose of contact tracing, appreciate the core concepts of contact tracing in case investigation as it relates to Kobe 19 infection and transmission and identify the complexities and added challenges that have to be overcome to perform effective contact tracing in health care setting. I want to start by discussing what contact tracing is. In a nutshell. Contact tracing is the process of identifying those who may have been exposed to an individual with an infectious disease. While many may have heard of contact tracing for the first time during the Koven 19 pandemic, it's an important public health tool that's used for many other diseases as well. Contact tracing is one of several important steps in controlling spread of disease to enable contact tracing teams to identify those who may have been exposed to an individual with an infectious disease process needs to support early detection before contacts, development spread and disease, or Koven 19. We want contact tracing to be really fast and identify contacts early before they could spread this disease. Ideally, this is within 1 to 2 days of contact with an infected person, but often they're identified as infected. Further out than that. We also want contact tracing to be thorough and geographically broad to include work, home and community contacts. The World Health Organization has provided a nice schematic outlining these steps of early detection and isolation, as well as treatment to decrease transmission within communities and workplaces and increase those survival for those who do unfortunately become infected. The overarching goal of contact tracing is to identify exposed individuals and quarantine them before the exposed individuals developed cove it and infect others. We do this to stop the spread of disease. One thing that has become very clear during the pandemic is that modern life involves a lot of interaction with others, which can make it difficult for people to recall their movement and contacts in the event they do develop. Cove in 19 infection With contact tracing, we worked very hard to assist them and recalling those events set the groundwork for details later in the presentation. I want to start out by discussing some of the core principles and key elements of the case investigation we perform with contact racing. We start by contacting the person who has been identified as infected. Often this is following a covert positive PCR test, but it can also be after a clinical diagnosis. We work with them to recall their activities and close contacts with others during the time frame when they would have been considered communicable. And then we begin contacting each of those potentially exposed individuals to perform a risk assessment. We advise whether they should quarantine and be monitoring for monitored for symptoms as well. Any individuals who already have symptoms are sent for testing to identify if they're infected and connected. Appropriate care case investigation supports the covert infected person to assist in the process of warning contacts of the exposure in order to stop the chain of transmission. I want to discuss in more detail the elements that are included in the interview with the covert infected person. We first determine whether they have a known exposure at work home or the community to identify the source of their infection. If able, we advise the employee on isolation for public health recommendations and also facilitate restrictions for work. Prevent prevent transmission we ask about when their symptoms began. If they do have symptoms, calculate their communicable period or employees exposed to patients in a health care setting. We use Elektronik medical record tools as well as work unit schedules, interviews with supervisors and other digital tools for conflict racing. Yeah, for coworker exposures, we ask about work history and get a list of close contacts that work from both the covert infected individual as well as their supervisor. If the individual was at work, the supervisor interview is crucial to confirm if precautions were in place, including facemasks. We then proceed with contacting those individuals who may have been exposed to assess in more detail. We then perform a risk assessment of each employee who had close contact at less than 6 ft or a prolonged periods such as 15 minutes in a community setting without all appropriate PPE, the timing of the contact is crucial. We look back 48 hours from either the onset of symptoms or the paths positive cov PCR test to identify interactions with others that could have resulted in exposure from that time through the end of the musical period. At this point, I'd like to hand it over to my colleague Caitlin Haney, who will discuss details of risk assessment, quarantine, isolation as well as some of the challenges the appreciate with contact tracing. Thank you, Dr Breer. So when evaluating the risk of exposure for close contacts of a known cove, it positive individual it is crucial to determine what risk level of exposure occurred. This is where personal protective equipment is so important in preventing further transmission of Covad 19, both in the health care setting as well as in our communities. When interviewing close contacts of a covert positive patient, it's important to ascertain not on Lee what the exposed individual was wearing for PPE, but also what the infected cove in 19 positive individual was wearing at the time of close contact. The picture shown here is a quick schematic showing the risk assessment based on different PPE configurations. You can see that if the source or infected person has no mask, someone in close contact at less than 6 ft for an extended duration of time would have a high risk exposure if they were also unmasked, a medium risk exposure if they were wearing a mask and a low risk exposure on Lee if they were wearing a mask and eye protection. If the infected individual is wearing a mask themselves, this would be considered source control, which does help reduce the risk of exposure for a unmasked contact down to medium instead of high risk and a mass contact to low risk. The determination of high medium and low risk of exposure will ultimately determine the outcome, management or action that will be taken for the exposed close contact. So here you could see the risk level of low, medium and high in the actions that will be taken based on the level of exposure at the time of contact with the cove in 19 positive individual for those who are assessed as having a low risk exposure, for example, to people who had mass at the time of contact and later learned that one of them was communicable for Cove in 19. The exposed individual can continue to self monitor for symptoms of Cove in 19 and may continue toe work as well as moving the community without restriction. However, for those who incurred a medium to high risk exposure, which would be anyone unmasked who had close prolonged contact with the covert infected individual would be advised to quarantine for 14 days. Undergo active monitoring for symptoms with daily questionnaires, and that male clinic would be required to complete an end of quarantine. PCR Covad 19 Test to ensure we're not returning in asymptomatic individuals, the ace and affected individuals back to work. So what exactly is the difference, though? Between the terminology of isolation versus quarantine in correlation to Cove in 19 isolation or the direction to isolate away from others is provided to individuals who are either symptomatic or displaying symptoms consistent with Kobe 19 and being sent for testing, or an individual who has received a confirmed positive cove in 19 test or diagnosis and thus is infected with the virus themselves. Isolation is essentially used to separate people infected with cove in 19 from people who are not infected, mitigating or stopping any further spread of the virus. Individuals and isolation are directed to stay home and isolate from others in the household or in the community until they're considered no longer contagious or at risk for spreading the disease. Further quarantine, on the other hand, is used for asymptomatic individuals who have been exposed to a confirmed case of Copan 19, or traveled to an area possibly with high prevalence of an infectious disease, and may have been exposed. Quarantine helps prevent the spread of disease that can occur before the person even knows they are sick or have been infected with the virus without feeling symptoms again, helping to prevent the spread of infection and the event that an infection develops After significant exposure, individuals in quarantine must stay home, separate themselves from others and monitored for symptoms consistent with cove. In 19, the duration of quarantine for Kobe, 19 will last up to 14 days from the last known date of exposure or during the full 14 day incubation period when performing contact tracing. There are essentially four key steps to remember one we need to test widely for the virus. We need to find people who are infected, including those who may be asymptomatic and spreading the virus unknowingly. Two. We need to isolate individuals infected with the virus or those displaying symptoms consistent with cove in 19 and separate them from those who are not infected. Three. We need to identify everyone who has been in contact with the infected individuals and potentially exposed. And four we need to quarantine those who have been in close contact with infected individuals for up to 14 days from the date of their last known exposure. They should not leave home and should avoid close contact with other members of their households. Remember, infected individuals shed a lot of infectious virus even before they have symptoms, so quarantine of contacts is critically important in slowing the spread of cove in 19. Why, then, is contact tracing for Kobe 19 so challenging as we previously shared when discussing the importance of quarantine? One of the biggest challenges with Cove in 19 is that the infected individual may spread cove in 19 before they developed symptoms or no, they have become infected. In fact, the cove in 19 virus can be shed two days before symptoms on set, with the peak of infectious period occurring approximately one day before symptoms develop. Because infected individuals may feel well and look well, they're likely not to limit their normal daily activities or perhaps follow the recommended precautions of social distancing and wearing a mask and shared spaces, therefore potentially exposing many during that asymptomatic period of communiqu ability. We know the incubation period of Cove in 19 is between 2 to 14 days after the last known date of exposure, and that most covert infections will develop on average, between 5 to 7 days during that 14 day incubation. Since the test, turnaround times in many areas can be longer than the minimum incubation period. By the time an individual test positive, they have likely been communicable for an average of 4 to 5 days, thus highlighting why it is so critically important to start contact tracing As soon as we're notified of any new covert positive cases, contact tracing must be initiated quickly to ensure potentially exposed individuals are made aware of their exposure and the right steps were taken to quarantine these individuals away from others or be tested themselves if they are already displaying symptoms of Cove in 19. Essentially, we need to get in front of the moving train and stop the virus before it leaves station or travels to another area to expose uninfected individuals. Further adding to the complexity of contact tracing, though, is the challenges of contact tracing within the health care setting. As the pandemic has progressed in, the critical importance of contact tracing has been emphasized. Many technology teams have attempted to develop digital contact tracing tools to assist with early and quick identification of close contacts to a covert 19 case. Well, this may be a potential and viable option within the community settings. Many of these digital tools air on Lee two tea and therefore cannot accurately identify contacts within the three D layout of a large hospital or health care setting. Such tools may detect what appeared to be two individuals standing next to each other when in reality, they're standing on separate floors with either a ceiling or floor in between and never come in close contact with each other throughout the day. These tools also rely on user adoption of the technology and are only good if used by all. Potentially exposed contacts, therefore, not eliminating the need to identify, notify and evaluate all exposed individuals. The historic workflow and healthcare also poses a challenge, with large teams involved in each patient's care. Large teams rounding or shift change, handoff occurring in close proximity and shared workspaces or teamwork rooms used by multiple staff throughout the day. Many facilities have space constraints, including crowded cafeterias, break rooms or work rooms where staff must remove their mass at times such as eating lunch. But due to the space, constraints are unable to socially distance from others. And scheduling of employees could become increasing complex, with float staff rotating through several different units, often multiple times during one scheduled shift. Alternating schedules or rotating shifts with new team members and employees who have multiple jobs, and maybe moonlighting and skilled nursing facilities or critical access hospitals and adjacent communities. All of these posey and a increased risk of new exposure and further spread of Covad 19 now that we've explained the purposes of contact tracing described the core concepts in general considerations, let's put it all together by walking through a briefcase of a real life situation. An in patient nurse working in direct patient care, presented to work on Monday morning, feeling well with no concerns. However, halfway through her shift, she develops new onset of headache and sore throat. She called her local Occupational Health Services Nurse Line, was instructed to leave work early, isolate away from others and sent for a covert 19 PCR test. Unfortunately, the test did return positive the following day, and she was, in fact infected with Cove In 19. A member of the Exposure Investigation team was alerted to the new employees positive test result and called the nurse to interview her and ask about any close contacts with other employees or patients that may have occurred during the 48 hour communicable period and symptomatic period. Upon interview, it was found that the nurse was part of the float staff and had worked several shifts during the three day communicable period across many different units. Unfortunately, she and her co workers were diligent about masking at work, so there were no medium or high risk occupational exposures from her workplace contact. However, we also learned that she had carpool toe work with two other coworkers and had to remove her mascots. Her glasses were fogging while driving. She had also gone to dinner with a group of co workers during the communicable period, and her spouse had been ill the week prior, after traveling by plane on a domestic flight. During the investigation, it was discovered that she also had many close contacts in the community and her neighborhood of whom also worked in health care. All of the identified close contacts received their own follow up phone call from this exposure team for their individual exposure, assessment and risk level determination. While many were low risk as they were never less than 6 ft away, where were wearing the appropriate PPE, Several close contacts met. Criteria for high risk exposure as mass were not used, and they were advised to quarantine and restrict from work on campus for 14 days from the last Monday of contact. A few of the close contacts were already reporting symptoms at the time of the phone call, were asked, isolate away from others and sent for testing of the employees evaluated as part of this exposure, three went on to test positive for Kobe. 19. So, as you can see in this example, contact tracing can be time consuming and requires some astute investigational skills, but is critically important and mitigating and slowing the further spread of Cove in 19 to close in summary. Contact. Tracing is a critical tool to public health and suppressing cove in 19, with the goal of stopping the spread of disease by identifying those who may have been exposed to an individual with an infectious disease. Early. Assessing the risk of exposure and potential for disease transmission, including onset of symptoms and facilitating quarantine for those with an elevated risk of exposure before they infect others. Remember, test, isolate, identify and quarantine. We may not be able to completely eliminate the eliminate Kogan 19, but with contact tracing, weaken slow the spread of disease and keep our communities open. Here are our references for today's presentation and on behalf of Dr Breer and I, we would like to thank you all for your time and attention during today's presentation.