Time is of the essence: impact of delays on effectiveness of contact tracing for COVID-19, a modelling study
Authors: Kretzschmar Mirjam E. , Rozhnova Ganna , Bootsma Martin , van Boven Michiel , van de Wijgert Janneke , Bonten Marc 
Published: May 2020

SummaryBackgroundWith confirmed cases of COVID-19 declining in many countries, lockdown measures are gradually being lifted. However, even if most social distancing measures are continued, other public health measures will be needed to control the epidemic. Contact tracing via conventional methods or mobile app technology is central to control strategies during deescalation of social distancing. We aimed to identify key factors for a contact tracing strategy (CTS) to be successful.MethodsWe evaluated the impact of timeliness and completeness in various steps of a CTS using a stochastic mathematical model with explicit time delays between time of infection and symptom onset, and between symptom onset, diagnosis by testing, and isolation (testing delay). The model also includes tracing of close contacts (e.g. household members) and casual contacts, followed by testing regardless of symptoms and isolation if positive, with different delays (tracing delay) and coverages (tracing coverage). We computed effective reproduction numbers of a CTS (Rcts) for a population with social distancing measures and various scenarios for isolation of index cases and tracing and quarantine of its contacts.FindingsFor the best-case scenario (testing and tracing delays of 0 days and tracing coverage of 80%), and assuming that around 40% of transmission occur before symptom onset, the model predicts that the effective reproduction number of 1.2 (with social distancing only) will be reduced to 0.8 by adding contact tracing. A testing delay of 2 days requires tracing delay to be at most 1 day, or tracing coverage to be at least 80% to keep Rcts below 1. With a testing/isolation delay of 3 days, even the most efficient CTS cannot reach Rcts values below 1. The effect of minimizing tracing delay (e.g., with app-based technology) declines with decreasing coverage of app use, but app-based tracing alone remains more effective than conventional tracing alone even with 20% coverage. The proportion of transmissions per index case that can be prevented depends on testing and tracing delays, and ranges from up to 80% in the best-case scenario (testing and tracing delays of 0 days) to 42% with a 3-day testing delay and 18% with a 5-day testing delay.InterpretationIn our model, minimizing testing delay had the largest impact on reducing onward transmissions. Optimizing testing and tracing coverage and minimizing tracing delays, for instance with app-based technology, further enhanced CTS effectiveness, with a potential to prevent up to 80% of all transmissions. Access to testing should therefore be optimized, and mobile app technology may reduce delays in the CTS process and optimize contact tracing coverage.Research in contextEvidence before this studyWe searched PubMed, bioRxiv, and medRxiv for articles published in English from January 1, 2020, to June 20, 2020, with the following keywords: (“2019-nCoV” OR “novel coronavirus” OR “COVID-19” OR “SARS-CoV-2”) AND “contact tracing” AND “model*”. Population-level modelling studies of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have suggested that isolation and tracing alone might not be sufficient to control outbreaks and additional measures might be required. However, few studies have focused on the effects of lifting individual measures once the first wave of the epidemic has been controlled. Lifting measures must be accompanied by effective contact tracing strategies (CTS) in order to keep the effective reproduction number below 1. A detailed analysis, with special emphasis on the effects of time delays in testing of index patients and tracing of contacts, has not been done.Added value of this studyWe performed a systematic analysis of the various steps required in the process of testing and diagnosing an index case as well as tracing and isolating possible secondary cases of the index case. We then used a stochastic transmission model which makes a distinction between close contacts (e.g. household members) and casual contacts to assess which steps and (possible) delays are crucial in determining the effectiveness of CTS. We evaluated how delays and the level of contact tracing coverage influence the effective reproduction number, and how fast CTS needs to be to keep the reproduction number below 1. We also analyzed what proportion of onward transmission can be prevented for short delays and high contact tracing coverage. Assuming that around 40% of transmission occurs before symptom onset, we found that keeping the time between symptom onset and testing and isolation of an index case short (<3 days) is imperative for a successful CTS. This implies that the process leading from symptom onset to receiving a positive test should be minimized by providing sufficient and easily accessible testing facilities. In addition, reducing contact-tracing delays also helps to keep the reproduction number below 1.Implications of all the available evidenceOur analyses highlight that CTS will only contribute to containment of COVID-19 if it can be organised in a way that time delays in the process from symptom onset to isolation of the index case and his/her contacts are very short. The process of conventional contact tracing should be reviewed and streamlined, while mobile app technology may offer a tool for gaining speed in the process. Reducing delay in testing subjects for SARS-CoV-2 should be a key objective of CTS.