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Contact tracing: Bay Area, despite strides, faces hurdles in mapping who is infected
The Bay Area’s efforts to track coronavirus cases and prevent the spread of disease are showing early signs of success, although plans to directly contact a vast majority of people who tested positive still face daunting challenges,
Many local counties are approaching their goal of contacting 90% of the region’s positive cases, while others are still scrambling to ramp up their contact-tracing operations. Despite those obstacles, the Bay Area’s early progress is encouraging, even as coronavirus cases spike across the state.
The relatively high rates of contact reported by coun
ty health officials compare favorably with other metropolitan areas hit hard by the pandemic. In New York City, for example, less than half of cases reached provided information about their close contacts, according to the New York Times.
Despite these early victories, Bay Area health workers say extensive challenges lie ahead, especially when it comes to identifying contacts with infected individuals and overcoming societal reluctance to participate.
“We knew early on that there were going to be challenges with effectively doing case investigation and contact tracing with this number of cases in a pandemic of this scale,” said Dr. Nick Moss, acting director of Alameda County’s Division of Communicable Disease Control and Prevention. “This is really unprecedented compared to what health departments are usually doing.”
Contact tracing is one of the primary public health tools used to break the chain of coronavirus infection. Case investigators call people who tested positive and work to quarantine those individuals, while also trying to identify and contact others who may have been exposed. The end goal is creating a database of cases and a road map to exposure and containment.
It’s a challenging job. Dr. Lucia Abascal provides clinical support to a team of San Francisco contact tracers, drawing on her bilingual skills to coldcall strangers. But that doesn’t mean they’re willing to talk.
Even if people with the virus, and their subsequent contacts, pick up the phone, they may be reluctant to give personal information. Others worry about losing wages if they miss work, or live with family and can’t isolate. One man wanted to make sure his information wouldn’t be shared with the federal government because his wife is undocumented.
Here’s how Bay Area counties are coping with a variety of those challenges.
Workforce: Before the pandemic, local health departments staffed a handful of contact tracers to track HIV or tuberculosis infections. When COVID19 hit, the state and counties embarked on a huge mission to multiply that workforce. Health departments filled emergency staffing needs with volunteers, county workers and state employees.
UCSF has trained thousands of contact tracers per week for San Francisco and the state. The California Department of Public Health set a goal of 10,000 contact tracers by July 1. So far, that number includes 3,000 county employees and 3,300 state workers deployed to counties for six to nine months.
The state set a goal of 15 tracers per 100,000 residents in each county, which some Bay Area departments already exceeded. San Francisco, Santa Clara, San Mateo, and Alameda are able to track nearly all cases with their current workforce, but are prepping for a possible case surge.
Alameda County’s 83 contact tracers were able to reach about 85% of cases as of Wednesday. They eventually want 300 workers, but it can take a month for training. Santa Clara is still hiring and waiting for more state employees. San Mateo is ready to repurpose state workers.
Other counties haven’t met their goals yet and are facing pressure to keep up. Marin County, which was swamped with new cases this week, reached 70% of confirmed cases and only 46% of their contacts in the past two weeks.
“We’re getting snowed a little bit,” said Marin County Deputy Health Officer Dr. Stephen A. McCurdy. At one point earlier this week, he was one of only three workers making calls as the rest were trained on a new state software, which he said had some hiccups. The county currently has 39 contact tracers and wants to get to at least 50.
Contra Costa County contacted 74% of confirmed cases and 68% of their contacts in the first three weeks of June. The biggest hurdle is staffing, as redeployed county employees return to day jobs and new staff tracers are hired, spokesman Will Harper said. By the end of the week, the county will have 146 contact tracers, Public Health Director Anna Roth said Tuesday, with a goal of 173 by August.
Privacy: The first hurdle contact tracers face is simply getting in touch with people and convincing them to participate.
McCurdy of Marin County said data on confirmed cases from testing sites can take up to a week to come in. In Alameda, contact information is sometimes spotty, without a phone number or address, said Public Health Director Kimi WatkinsTartt.
Even if contact tracers have a number, not everyone answers an unknown incoming phone call. Santa Clara County’s main limiting factor in reaching most, but not all, cases, is the willingness of the public to share information, a spokesman said.
Technology could provide an answer to that problem. The state recently rolled out a new tracking system called CalCONNECT, which five Bay Area counties are using. The program lists the caller ID on contact tracing calls as “CA COVID Team” and can also text and email. San Francisco uses software from a company called Dimagi for similar purposes.
Apple and Google teamed up to develop a contact tracing app to help notify people of their exposure, but California state and county contact tracing programs don’t use any cell phone tracking technology yet.
For now, contact tracers may try the number of a confirmed case three times over the course of two days. Once someone picks up the phone, San Francisco’s refusal rate to participate is less than 2%. Marin County’s McCurdy said people have immediately hung up on him.
Contact tracers also never ask for Social Security numbers, bank account information, or immigration status, but sometimes still need to reassure people it’s not a scam and persuade them to comply.
“They have to see it’s not just in their best interest, but in the interest of the community,” McCurdy said.
New York City is starting to knock on doors to reach more people. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said Friday that President Trump’s coronavirus task force is considering ways to beef up contact tracing in person, the New York Times reported.
Support: Even when people are on board with the idea of staying at home, many who are most vulnerable to the virus cannot do so safely if they live with others or can’t miss work. In San Francisco, only about 60% of people contacted through the program could adequately selfisolate.
Contact tracers connect those isolating with county social services who can provide hotel rooms and arrange for food delivery. San Francisco also drops off medicine and cleaning supplies to some people in quarantine.
Marin County offers disaster relief payments of up to $1,500 per individual and $2,000 per family for individuals isolating who tested positive. McCurdy wants to see it extended to people who quarantine to monitor symptoms.
A San Francisco program to give cash assistance to people who don’t qualify for federal aid or paid sick time is in the late stages of development.
“The health department has a responsibility to ensure that our most vulnerable citizens have access to resources,” said Dr. Darpun Sachdev, case investigation and contact tracing unit chief for the San Francisco Department of Public Health.
Culture: The virus has disproportionately affected communities of color: In San Francisco, Latinos account for half of the infections in San Francisco despite making up only 15% of the population. More than half of contacttracing calls are conducted in Spanish. Sachdev attributed the county’s relative success to the diversity of its staff such as Abascal, a Mexico native who uses her language and cultural knowledge to build trust with other Latinos.
As counties look for more contact tracers, they’re turning to organizations that speak the language and understand the culture of vulnerable communities. Alameda County is contracting with local health clinics. Santa Clara County wants to hire 65 people to address the needs of disproportionately affected groups. San Francisco already trained four staff members from Instituto Familiar de la Raza, a Latino organization in the Mission District that can build on existing relationships to overcome the community’s mistrust in the health system, said Rafael Velázquez, the center’s HIV services program director.
“The contact tracing for us is absolutely a priority in terms of how we continuously flatten the curve and reduce transmission,” said Jon Jacobo, chairman of the health committee on San Francisco’s Latino Task Force. “We understand very well that community led efforts will always have better results because the level of connection is deeper than that of a government agency.”