Over recent decades, public health officials have used contact tracing to varying degrees of success. The focus on STIs, HIV, and COVID-19 has shifted and changed.1
“Now, interest in terms of monkeypox infections is becoming more and more a topic of conversation,” says Wafaa El-Sadr, MD, MPH, MPA, lead author of a recent study on the topic and director of ICAP at Columbia University and Columbia World Projects.
Yet it is the new surge in syphilis cases that highlights the importance of contact tracing and how damaging it can be when there are not enough public health officials and healthcare providers to identify people who are exposed and convince them to seek testing.
An obvious nationwide barrier to better STI contact tracing was the COVID-19 pandemic, during which public health officials were shifted to contact tracing COVID-19 infections, leaving less time for STI contact tracing.
“I don’t have detailed data on COVID contact tracing, but I would suspect — based on what we know about what the health departments in the country have faced during different surges of COVID-19 — is that they had enormous pressure to handle enormous numbers of COVID-19 cases,” explains El-Sadr, professor of epidemiology and medicine at Columbia Mailman School of Public Health. “Some of the limitations included the inability to travel, the inability to have those kinds of trusted conversations with patients, and difficulty in going out into the community.”
COVID-19 Lessons Learned
All those things related to the pandemic made it difficult to conduct contact tracing effectively, but El-Sadr is optimistic there are lessons the health community can learn from the COVID-19 experience.
“Some lessons learned are, for example, we’ve become much more effective at being able to do telehealth and making it easy for individuals to seek care,” El-Sadr says. “Contact tracers can also use cellphones, texting, and phone calls rather than knocking on doors.”
Since the pandemic began, contact tracers have become much more adept at using various means of communication.
“Because of the volume of COVID-19 cases and contacts, there have been efforts to do more automation of the whole process,” El-Sadr says. “We’ve learned from COVID-19 a lot of efficiencies that I am hopeful will spill over to other conditions, like sexually transmitted infections.”
One efficiency could be text messaging that includes links to resources. This method provides data on when a person was contacted and what they were told.
“Some of these new tools have made it easier for supervisors of contact tracers to know who is doing what and when,” El-Sadr notes. “Having electronic systems that are able to document what is being done by whom more efficiently can help, and hopefully that will allow more efficiencies.”
For instance, if a supervisor can see that one contact tracer’s workload is larger than others, the supervisor can shift some of the work around.
“It allows for more nimble decision-making, in general,” El-Sadr says. “I think what we’ve learned from the pandemic is how important it is to have accurate communication about infectious diseases, overall. A bacteria or virus does not discriminate; everyone is susceptible if they’re exposed.”
Reproductive health providers can improve STI screening and contact tracing through communication with other providers and with the public. “We can demystify and overcome a lot of the myths about infectious diseases and let people know about a surge in cases and how they can protect themselves,” El-Sadr says.
Stigma Is a Serious Issue
But there is another major barrier to optimal STI contact tracing: stigma. El-Sadr has tried to identify some commonalities and factors that cut across every aspect of contact tracing. The chief common factor is stigma.
“Stigma is particularly related to the conditions themselves for which contact tracing is being done, whether it’s STIs or COVID,” El-Sadr notes. “If stigma is not tackled, that can hinder the effectiveness of contact tracing and its potential.”
Despite decades of contact tracing and public education about STIs, there remains substantial stigma in communities. “Contact tracing is not a simple endeavor,” El-Sadr says. “It requires people to identify those with infection as rapidly as possible, and the individuals who are diagnosed with an STI have to be willing to disclose their contacts.”
Clinicians and public health officials depend on patients cooperating with STI diagnosing and contact tracing. “We need people to be diagnosed quickly and be willing to share their contacts so we can do this faster,” El-Sadr says. “That’s the critical first step in contact tracing — the need to have a list of names and contacts of individuals.”
As a reportable condition, private providers, clinics, and labs report syphilis to local departments of health. “Usually, if there’s a trusting relationship between the provider and patient, that’s often the best position to solicit information about contacts,” El-Sadr says. “If the patient trusts the provider, and the provider explains why it’s important, I think that works best.”
When patients share the names of their contacts, providers often let the department of health handle the tracing. Those contact tracers are well-trained and will never give away the name of the source.
“We highlight this to patients and say, ‘Your name will never be shared,’” El-Sadr says. “Contact tracers always say, ‘We will let you know you’ve had exposure, and the source of the disclosure is never exposed.’”
It is hoped public health literacy has improved because of the COVID-19 pandemic, and maybe stigma about infectious diseases — including STIs — will decline.
“People have a better appreciation of the fact that infections do happen, and it’s not their fault or because they did something wrong,” El-Sadr says. “There may be a more tolerant and a more supportive environment now, rather than a stigmatized environment.”
REFERENCE
- El-Sadr WM, Platt J, Bernitz M, Reyes M. Contact tracing: Barriers and facilitators. Am J Public Health 2022;112:1025-1033.
Over recent decades, public health officials have used contact tracing to varying degrees of success. The focus on STIs, HIV, and COVID-19 has shifted and changed. Yet it is the new surge in syphilis cases that highlights the importance of contact tracing and how damaging it can be when there are not enough public health officials and healthcare providers to identify people who are exposed and convince them to seek testing.
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