Effect of an enhanced public health contact tracing intervention on the secondary transmission of SARS-CoV-2 in educational settings: The four-way decomposition analysis
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eLife assessment
This study provides a potentially useful assessment of the effect of testing contacts of cases in school classes when identified, rather than at the end of quarantine, on both the number of secondary infections and other outcomes including tracing delay and identification of the possible source of infection. The authors find that the intervention likely led to a decrease in tracing delay and an increase in the number of possible sources of infection, though were unable to determine whether secondary transmission decreased, due in part to unmeasured confounding. While the surveillance system described provides a solid dataset appropriate for this analysis, the description of methods, study outcomes, and consideration of potential confounding factors is incomplete.
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Abstract
The aim of our study was to test the hypothesis that the community contact tracing strategy of testing contacts in households immediately instead of at the end of quarantine had an impact on the transmission of SARS-CoV-2 in schools in Reggio Emilia Province.
Methods:
We analysed surveillance data on notification of COVID-19 cases in schools between 1 September 2020 and 4 April 2021. We have applied a mediation analysis that allows for interaction between the intervention (before/after period) and the mediator.
Results:
Median tracing delay decreased from 7 to 3.1 days and the percentage of the known infection source increased from 34–54.8% (incident rate ratio-IRR 1.61 1.40–1.86). Implementation of prompt contact tracing was associated with a 10% decrease in the number of secondary cases (excess relative risk –0.1 95% CI –0.35–0.15). Knowing the source of infection of the index case led to a decrease in secondary transmission (IRR 0.75 95% CI 0.63–0.91) while the decrease in tracing delay was associated with decreased risk of secondary cases (1/IRR 0.97 95% CI 0.94–1.01 per one day of delay). The direct effect of the intervention accounted for the 29% decrease in the number of secondary cases (excess relative risk –0.29 95%–0.61 to 0.03).
Conclusions:
Prompt contact testing in the community reduces the time of contact tracing and increases the ability to identify the source of infection in school outbreaks. Although there are strong reasons for thinking it is a causal link, observed differences can be also due to differences in the force of infection and to other control measures put in place.
Funding:
This project was carried out with the technical and financial support of the Italian Ministry of Health – CCM 2020 and Ricerca Corrente Annual Program 2023.
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Author Response
Reviewer #1 (Public Review):
Summary:
The study assesses the impact of testing contacts of cases in school classes when identified, rather than at the end of quarantine, on various outcomes such as secondary infections, tracing delay, and identification of the possible source of infection. The authors find that the intervention likely reduced tracing delay and increased the number of possible infection sources. However, due to unmeasured confounding, it remains unclear if secondary transmission actually decreased. The analysis requires clarification and further explanation in parts.
Major strengths and weaknesses:
The study benefits from the assessment of various outcomes in contact tracing in addition to changes in transmission, such as tracing delay, and the identification of putative infectors; however the …
Author Response
Reviewer #1 (Public Review):
Summary:
The study assesses the impact of testing contacts of cases in school classes when identified, rather than at the end of quarantine, on various outcomes such as secondary infections, tracing delay, and identification of the possible source of infection. The authors find that the intervention likely reduced tracing delay and increased the number of possible infection sources. However, due to unmeasured confounding, it remains unclear if secondary transmission actually decreased. The analysis requires clarification and further explanation in parts.
Major strengths and weaknesses:
The study benefits from the assessment of various outcomes in contact tracing in addition to changes in transmission, such as tracing delay, and the identification of putative infectors; however the assumption that other cases found in households are infectors of the index case rather than putative infectees, may introduce significant bias, but this is not mentioned in the Discussion despite being significant. It is difficult to understand the intervention in Figure 1 due to unclear labelling and incomplete descriptions in the caption. The authors mention that the same school class could be included multiple times for multiple outbreaks - was there a time cutoff for inclusion? I had a lot of trouble interpreting or reproducing the values given in Table 1. Firstly, the methods used to produce the RRs given are not described in the methods section of the paper. What are the outcomes - "classes" and "indexes" are poroly defined. Is this output from univariate or multivariate regression model, and what is the link function? I was also unable to reproduce the RRs listed in the table despite attempting several methods. The closest numbers I achieved were by crudely dividing the risks (e.g. for the RR for known infection source I took the ratio of indexes for which a school contact was suspected pre and post-intervention (644/1175)/(146/429) = 1.61), but if this is the case then the unknown class is by definition not the reference category. This is the same for the other RRs stated in the table. The methods used should be clarified and results updated if erroneous. The mediation analysis components and their relevance to the study could be better explained in the methods and results.
Achievement of aims and support for conclusions:
The authors partially achieved their aims by demonstrating a likely decrease in tracing delay and an increase in possible infection sources. However, the study's inability to determine if secondary transmission decreased due to unmeasured confounding limits the conclusiveness of the findings. The authors should reiterate the main numerical results in the first few paragraphs of the discussion.
Impact on the field and utility of methods and data:
This study has the potential to impact the field by highlighting the benefits of testing contacts earlier in school classes. The findings on reduced tracing delay and increased identification of infection sources can inform future strategies and interventions. However, clarity on the analysis methods, as well as the results, are necessary to ensure the utility and reliability of the findings.
We thank the reviewer for his encouraging comments, we completely agree with the interpretation of our findings. Nevertheless, the intervention under evaluation is not exactly as descried by the reviewer. In fact, the change of contact tracing targeted mostly the tracing in household cases. Investigation in schools used the immediate testing of all contacts already before the intervention, even if after the intervention the timeliness increased. It was in the household where we had a clear change with immediate testing of all asymptomatic family contacts.
The assumption of direction of infection: We understand the reviewer’s point and we agree that such an assumption would introduce an important bias. Nevertheless, we do not assume any direction of the infection. We only report the conclusions of the field investigation conducted during the school outbreak about a known source of infection for the index case.
On the contrary, in our conceptual framework, we make the hypothesis that introducing backward contact tracing for all cases in the community (mostly household infections) asymptomatic cases in school age were more promptly identified and this improved the surveillance of school outbreaks and possibly reduced transmission in school outbreaks. This increase in timeliness could occur whatever the direction of infection within the household was, i.e. from the symptomatic adult to the asymptomatic child or the other way round.
Figure 1: we completely changed figure 1 according to reviewer’s suggestions.
Table 1: it has been split in two tables, the first describe the characteristics of the classes and index cases and the outcomes of the outbreaks, and the second is a table showing the association between possible confounders and the main outcome. We are sorry; trying to make the paper shorter, we made the table very unclear.
Repeated outbreaks in the same class: we thank the reviewer for this point. We did not define a time limit to distinguish two episodes. The outbreaks were defined by the field investigations. If the class was involved in two investigations, public health operators firstly tried to assess if there was a direct link between the two. Actually, it was impossible that two outbreaks were considered independent if there was less than 21 days between the two index cases notifications. We added a sentence in the methods.
Mediation analysis rationale: we added a DAG to explain the mediation analysis, we also changed the results reporting following step by step the preliminary results to introduce the mediation analysis to justify the selection of the mediators and the confounders.
Discussion: we added the main findings in a quantitative way at the beginning of the discussion.
Reviewer #2 (Public Review):
This is a review of "Effect of an enhanced public health contact tracing intervention on the secondary transmission of SARS-CoV-2 in educational settings: the four-way decomposition analysis", by Djuric et al.
In late 2020, a province in northern Italy implemented a new testing regimen for all contacts of people known to have COVID-19, offering them SARS-CoV-2 testing immediately after the detection of the index case instead of at the end of a quarantine period. The authors of this study investigated whether this policy change reduced secondary transmission of SARS-CoV-2 in schools. In addition to studying this primary outcome, they examined two "process" outcomes; whether this policy of testing earlier enabled public health officials to more successfully identify the source of infection of the index case, and if the time interval from detection of the index case to testing of contacts in the educational setting reduced.
They concluded that the time between detection of the index case and testing of contacts did reduce before and after the policy change. Similarly, the proportion of cases for which the source of infection was identified also increased after the policy change. Both of these "process" indicators correlated with reduced secondary transmission, though only identifying the source of infection was associated with a statistically significant (at the 5% level) reduction in secondary transmission.
Strengths of this paper
Educational settings experienced significant disruption during the COVID-19 pandemic, and efforts to better understand the spread of SARS-CoV-2 in schools - and how to mitigate this spread - are of significant public health importance. This paper, therefore, addresses an important topic.
Additionally, the authors describe a detailed dataset comprising case and contact tracing data from over 1,600 index cases with in-school contacts. The richness of the data described in Table 1 provides a good opportunity to conduct a natural experiment on the potential impact of testing contacts immediately after exposure on secondary transmission. The authors also appropriately acknowledge that this interrupted time series study would be insufficient to provide causal information, given the potential for confounders.
Finally, the primary statistical method (a four-way decomposition analysis) was new to me, but - from the references cited - seems appropriate. Given the relative novelty of this method, more space could be dedicated to explaining it in the methods.
Weakness of this paper
Although the paper tackles an important topic with an appropriate dataset, the analyses feel insufficient to fully support the authors' conclusions.
First and most critically, it is difficult to understand exactly what the primary outcome of the study is. Both the median number of secondary cases per class and the proportion of classes that experienced any secondary transmission are presented in Table 1, but - at least in the unadjusted analyses - point in different directions regarding the impact of the effect of the intervention (albeit neither strongly). For example, before the policy change, the median number of secondary cases per index case is 2, while after the policy change, it has reduced to 1. In contrast, before the policy change 37% of classes experienced any secondary transmission, but after the policy change, this had increased to 39% of classes. In some of the adjusted analyses, "number of secondary cases" is stated as the outcome variable, but that is not fully defined. The "attack rate", which is well defined in the methods, could be one option for use as a consistent primary outcome, however, it is only provided for the total study population and the attack rates pre- or post-policy change are not presented or compared.
Additionally, although using a "process measure" as a secondary outcome could be valuable - especially in a natural experiment like this, where identifying a causal relationship with a complex outcome like secondary transmission will be difficult - it was somewhat unclear how the process measures described in this study were measured, or their validity. For example, the reduced time between detection of the index case and testing of contacts seems unsurprising, since the intervention itself is to test contacts immediately after the index case is identified. Additionally, the results describe reductions in median testing delay and median tracing delay, but only testing delay is defined in the methods.
Finally, there is existing published literature that provides additional context on the impact of testing on secondary transmission within schools that arguably provides a higher level of evidence than the current study, but is not cited by the authors. A key limitation of this study - which the authors acknowledge - is the interrupted time series nature of their study, which is open to confounding by other important factors that happened at the same time, including but not limited to: changes in overall incidence of COVID-19; viral evolution (e.g. the emergence of the Alpha variant (B.1.1.7) which occurred during this study and which significantly altered the risk of secondary transmission); the efficiency of the contact tracing system (including skill and size of the contact tracing workforce); and the availability of non-molecular diagnostic tests (e.g. lateral flow devices) that might allow individuals to change their behaviors even without enrolling in this study. Examples of alternative studies which might reduce some of this potential confounding include around 400 schools in Los Angeles County, California, USA, that implemented "test to stay" in 2021 and were compared to 1,600 schools that did not implement "test to stay" [https://www.cdc.gov/mmwr/volumes/70/wr/mm705152e1.htm] and a cluster-randomized trial of daily testing of exposed contacts to study in-school transmission in England, UK, also in 2021 [https://www.sciencedirect.com/science/article/pii/S0140673621019085]. Although these examples describe slightly different interventions involving enhanced testing of exposed contacts, they both compared educational settings with and without the intervention across the same time periods; and the UK study in particular has methodological advantages over this current paper, including randomization. While the findings in the current paper did not contradict these earlier, stronger papers, the example from this province should be placed in context with the totality of evidence around testing in schools.
We thank the reviewer for his encouraging and useful comments.
We have completely reframed Table 1 and split it in two separate tables. We have added suggested references.
According to the reviewer’s suggestions, we tried to better describe the main outcome and to justify our choice. We also added a definition of testing delay that was missing. We added a box explaining in plain language all the outputs of the mediation analysis. We improved reporting of the descriptive data in table 1, including attack rate.
Furthermore, we better explained the choice of process outcomes and how they were related to the main outcome a priori and what changes were expected under the hypothesis that the intervention worked correctly. In particular, we agree that a reduction in the time to testing was unsurprising, in fact, this was just to check that the intervention was actually and correctly implemented; increasing the proportion of index cases with a known source of infection (and the proportion of asymptomatic index cases, that was not identified in the initial protocol but we identified later as an important process indicator) is a process indicator suggesting that more index cases have been identified as a consequence of a household investigation, i.e. the change in tracing helped in early detection of school exposure.
Regarding the proportion of classes with secondary transmission, we added a sentence in the discussion explaining why we did not expect that this would change after the intervention. In fact, as described in the new figure 1, household contacts were immediately quarantined before as well as after the intervention, what changed is that they are timely identified as contacts and therefore school contacts are identified and isolated. Only if a secondary transmission in the class already occurred we could reduce transmission in the class, i.e. we are preventing tertiary cases not secondary. Nevertheless, the number of classes investigated is also expected to change, so it was difficult to predict if the proportion of investigated classes with transmission should increase or decrease.
In the discussion, we reported examples of studies that applied an experimental or semi-experimental design and thus overcame the main limits of our observational study. Nevertheless, we also highlighted that the intervention we are evaluating in this study was particularly difficult to be conducted in a trial or a semi-experimental setting, in fact, we are trying to evaluate a change in the contact tracing in the community that occurred during the peak of the second wave.
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eLife assessment
This study provides a potentially useful assessment of the effect of testing contacts of cases in school classes when identified, rather than at the end of quarantine, on both the number of secondary infections and other outcomes including tracing delay and identification of the possible source of infection. The authors find that the intervention likely led to a decrease in tracing delay and an increase in the number of possible sources of infection, though were unable to determine whether secondary transmission decreased, due in part to unmeasured confounding. While the surveillance system described provides a solid dataset appropriate for this analysis, the description of methods, study outcomes, and consideration of potential confounding factors is incomplete.
-
Reviewer #1 (Public Review):
Summary:
The study assesses the impact of testing contacts of cases in school classes when identified, rather than at the end of quarantine, on various outcomes such as secondary infections, tracing delay, and identification of the possible source of infection. The authors find that the intervention likely reduced tracing delay and increased the number of possible infection sources. However, due to unmeasured confounding, it remains unclear if secondary transmission actually decreased. The analysis requires clarification and further explanation in parts.Major strengths and weaknesses:
The study benefits from the assessment of various outcomes in contact tracing in addition to changes in transmission, such as tracing delay, and the identification of putative infectors; however the assumption that other cases …Reviewer #1 (Public Review):
Summary:
The study assesses the impact of testing contacts of cases in school classes when identified, rather than at the end of quarantine, on various outcomes such as secondary infections, tracing delay, and identification of the possible source of infection. The authors find that the intervention likely reduced tracing delay and increased the number of possible infection sources. However, due to unmeasured confounding, it remains unclear if secondary transmission actually decreased. The analysis requires clarification and further explanation in parts.Major strengths and weaknesses:
The study benefits from the assessment of various outcomes in contact tracing in addition to changes in transmission, such as tracing delay, and the identification of putative infectors; however the assumption that other cases found in households are infectors of the index case rather than putative infectees, may introduce significant bias, but this is not mentioned in the Discussion despite being significant. It is difficult to understand the intervention in Figure 1 due to unclear labelling and incomplete descriptions in the caption. The authors mention that the same school class could be included multiple times for multiple outbreaks - was there a time cutoff for inclusion? I had a lot of trouble interpreting or reproducing the values given in Table 1. Firstly, the methods used to produce the RRs given are not described in the methods section of the paper. What are the outcomes - "classes" and "indexes" are poroly defined. Is this output from univariate or multivariate regression model, and what is the link function? I was also unable to reproduce the RRs listed in the table despite attempting several methods. The closest numbers I achieved were by crudely dividing the risks (e.g. for the RR for known infection source I took the ratio of indexes for which a school contact was suspected pre and post-intervention (644/1175)/(146/429) = 1.61), but if this is the case then the unknown class is by definition not the reference category. This is the same for the other RRs stated in the table. The methods used should be clarified and results updated if erroneous. The mediation analysis components and their relevance to the study could be better explained in the methods and results.Achievement of aims and support for conclusions:
The authors partially achieved their aims by demonstrating a likely decrease in tracing delay and an increase in possible infection sources. However, the study's inability to determine if secondary transmission decreased due to unmeasured confounding limits the conclusiveness of the findings. The authors should reiterate the main numerical results in the first few paragraphs of the discussion.Impact on the field and utility of methods and data:
This study has the potential to impact the field by highlighting the benefits of testing contacts earlier in school classes. The findings on reduced tracing delay and increased identification of infection sources can inform future strategies and interventions. However, clarity on the analysis methods, as well as the results, are necessary to ensure the utility and reliability of the findings. -
Reviewer #2 (Public Review):
This is a review of "Effect of an enhanced public health contact tracing intervention on the secondary transmission of SARS-CoV-2 in educational settings: the four-way decomposition analysis", by Djuric et al.
In late 2020, a province in northern Italy implemented a new testing regimen for all contacts of people known to have COVID-19, offering them SARS-CoV-2 testing immediately after the detection of the index case instead of at the end of a quarantine period. The authors of this study investigated whether this policy change reduced secondary transmission of SARS-CoV-2 in schools. In addition to studying this primary outcome, they examined two "process" outcomes; whether this policy of testing earlier enabled public health officials to more successfully identify the source of infection of the index case, …
Reviewer #2 (Public Review):
This is a review of "Effect of an enhanced public health contact tracing intervention on the secondary transmission of SARS-CoV-2 in educational settings: the four-way decomposition analysis", by Djuric et al.
In late 2020, a province in northern Italy implemented a new testing regimen for all contacts of people known to have COVID-19, offering them SARS-CoV-2 testing immediately after the detection of the index case instead of at the end of a quarantine period. The authors of this study investigated whether this policy change reduced secondary transmission of SARS-CoV-2 in schools. In addition to studying this primary outcome, they examined two "process" outcomes; whether this policy of testing earlier enabled public health officials to more successfully identify the source of infection of the index case, and if the time interval from detection of the index case to testing of contacts in the educational setting reduced.
They concluded that the time between detection of the index case and testing of contacts did reduce before and after the policy change. Similarly, the proportion of cases for which the source of infection was identified also increased after the policy change. Both of these "process" indicators correlated with reduced secondary transmission, though only identifying the source of infection was associated with a statistically significant (at the 5% level) reduction in secondary transmission.
Strengths of this paper
Educational settings experienced significant disruption during the COVID-19 pandemic, and efforts to better understand the spread of SARS-CoV-2 in schools - and how to mitigate this spread - are of significant public health importance. This paper, therefore, addresses an important topic.
Additionally, the authors describe a detailed dataset comprising case and contact tracing data from over 1,600 index cases with in-school contacts. The richness of the data described in Table 1 provides a good opportunity to conduct a natural experiment on the potential impact of testing contacts immediately after exposure on secondary transmission. The authors also appropriately acknowledge that this interrupted time series study would be insufficient to provide causal information, given the potential for confounders.
Finally, the primary statistical method (a four-way decomposition analysis) was new to me, but - from the references cited - seems appropriate. Given the relative novelty of this method, more space could be dedicated to explaining it in the methods.
Weakness of this paper
Although the paper tackles an important topic with an appropriate dataset, the analyses feel insufficient to fully support the authors' conclusions.
First and most critically, it is difficult to understand exactly what the primary outcome of the study is. Both the median number of secondary cases per class and the proportion of classes that experienced any secondary transmission are presented in Table 1, but - at least in the unadjusted analyses - point in different directions regarding the impact of the effect of the intervention (albeit neither strongly). For example, before the policy change, the median number of secondary cases per index case is 2, while after the policy change, it has reduced to 1. In contrast, before the policy change 37% of classes experienced any secondary transmission, but after the policy change, this had increased to 39% of classes. In some of the adjusted analyses, "number of secondary cases" is stated as the outcome variable, but that is not fully defined. The "attack rate", which is well defined in the methods, could be one option for use as a consistent primary outcome, however, it is only provided for the total study population and the attack rates pre- or post-policy change are not presented or compared.
Additionally, although using a "process measure" as a secondary outcome could be valuable - especially in a natural experiment like this, where identifying a causal relationship with a complex outcome like secondary transmission will be difficult - it was somewhat unclear how the process measures described in this study were measured, or their validity. For example, the reduced time between detection of the index case and testing of contacts seems unsurprising, since the intervention itself is to test contacts immediately after the index case is identified. Additionally, the results describe reductions in median testing delay and median tracing delay, but only testing delay is defined in the methods.
Finally, there is existing published literature that provides additional context on the impact of testing on secondary transmission within schools that arguably provides a higher level of evidence than the current study, but is not cited by the authors. A key limitation of this study - which the authors acknowledge - is the interrupted time series nature of their study, which is open to confounding by other important factors that happened at the same time, including but not limited to: changes in overall incidence of COVID-19; viral evolution (e.g. the emergence of the Alpha variant (B.1.1.7) which occurred during this study and which significantly altered the risk of secondary transmission); the efficiency of the contact tracing system (including skill and size of the contact tracing workforce); and the availability of non-molecular diagnostic tests (e.g. lateral flow devices) that might allow individuals to change their behaviors even without enrolling in this study. Examples of alternative studies which might reduce some of this potential confounding include around 400 schools in Los Angeles County, California, USA, that implemented "test to stay" in 2021 and were compared to 1,600 schools that did not implement "test to stay" [https://www.cdc.gov/mmwr/volumes/70/wr/mm705152e1.htm] and a cluster-randomized trial of daily testing of exposed contacts to study in-school transmission in England, UK, also in 2021 [https://www.sciencedirect.com/science/article/pii/S0140673621019085]. Although these examples describe slightly different interventions involving enhanced testing of exposed contacts, they both compared educational settings with and without the intervention across the same time periods; and the UK study in particular has methodological advantages over this current paper, including randomization. While the findings in the current paper did not contradict these earlier, stronger papers, the example from this province should be placed in context with the totality of evidence around testing in schools.
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