[MUSIC PLAYING] EMILY S. GURLEY: Hello. My name is Emily Gurley, and I'm an infectious disease epidemiologist at the Johns Hopkins Bloomberg School of Public Health. I want to talk to you now about the steps to investigate cases and trace their contacts. By the end of this lecture, you should be able to identify all of the basic steps to investigate cases and trace their contacts. You should be able to provide examples of the kinds of questions that you might ask of cases and contacts during each step. And you should be able to describe the kinds of social support that cases and contacts may need to carry out isolation and quarantine. After all, asking people to isolate and quarantine is difficult, and they may need some additional support. And finally, we're going to present an example of a simple case investigation and contact tracing call so that you can hear what this sounds like in practice. Next, let's go through the basic steps-- naming them, understanding what they mean, and how they come in the sequence. On this slide, you can see the six steps of case investigation and contact tracing. Please know that this is a major simplification of what's actually happening, but hopefully it can provide you with a framework to think through the different components of what you'll do while you're investigating cases and tracing contacts. So let's go through these briefly first. First, when you call a case, you'll introduce yourself, and you'll get their basic information. We'll talk more about that in just a minute. Next, you would inquire and find out about their infectious period. So you need to ask them questions to be able to determine that. Once you define their infectious period, you would move on to step 3, which is identifying the contacts they had during their infectious period. Then you would move on to step 4 of that call with the case, where you're providing them with instructions on isolation and helping them to identify challenges to their ability to do that. You would also provide them with any support that you could to allow them to isolate. So then we move on to number 5, which is about the contacts. You'll initiate contact tracing, which means calling or contacting the contacts in some way, informing them about their exposure, asking about symptoms, and giving them instructions about quarantine. Finally, in step 6, you're going to implement regular check-ins. And this refers to the contacts as well as the cases, and you're going to follow up with them throughout their isolation or quarantine period. On this slide, you can see how the steps fit together in a sequence, one after the other. So steps 1 through 4, again, are about calling the case and having a number of conversations with that case on introducing yourself, inquiring about the infectious period, identifying their contacts, and giving them instructions on how to isolate. After that first call, where you've done all four steps, you move on to step 5 where you call their contacts. And that step-- step 5, where you're calling the contacts-- could be repeated many times. It would be repeated for all the different contacts that they had. And on those calls, you're asking about symptoms and instructing them on quarantine. Finally, step 6 is an ongoing step as well. So you're going to be implementing regular check-ins, being in constant contact with the case and their contacts to follow up on symptoms and how things are going with their isolation and quarantine. So you can refer back to this to see how each of the steps are going to link together. Now that we've defined each of the steps, let's talk about what happens in each step and talk about some of the questions that you might use in each of the steps. So on this slide, please note that the words in italics are the questions that you may use during each of these steps, or something similar, just to give you an idea of how these conversations flow. First, you might want to identify your organization. To do this, you may say something like, "Hi. This is Julie from the health department." Next, you want to be able to confirm their identity and their residence. Because you're going to be talking with them about personal information, you want to make sure that you have the right person. So when you say, "Is this Swetha," they confirm that it is them. And you say, "Nice to meet you. I need to discuss some sensitive information with you. Before we keep talking, can you please tell me your birthday and address?" And then if they can confirm that, then you can feel confident going on. Next, in this step, you want to discuss the positive test with them, because that's really the reason why you're calling. So you might say, "I'm calling about your coronavirus test. Have you talked with your provider yet?" It's possible that they've already heard about their test from their health care provider. You also want to describe the importance and the benefits of the call to the case. You want to say something like, "I'm calling to see how you are and to help keep you, your family, and your community safe." You want to provide them some assurances and confirm that the call is confidential. So you might say something like, "What we talk about is between you and me." You want to check in about the length and the safety of the call before you continue. So you may say something like, "This call should take about 20 minutes. Is now a good time to talk? Are you in a safe place to talk?" While you're on the call, it's important to pause and ask and assess about the need for medical care. If you notice that the person you're talking to has trouble breathing, or is having chest pain that doesn't go away, if they seem confused or is having trouble talking, those could be some indicators that the person is very severely ill. And if that's true, you would need to help get them medical care right away. You wouldn't finish the call. You would just turn from the questions you're asking to helping them get medical care. As you remember, step 2 is also part of the call with the case. In step 2, you want to inquire about their infectious period. So there are a few questions you're going to have to ask to determine when their infectious period started. If they had symptoms, you're going to ask questions like, "What date did your symptoms start," or, "Did you feel like you had a fever? How has your fever improved without medication? How are you feeling now?" And if they didn't have any symptoms-- maybe it's someone who's been diagnosed with an infection, but they never had signs and symptoms-- remember, we call this an asymptomatic case-- you may ask them, what date did they get tested? So depending on the answers that they provide, you can calculate the period of time that the case may have spread SARS-CoV-2 to others or when they were infectious. You can also find out who was close to the case during that period of time. Please note that there may be differences in how the infectious period is calculated, depending on whether there were symptoms or fever. While you're talking with the case, you'll move on then to step 3. Now that you've identified their infectious period, you'll need to identify who they had contact with during that period. So anyone considered a contact of the case during their infectious period will be quarantined, which includes but isn't limited to people who live with the case, were face-to-face within six feet of the case for 15 minutes or more, or had other types of direct contact with the case, like kissing, or had contact with secretions of the case. So someone taking care of them may have cleaned up their used tissues, for example. Some helpful questions you may want to use are, "Do you have any caretakers or housemates? Would you be willing to look at your calendar, or phone, or social media to help jog your memory about what you did this past week? Where have you traveled?" All of those questions will help you to help the case remember the things that they may have been doing during their infectious period. So in step 4, you're still on the call with the case, and you're going to issue isolation instructions for them. There are four components of issuing the isolation instructions. First, you'll explain isolation to them in simple terms. So what does isolation mean? What are you asking them to do? Then in number 2, you'll ask questions to check that they understood completely about what isolation means and help them make a plan. Isolating yourself isn't easy, so they'll need a plan. Third, you should identify the challenges that may stop them from following your isolation instructions. And then, finally, offer them resources to improve the chances of following the isolation instructions and being able to carry it out. Let's break these four components of the isolation instructions out a little bit more and think about some things you may do. So to explain isolation simply, you could say something like this. "Isolation means that you should try to eliminate your contact with other people, except if you need to see a doctor. If you live with others, you might try to find a different place to stay, or you might use your own bedroom and bathroom. If you need to be around other people, you should wear a mask." Next, you'll need to check their understanding and help them make a plan. To do that, you'll need to ask them some questions. So you may ask questions like, "Do you have a safe place to stay? Will you need food soon? If so, how could you get it? Do you take any medications, and will you need a refill soon? And do you have a mask?" So they'll need plans. Next, you'll want to help them identify challenges. Again, this could be done through asking them some more questions, like, "What concerns do you have about your responsibilities and mental health?" Some examples of concerns they may have are taking care of their parents or kids, or they're the only employed person in their home. It's also possible they're in a domestic violence situation and may need help finding a safe place to stay. Finally, based on the challenges that they've identified with you, you would want to be able to offer them some resources. It's important to keep in mind that the resources available to people are going to be different depending on where you are. Some examples of resources you may have to offer them include the 211 number. This is not available in all parts of the United States, but it is in some. And it's a place where people can access some immediate needs they may have. You could put them in touch with food banks, other local services, organizations, or neighborhood and community support groups that can support people during this time. At the end of the call with the case, you're going to wrap up that call. You're going to make sure that you answer their questions and have a plan for follow-up. So you'll say something like, "Thank you for your time. We've talked a lot today, and I've given you tons to think about. You'll probably have more questions over the next few days. If you think of something, here's our phone number. But either way, I'll be calling back soon to check on you. Bye." After you're done with the call with the case, you're going to move on to step 5, which is contact tracing. When you call a contact, first you're going to inform them that they were in close contact with someone who has coronavirus, or COVID-19. Next, you're going to check to see if they have any symptoms, such as a fever. You're going to provide them instructions to quarantine. You're going to help them identify challenges and offer resources to overcome those challenges. You're going to answer their questions and then make a plan to follow up. So you should recognize many of these, because it's very similar to some of the things you're going to do on the call with a case. Checking if they have symptoms, identifying challenges to quarantine, offering resources, answering questions, and following up are very similar to what you do with a case. Some frequently asked questions from the contacts include things like, "What happens if I get sick? How do I get tested? Do I need a mask? Can you give me a letter for my job or landlord?" And those are questions that you should anticipate and have some answers for when you are ready to talk to contacts. Finally, we've come to step 6, which is implementing regular check-ins. So at this stage, you've established a relationship with the case and with all their contacts, and you're going to make sure that you keep following up with them to check in on their isolation and quarantine and, of course, their symptoms. It's important to check in on symptoms, because that can determine when they can end their isolation or quarantine. So on these regular check-in calls, you're going to ask cases about their symptoms. If they're getting worse, they may need medical care. If they're getting better, then they may be able to end their isolation soon. You're going to ask them, importantly, if they've had new contacts, because then you would need to find those people as well. You're going to offer continued support for isolation. For follow-up calls with contacts, you want to track and see if they've had any symptoms. If so, they may need to get a test and then may also need medical care. And you'll also continue to offer support for quarantine. As a contact tracer, you're going to be providing important support to members of your community to help stop the spread of COVID-19. [MUSIC PLAYING]
