Coronavirus Disease Contact Tracing Outcomes and Cost, Salt Lake County, Utah, USA, March–May 2020

Victoria L. Fields; Ian T. Kracalik; Christina Carthel; Adriana Lopez; Amy Schwartz; Nathaniel M. Lewis; Mackenzie Bray; Carlene Claflin; Kilee Jorgensen; Ha Khong, Walter Richards; Ilene Risk; Maureen Smithee; Madison Clawson; Lee Cherie Booth; Tara Scribellito; Jason Lowry; Jessica Huynh; Linda Davis; Holly Birch; Tiffany Tran; Joseph Walker; Alicia Fry; Aron Hall; Jodee Baker; Eric Pevzner; Angela C. Dunn; Jacqueline E. Tate; Hannah L. Kirking; Tair Kiphibane; Cuc H. Tran

Disclosures

Emerging Infectious Diseases. 2021;27(12):2999-3008. 

In This Article

Results

Index Case Identification and Contact Tracing

Of the 229 cases identified from the line list, 45 were excluded; 12 were excluded because the case-patient was a contact of a previously included index case and 33 because of incomplete data (Figure 1). Our final analysis included 184 index cases and 1,499 linked contacts. Among linked contacts, 922 were first-generation, 387 second-generation, 99 third-generation, 39 fourth-generation, 49 fifth-generation, and 3 sixth-generation contacts. Third-, fourth-, fifth-, and sixth-generation contacts were directly or indirectly linked to first-generation contacts of patients who tested positive, who had confirmed cases, or who had symptomatic but untested probable cases (Figure 1). Among 184 index case-patients, 153 (83%) did not have known contact with a laboratory-confirmed COVID-19 case-patient. Across all generations, we identified a median of 5 (range 0–97) contacts and a mean of 2.03 confirmed and probable secondary cases for each index case (Table). Of 1,499 contacts, 96 were unreachable; 89 were unreachable or did not have adequate information to trace, and 7 were out of jurisdiction and did not have final disease status. Of 1,499 contacts, 374 (25%) became confirmed or probable cases, of which 285 (19%) were confirmed and 89 (6%) were probable. The rate of secondary case detection was ≈31% among first-generation contacts; ≈16% among both second- and third-generation contacts; and ≈12% among fourth-, fifth-, and sixth-generation contacts.

Figure 1.

Flowchart of index case-patients and their contacts identified during coronavirus disease contact tracing, Salt Lake County, Utah, USA, March–May 2020. Confirmed cases comprised disease categories positive symptomatic, positive asymptomatic, and positive unknown symptoms. Probable cases comprised contacts in the not tested symptomatic disease category. Twenty-three HH contacts and 13 NH contacts were symptomatic on the same day or before the index case; contacts with an earlier symptom onset date were not reclassified. HH, household contacts; NH, nonhousehold contacts.

Disease Status at Initiation and end of the Contact's Monitoring Period

Among 1,499 contacts, 277/1,027 (27%) were tested during their monitoring period (Figure 2). Of the 277 tested contacts, 98 (35%) were SARS-CoV-2–positive after initial health department interaction. Among the 362 (24%) SARS-CoV-2–negative contacts, 183 (51%) had tested negative before their initial health department interview and 179 (49%) tested negative after the initial interview.

Figure 2.

Coronavirus disease status at initial health department interaction and after 14-day monitoring period, Salt Lake County, Utah, USA, March–May 2020. Numbers in the center signify the change in status from initial interaction by health department after the monitoring period. Numbers on left and right represent total (%) of cases in each group. The median monitoring period was the time from initial health department interview to 14 days after the last exposure to the index case. Colors represent disease status classification category.

The proportion of household contacts who were symptomatic and positive increased from 11% at initial health department interaction to 18% after the monitoring period (Figure 2). When comparing the final disease status of contacts exposed within their household versus outside of their household, more contacts exposed within their households received testing (23% vs. 13%) (data not shown).

Key COVID-19–Associated Dates

The median time from symptom onset to initial health department interaction was 7 days (interquartile range [IQR] 4–10 days) for index cases compared with 4 days (IQR 1–7.25 days) for first-generation contacts (Figure 3; Appendix). The median time from laboratory PCR test collection to initial interview was 2 days (IQR 2–4 days) for index case-patients compared with 0 days (IQR 2–4 days) for first-generation contacts. Index case-patients generally started isolation on the day of the initial SLCoHD interview (median 0 days, IQR 0–3 days). First-generation contacts reported having quarantined themselves for a median of 0 days (IQR 0–5 days) before initial interview. First-generation contacts reported a date of last exposure as a median of 4 days (IQR 0–7 days) before the initial interview; household contacts reported a median of 1 day (IQR 0–5 days), and nonhousehold contacts reported a median of 6 days (IQR 4–9 days). The time between last exposure to isolation decreased for each subsequent generation (Appendix). Among 270 contacts who reported ongoing exposure, such as persons who could not or did not isolate, 96% were household contacts.

Figure 3.

Box-and-whisker plots showing time from key coronavirus disease contact tracing–associated dates to other key dates, Salt Lake County, Utah, USA, March–May 2020. A) Days from symptom onset to PCR testing; B) days from PCR testing to initial interaction with Salt Lake County Health Department (SLCoHD); C) days from symptom onset to initial interaction with SLCoHD; D) days from last day of exposure to a confirmed or probable case to initial interaction with SLCoHD; E) days from monitoring start date to initial interaction with SLCoHD. The all contacts category includes contacts with an unknown relationship to a confirmed or probable case. Dotted red lines represent when the Salt Lake County Health Department had initial interactions with cases or contacts. Vertical lines within boxes indicate the median, left and right box edges indicate the interquartile range (IQR), and whiskers indicate the lower extreme and upper extreme quartiles; black dots indicate outliers. Negative values along the x-axis indicate that the second event happened before the first event.

Effort and Staffing Cost

We calculated time and salary cost (in USD) required to conduct contact tracing (Figure 4). Total time required to investigate 184 index cases and their 1,499 contacts was 1,102 staff hours at a total cost of $29,234 (Appendix). Median time and cost spent investigating an index case and all successive generations of contacts was 4.16 hours (95% CI 4.06–4.72 hours) at $107.22 (95% CI $92.60–$120.70).

Figure 4.

Estimated median time and cost spent educating, interviewing, and charting index cases and their contacts by final coronavirus disease status, Salt Lake County, Utah, USA, March–May 2020. Community notifications consisted of notifying businesses or persons that might have been exposed to the confirmed case such as in a workplace, at a wedding, or in a church. Asterisk (*) indicates case; dagger (†) indicates probable case. A) Median time in minutes and 95% CIs are reported above each bar. B) Median cost in USD and 95% CIs are reported above each bar.

Time and costs varied depending on the status of the contact. For each index case, the median investigation time was 79.23 (95% CI 76.56–81.40) minutes and median cost was $33.67 (95% CI $32.34–$35.22). Negative asymptomatic cases required the least amount of staff time, 21.50 (95% CI 21.05–22.08) minutes costing a median of $9.29 (95% CI $9.07–$9.50). The total time spent on community notification for exposure to a confirmed case was 84.13 hours (Figure 4). Each notification took a median of 34.67 (95% CI 32.45–37.78) minutes, including 121 (66%) index case-patients who requested work excuse letters and 14 (7.6%) index case-patients who requested notifications to community locations, such as medical facilities, event venues, churches, and grocery stores. The average gross hourly wage for salaried epidemiologists, nurses, and office support staff involved in contact tracing efforts was $29.52 (range $23.61–$35.42) (Appendix Table 4).

processing....