- Contact tracing is crucial to cutting off chains of infection before they balloon into outbreaks and along with social distancing and mask wearing, it's one of the only proven strategies in containing the coronavirus.
- In lieu of federal coordination, states, counties and cities are developing their own plans.
- But as cases and hospitalizations spike in a number of states, some public health specialists worry that local efforts have been too little and reopening, too aggressive.
Kimberly Jocelyn graduated from college last month as millions across the country sheltered in place to avoid the coronavirus pandemic. Looking for a pandemic-friendly way to connect with her community, she applied to be a New York City contact tracer.
After a FaceTime interview with New York City Health + Hospitals' test and trace corps and a six-hour online course through Johns Hopkins University, Jocelyn joined the city's team of roughly 3,500 in the effort to contact those who have tested positive for Covid-19 and identify who they might have exposed to the virus.
The work is crucial to cutting off chains of infection before they balloon into outbreaks. Along with social distancing and mask wearing, contact tracing is one of the only proven strategies in containing the coronavirus. It's also difficult work, Jocelyn said, and it's nonstop.
"My first call was with someone who was confused about how they contracted the virus," she said, adding that it takes compassion and patience to do the job well. "We're here to provide information about Covid, understand how they contracted Covid, and also to understand how they are, to see if they need any resources."
Jocelyn, who's now a supervisor of about 15 other tracers, said ideally, a tracer comes out of one of those conversations with contact information for family members, co-workers and anyone else who might have been exposed. Throughout a given day, a tracer on her team will contact between 30 and 50 people, tracking the virus around the city and trying to corner it off into identified chains of people.
The strategy is no silver bullet, public health specialists say, but it's an age-old, proven method of containing the most contagious of infectious diseases. It has been and is still used across the world to contain viruses from measles to sexually transmitted infections. World Health Organization officials have repeatedly called on countries to scale up their contact-tracing infrastructure along with the ability to test broadly for the coronavirus.
The White House advised states not to reopen until they had built the infrastructure to conduct contact tracing. That means hiring and training thousands of people in some cases, though the federal government did not specify what a robust tracing infrastructure would look like. Now, as states across the U.S. push forward with reopening, stretched health departments are scrambling to build tracing systems on an unprecedented scale. Tracing specialists who spoke with CNBC said they're concerned that the systems in place are not enough and that reopening has been too aggressive.
"If you're not doing mitigation, so closing things down, implementing social distancing, once you stop doing that, the only tool you have to keep people from transmitting to each other is contact tracing, isolation and quarantine," said Dr. Karen Smith, former director of the California Department of Public Health. "It's the only tool you've got and it's a tool that works really well when adequately staffed."
Smith got her start in public health as a tuberculosis control officer, she said, so she understands the investment that goes into a large contact-tracing effort. She's been involved with the efforts to ramp up coronavirus contact tracing in Napa, Santa Clara and Mendocino counties in California, she said, adding that departments generally waited until cases began to level off in California around late May to estimate what the necessary magnitude of contact tracing would be.
Counties began to hire from within the local health departments first until it became clear more boots on the ground would be necessary, Smith added. Santa Clara County has now scaled up to 296 tracers, she said, and Mendocino County, which is more rural, has 25. Napa County has 21, she said, but has plans to grow to 35.
Most counties in California began to reopen before they had the necessary infrastructure in place, such as staff and also technology, she said, adding that local health departments, suffering from more than a decade of budget cuts, are running on outdated systems that will hinder their tracing efforts.
"[Contact tracing] is a standard tool and it really works, but when it's not in place, or in the case of when you start trying to implement it after the virus is quite literally already spreading in your community, it's almost impossible to catch up," Smith said.
"Ideally, when we started reopening, it would have been great if we had asked states for contact tracing," said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials.
Some states did tie regional reopenings to contact-tracing metrics. New York, for example, required that regions have 30 contact tracers per 100,000 residents to begin to reopen. If applied nationwide, that would mean about 100,000 contact tracers.
Infectious disease specialists from Johns Hopkins University and ASTHO proposed a plan in early April to ramp up a national test and trace effort. It would require a workforce of 100,000 people, the proposal said, and cost $3.6 billion. Plescia added that some researchers have called for up to 300,000 national tracers. Instead, the CDC allocated $631 million from the $2 trillion CARES Act to 64 jurisdictions for the effort.
Rather than developing a coordinated national tracing plan, which countries like Germany have done, the CDC has sought instead to support local efforts. Last week, the agency published a downloadable spreadsheet to help local health departments calculate how many tracers they might need based on population and current level of spread. And earlier this month, the CDC released an infographic defining its expectations for local departments and calling on them to "scale up and train a large case investigation and contact tracer workforce."
That guidance came well after every state began to reopen, and many have already begun to see an increase in cases. Arizona, for example, began to reopen on May 15 and has since seen a spike in cases and some hospitals are nearing capacity.
The CDC did not provide comment in time for publication.
"The stay-at-home order ended before the counties had hired the necessary number of contact tracers and got their administrative procedures together," said Will Humble, former director of the Arizona Department of Health Services. "That put the counties in a position where the stay-at-home order was lifted and a rebound in cases came before they were able to get their capacity up."
Cases began to rise in Arizona after Memorial Day weekend. On Wednesday, Gov. Doug Ducey reversed his previous stance that the state would continue to reopen and could handle any uptick in cases. In his updated guidance, Ducey placed an emphasis on the role of contact tracing and he announced the state is deploying 300 National Guardsmen to assist counties with contact tracing.
"[Contact tracing] is going to help to contain new infections and to prevent and slow the transmission of coronavirus in our communities," he said at a news briefing, adding that it's one of the "core state preparedness" criteria laid out by the White House.
But in Maricopa County, where the virus has hit hardest in Arizona, the county health department has so far hired 82 tracers, spokesperson Fields Moseley told CNBC, and intends to hire 20 more. That would work out to be just more than 2 tracers per 100,000 residents in the county.
It's not just about the number of tracers, Smith of California explained, but it's also about having a trained workforce that understands the epidemiology of the virus. As health departments scramble to ramp up, many are hiring people who have no familiarity with epidemiology nor contact tracing. Maricopa County, for example, has recruited students from local universities and Americorp volunteers to supplement the 82 Department of Public Health employees involved in the effort, Moseley said.
"Everyone is aware the number of cases increased far beyond expectations in the past two weeks," Moseley said. "Public Health is evaluating adding more employees and incorporating technology such as robo-calls and text messaging for low-risk positive cases, while focusing human resources on those cases that are most at-risk of serious complications."
Effective contact tracing is not just about the number of tracers, but it's also important that the staff have a nuanced understanding of the local outbreak and their role in it, said Emily Gurley, an epidemiologist at Johns Hopkins University and instructor of the school's new six-hour online contact-tracing course. New York state, among jurisdictions, has used Gurley's course to quickly train inexperienced contact tracers.
The course gives students a rundown of what's known about the virus: how long a person can be presymptomatic, when is someone no longer infectious, what qualifies as a close contact and more. While the course is helping to train a workforce on a scale that epidemiologists hoped would never be needed and never prepared for, Gurley said that ideally, contact tracing is done by classically trained epidemiologists with an intimate understanding of infectious diseases.
"It's hard to imagine that there were many health departments that had enough contact tracers at the beginning of this." she told CNBC. "Our public health system is chronically and severely underfunded, so most places need more and maybe a lot more [tracers]. But if you've got a smaller team and they're all really highly skilled, very good at what they do, and they've been doing it a long time, maybe you need fewer."
Nonetheless, anything helps curb the spread of the virus, Gurley said, adding that her colleagues at Johns Hopkins are working on a model to quantify the impact of tracing programs so local health officials can see the difference they're making. As researchers learn more about how the virus spreads and that information is passed down to the growing workforce of rookie tracers, Gurley said she's optimistic such programs will become increasingly fundamental to the country's response.
"I think that there's still often an under-appreciation of how difficult this work is and really what we're up against, frankly," she said. "This isn't something that is just a fire drill and then in a couple months it can be over. You really have to invest in these programs, and follow them closely and get them working well and keep after it with the hard slog required to make them worthwhile. We are in this for the long haul"
Contact tracers do more than identify people who might be spreading the virus. They are also expected to help patients and potentially exposed people navigate the illness. Jackie Bray, deputy executive director of the NYC Test and Trace Corps, said tracers in New York are trained to inform contacts about options such as free meal delivery while they're isolating and financial counseling if they're unable to work from home.
"It's testing, tracing and isolating, or testing, tracing and, what we call here in New York, safely separating," she said. "They come as a package."
The city has leased several hotels, now empty because the pandemic has restricted travel, to offer as temporary housing for potentially exposed individuals who live in crowded homes, Bray said. While about 20% of contacts accept some kind of support from the agency, Bray said only a few dozen have accepted the offer to move into one of the leased hotels at this early juncture in the program.
As New York City continues to ramp up its tracing efforts and the public adjusts to it, Bray said she hopes they continue to get more participation from the community and believes that other parts of the country should take note of the work they've done so far.
"Invest in your testing infrastructure. Invest in contact tracing, but don't forget that they're both a means to an end. And the goal is isolation," she said of what other municipalities can learn from New York.
Countries like South Korea and Singapore made contact tracing famous when they used it to contain the first infections early in their outbreaks. Health officials in those countries were able to quickly roll it out with the help of surveillance technology, including credit card transactions and location-tracking data.
Some companies, including Google and Apple, have spearheaded efforts to implement tracing technology that can help the U.S. to replicate successes seen in Asia. But such technology is unlikely to be widely adopted in the U.S., due to concerns over privacy and government intrusion, Smith from California said.
Smith has been working with the counties she's involved with to consider how tech could help ramp up the local tracing efforts. Apple and Google's initiative would share anonymized location-tracking data with apps set up by public health departments that can alert users if they've come into contact with someone who tested positive.
Smith said there could be some use for a program like that, but much more helpful would be equipping underfunded local health departments with simple data entry systems to help track who's infected and their contacts. She added that some health departments around the country have yet to digitize and build out their systems.
"[Tech] can help, but it can't replace," she said.
In lieu of federal coordination, some cities, counties and states are looking elsewhere for support. In Louisville, Kentucky, the metro government decided to contract out the contact-tracing effort to Louisville-based Lacuna Health, which is owned by Kindred Healthcare.
Lacuna is a medical call center staffed largely by registered nurses and other trained medical personnel. The company previously focused on providing telehealth and other remote services to hospitals, but when the coronavirus pandemic took hold in the U.S., the company began to rethink how it could pivot to support the local response, CEO Brian Holzer told CNBC.
As of Wednesday, Lacuna had onboarded 50 people for its tracing effort, Holzer said, adding that it just officially launched on Monday. He said the call center is reaching out to 500 people per day on average, which has met demand so far as Louisville hasn't been hit hard by the virus. But Holzer said he expects the virus to spread throughout the city eventually, so he hopes that as Lacuna hires more people and irons out the logistics of the system, it'll eventually be contacting between 2,000 and 4,000 people per day.
"We've been hired because of our technology, our call center platforms and our ability to navigate within a complex health-care environment," Holzer said. "It would scare me if a local or state municipality thinks that when time is needed, they will set up a contact-tracing environment, hire a staffing firm, give people a bunch of cellphones and go to town. This is incredibly complex."
Lacuna's partnership with the city, which Dr. Sarah Moyer, director of the Louisville Metro Department of Public Health and Wellness, estimated could cost up to $1 million, allows the company to tap a city database of phone numbers, Holzer said. He added that the company can then efficiently deploy its workforce so tracers aren't spending time leaving voicemails or dialing numbers. Minutes spent on those activities add up, he said, and time is of the essence with tracing.
"Not to be overdramatic, but if done correctly, this will save lives," he said. "This is inordinately important to keep people safe, to allow the economy to restart, to allow the employers and small business owners to begin going back to work."