Testing and tracing the contacts of infected people will become crucial as states ease stay-at-home restrictions and allow people to return to work.
Rachel Brummert left her home in Charlotte, North Carolina, just once after March 2: to pick up a prescription at CVS on March 18.
That made the job of the contact tracer from the Mecklenburg County health department a lot easier after Brummert, 49, got her positive COVID-19 results on April 9.
The tracer had only two other transmission possibilities to consider. She had to talk to people near Brummert’s husband at the financial services company office where he worked until March 18, and find a 26-year-old neighbor who two days later left groceries on the bottom step while Brummert stood on the top step.
Public health officials are counting on such methodical contact tracing coupled with aggressive testing as the nation’s strategy to combat the coronavirus that causes COVID-19, which has killed more than 81,000 Americans at a continued rate of about 2,000 a day.
“This tidal wave has hit,” said David Levy, CEO of EHE Health. “Other than an effective antiviral or vaccine, the only solution is testing and tracing.”
But Levy said the lack of a coordinated, national approach has left “50 different states and 50 different approaches” to control a virus that does not stop at state or county borders. If states are unable to get adequate controls in place, some warn that a surge in infections would overwhelm the ability of contact tracers to help slow the spread.
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Still, other than keeping stay-at-home orders firmly in place, public health officials say rapid testing and contact tracing give states the best chance to slow the virus and restart the economy crippled by the highest rate of unemployment since the Great Depression. And as states ease stay-at-home restrictions and allow people to return to work, shopping and social activities, testing and tracing the contacts of infected people will become crucial.
The federal Centers for Disease Control and Prevention has issued broad guidelines and training resources for state and local public health agencies. The Trump administration, however, halted the release of a plan that would advise local public health agencies on strategies to reopen public places, the Associated Press reported.
CDC Director Robert Redfield said during a U.S.Senate hearing Tuesday that contact tracing is "going to be the difference from succeeding in containing this outbreak” or widespread transmission in communities.
He said the agency has 500 staff members on the effort and is looking to add another 650, but he stressed efforts to work with local health departments to get contact tracing capability in place by September.
“It’s going to be significant effort to build the contact tracing capacity that we need in this nation,” he said.
Without an overarching plan, state public health agencies are developing their own strategies on hiring and training contact tracers.
Massachusetts has added more than 1,000 workers and sent some into communities with large numbers of cases. California last week began training the first recruits of a planned 20,000-person contact tracing team. And New York plans to add as many as 17,000 contact tracers through a partnership with former Mayor Mike Bloomberg, Johns Hopkins Bloomberg School of Public Health and Resolve to Save Lives, headed by former CDC Director Tom Frieden.
Dr. Marcus Plescia is chief medical officer of the Association of State and Territorial Health Officials. The organization completed a study with Johns Hopkins Center for Health Security that estimated 100,000 new contact tracers are needed nationwide. The estimated price tag: $3.6 billion.
He said testing, isolating and tracking the contacts of new cases is pivotal as the nation enters a new phase of the pandemic.
“Everybody is impatient and ready to start reopening society and the economy,” Plescia said. “Unless we have some kind of infection control mechanism in place, it’s just a matter of time until we rev right back up into the same situation we’re starting to recover from.”'Surge of applications'
Brummert was impressed by the efficiency of Mecklenburg County health department's investigation.
On April 21, health department officials told her they cleared other potential sources and concluded she was likely infected by the CVS keypad when she typed in her debit card number to pay for her prescription back in March.
CVS has had "very few engagements" with state and local health department contact tracers investigating COVID-19 cases involving customers, said Mike DeAngelis, a senior director of corporate communications
The chain pharmacy frequently cleans hard surfaces and commonly handled items, has reduced the number of keypad prompts a customer must touch and puts disinfecting wipe stations at the front of each store, according to DeAngelis.
"We’ve enacted measures in our stores to help ensure proper social distancing, including floor markers to help our customers be mindful of how close they are to others, and we have installed protective panels at our pharmacy counters and front-store checkout stations in all stores," DeAngelis said.
Brummert, who has the inflammatory disorder sarcoidosis, was picking up her immune suppressant medications on March 18. She looked for face masks in the aisle near the pharmacy, but to be extra cautious, she said she didn’t stop for her usual snacks.
By March 21, she had a high fever, headache and trouble breathing, but she couldn’t get tested until April 2. A week later, she learned she had COVID-19, and she was contacted by a county health department contact tracer within a couple of days.
She couldn’t get tested earlier because she had not knowingly come in contact with anyone who was infected or traveled out of the country. She was told to isolate for 14 days.
On April 2, she went to the local emergency room in what she described as “respiratory distress,” and was prescribed the antibiotic azithromycin and the breathing treatment albuterol. Her chest X-ray was filled with what she said appeared to be “white smoke.” She wasn’t hospitalized because “our hospitals were overwhelmed with people who needed to be on ventilators,” she said.
The health department said she could come out of isolation one week after her symptoms disappeared, including at least 72 hours fever-free without Tylenol. That happened on April 26, though she has stayed home to be extra cautious after hearing people can become reinfected.
Brummert said she doesn't want to rely on contact tracing, even with increased testing, to keep people safe now that shelter in place restrictions are being lifted.
“Contact tracing is complicated by itself and becomes a more complex issue when we consider those who are essential workers or have to travel,” said Brummert, a consumer representative on advisory committee for the the Food and Drug Administration’s Center for Devices and Radiologic Health. “What makes contact tracing even more disconcerting is that people who are asymptomatic can also spread the virus.”
North Carolina is working to rapidly expand its ranks of contact tracers under the state's newly adopted Carolina Community Tracing Collaborative.
Under the program, Community Care of North Carolina will use state funding to hire 250 contact tracers. Community Care will not know how much the independent contractors will be paid until state funding amounts are finalized, nor does it know how long the positions will last given the unknowns about COVID-19's trajectory.
"We’ve gotten a surge of applications, nearly 5,000 applications," said Paul Mahoney, Community Care's vice president for communications. "The unemployment rate is off the charts right now."
Contact tracers will be hired from communities with the greatest need based on number of cases and resources of the local health departments, Mahoney said. That might mean contact tracers working from their own homes in small and rural towns that need help the most, Mahoney said.Massachusetts targets hard-hit communities
Massachusetts has tapped Partners in Health, a Boston-based nonprofit with extensive experience in international public health responses.
Partners in Health contact tracers are making thousands of calls a day to Massachusetts communities hard hit the virus. With the stay-at-home orders leaving thousands of workers furloughed or laid off, there’s no shortage of applicants. Partners in Health has hired more than 1,000 from a pool of about 40,000 people who applied for positions in the state, said John C. Welch, director of partnerships and operations for the MA Covid Response project.
Welch said the large pool of job-seekers means Partners in Health can quickly add staff if Massachusetts has a surge of cases.
The nonprofit recruited for three types of jobs. Case investigators contact a person who tests positive, advises them to isolate and interviews them to get a list of contacts who might’ve been exposed to the virus.
Contact tracers, which make up the bulk of new hires, reach out to people the infected person contacted. Those interviews can be done over the phone or face-to-face if the person can’t be reached by phone.
The CDC defines a close contact as someone within 6 feet of an infected person for at least 15 minutes. The agency recommends close contacts of an infected person should stay home and monitor symptoms until 14 days after a known exposure.
A third group of new hires, care resource coordinators, connect people who must isolate with resources such as food delivery services, medical care or other social services.
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Public health agencies are well versed on contact tracing for infectious diseases such as measles or HIV. Given the fast spread and spread of COVID-19, contact tracers hired to counter novel coronavirus face a much larger job.
“It’s really important to teach the public about what contact tracing is,” Welch said. “Contact tracing happens every day for over 90 reportable infectious diseases. People aren’t necessarily aware of those day-to-day activities by the public health sector.”
Partners in Health has sought to raise awareness of what it does statewide but also through targeted outreach and engagement in Boston-area communities such as Chelsea, Revere and Brockton, Welch said.
“Those areas have had relatively high transmission rates populated by a lot of working class individuals,” he said. “These are the folks who are keeping food on our table, keeping gas in our cars and keeping our hospitals clean. Those folks are experiencing the burden of disease transmission.”
The state released a public awareness video about contact tracing to encourage people to pick up the phone. Many were ignoring calls because they feared being scammed or getting an unwanted call. The nonprofit worked with telecommunication companies to make sure their calls were not blocked, Welch said.
“The people who we’ve been in touch with have been happy to hear from us and glad to have positive outreach,” Welch said. “Contact tracing is an act of caring, and by and large, people see that.”
Others say large-scale contact tracing will be difficult to put in place in time to make a meaningful difference.
Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said hiring thousands of people with limited or no public health experience to do contact tracing is "a great idea on paper" but will struggle to keep up with the pace of the virus.
He advocates a more limited approach: Public health workers contacting infected individuals and encouraging them to stay home until they recover.
"Once you see a big escalation in cases, contact tracing absolutely cannot work," Osterholm said. "You will be having contacts by the thousands and thousands and thousands. It’s just not going to work."
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Others worry about how effective or complete tracking will be.
Dr. George Fallieras of Los Angeles returned from a ski trip in Aspen, Colorado, when he suddenly felt a “crushing fatigue” and body aches. However, he did not have a fever, cough, sore throat or trouble breathing – classic symptoms of COVID-19.
He knew something was wrong but could not get a test based on his symptoms. He did not want to potentially expose others at a hospital emergency room or his patients to anything.
Fallieras talked with a colleague, an infectious disease doctor, who arranged testing. He tested positive for COVID-19, isolated himself and has recovered. Since then, because he has antibodies believed to offer some immunity, he began working at Los Angeles Surge Hospital, a newly opened facility in downtown L.A. for COVID-19 patients.
While the hospital caters to patients with more serious complications from COVID-19, Fallieras wonders about patients like himself, those with mild symptoms or symptoms different from those most commonly described.
He worries people with mild cases might not ever get tested and could pass the virus to someone more vulnerable, such as an older adult or a person with an underlying health condition that makes them more susceptible to complications.
“It is a blessing that many people are asymptomatic,” Fallieras said. But “that makes it very difficult to contact trace and isolate.”
California will attempt exactly that with an army of 20,000 contact tracers, under an ambitious initiative announced by Gov. Gavin Newsom last week. The University of California-San Francisco and the University of California-Los Angeles will train the new workers, many of whom have no public health experience. Newly recruited tracers began a 20-hour online training course last week.
Plescia, of the Association of State and Territorial Health Officials, said it’s important for states to hire contract tracers by this summer. He said states partnering with universities and cities such as San Francisco, which is using librarians and medical students, will have an advantage to quickly get contact tracers in the field.
“It has to be in place,” he said. “If we don’t, the concern is the next surge will not come in the fall, it will come sooner.”
Frieden, a former New York City heath commissioner who headed the CDC during the Obama administration, acknowledged that contract tracing will become more difficult as social distancing protocols ease.
Under social distancing, Frieden said, he has had only two contacts. That could expand from 20 to 100 as his state loosens restrictions, making tracing much more difficult.
"This is a big challenge to do contact tracing on this scale and with this speed," Frieden said. "There is skepticism. Is it really possible? The truth is we are not going to be able to find every case.
"Just because you can’t solve all of the problem doesn’t mean you shouldn’t solve any of the problem."
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