Counties vary in testing, tracing

Experts: Readiness vital for business reopenings

In order to manage COVID-19 as the state starts to reopen certain businesses, public health experts call for more testing, robust contact tracing and isolating positive cases and their personal contacts.

But Arizona’s 15 counties are at different levels of the preparedness in terms of supplies and personnel needed to manage proper testing and contact tracing.

Contact tracing is the practice of health departments tracing the contacts of positive cases to identify and test those exposed to COVID-19.

The practice helps health officials follow new cases and, ideally, helps slow the spread of the disease by containing new infections. In reality, it can be difficult given lack of resources or, in larger counties, the impracticality or inability of contacting everyone who could have been infected.

The White House’s reopening guidelines recommend robust contact tracing as one of the essential preparedness measures for states.

In many parts of the state, Arizona is still working to ramp this up.

Dr. Cara Christ, the Arizona Department of Health Services director, said during a May 4 news conference that some federal CARES Act funding would go to local health departments for them to “enhance their current contact tracing strategies.”

Health departments nationwide have been working on expanding contact tracing as a key element of managing additional positive cases, monitoring potential cases and planning for isolation, quarantine and reopening.

As society gradually reopens, numbers of positive cases likely will increase given more social interaction, so contact tracing will become even more essential to preventing further spread.

Arizona’s two largest counties, Maricopa County and Pima County, have faced challenges in getting enough test supplies and undertaking full contact tracing for all positive cases.

As of Monday, Maricopa County had 5,988 confirmed positive cases and Pima County had 1,602 cases, according to the state health department.

Maricopa County needs more test supplies and more personal protective equipment in order to test more people, spokesman Ron Coleman said. The county has done “some form of contact tracing” for the contacts of confirmed positive cases, but it hopes to do more.

The goal is for the county to return to “traditional public health contact tracing,” in which an investigator talks to each and every contact, rather than the “mediated contact tracing” it has been doing, where investigators still interview the positive case but ask them to provide information to the contacts themselves.

County health officials announced April 23 plans to ramp up contact tracing up to 10 times its current capacity of 25 employees, using CARES Act funding from the federal government. Some job positions have been posted and the county will continue to recruit, interview and hire until targets have been met, Coleman said.

Interested applicants can apply to open positions posted online. Applicants are screened and some will be interviewed. Once hired, employees will receive general training on COVID-19, contact investigations and county orientation, followed by “specific job training lasting many weeks,” Coleman said.

In Pima County, testing is still not adequate, according to interim health director Dr. Bob England. The situation has improved, but facilities are still having to prioritize who to test, he said.

For contact tracing, the county has focused mostly on notifying and tracking household and other close contacts rather than the traditional contact tracing of reaching everyone who might have been infected. England said for an infection as common and widespread as the new coronavirus, microlevel contact tracing doesn’t make sense practically. If COVID-19 is infecting 5% of the population, truly aggressive contact tracing would mean most of the population would be under some sort of quarantine or surveillance, England said.

“At some point, it just doesn’t make sense because so many people have been exposed to this,” he said.

Without better testing to get a more accurate sense of how many are infected, contact tracing beyond household members may not be very effective, England said.

“When you realize that it’s growing and you only know about one case in 50, there is no point in doing contact tracing when you’re missing 49 out of 50 initial cases. Then all you can do is blanket education, blanket warnings and the kind of social mitigation that you saw put in place,” England said. “If you don’t know about most of the cases, contact tracing is worthless. You’re preventing very little.”

A handful of county health departments told The Arizona Republic they are doing fine in terms of testing supplies and contact tracing resources.

Apache County (the southern part, excluding the portion in Navajo Nation), Cochise County and Graham County indicated that officials have an adequate testing supply to test everyone who needs it.

And officials with Pinal, Yavapai, Cochise, Apache, Gila, Mohave, Graham and La Paz counties said they are currently able to carry out full contact tracing investigations, including interviewing positive cases and providing guidance to potentially-infected contacts.

Contact tracers in Graham County even follow up daily with phone calls to contacts, said Brian Douglas, director of the county health department.

Health departments in Yavapai, Cochise, Apache and Gila counties said they have additional resources and trained staff ready to do contact tracing if case numbers increase. Gila County can even handle three to four times its current case load and still continue contact tracing, according to COVID-19 incident commander Joshua Beck.

If cases spread, Pinal County will need more assistance and more trained investigators, spokesman James Daniels said. Apache County is in the process of training more investigators in case they’re needed.

Other counties are finding that test supplies and contact tracing resources are inadequate to meet the demand.

Contact tracing, in addition to testing and isolation, are the key factors needed to safely reopen society and the economy, said Michael Worobey, head of the University of Arizona Department of Ecology and Evolutionary Biology and an infectious disease expert.

Worobey said some places largely gave up on contact tracing as soon as they had more than a few cases.

“I think there is a bit of a kind of defeatist attitude, of ‘Oh well, there’s so many people infected now that it’s too late to do contact tracing,’” he said. “That is not the case. It’s not too late and, in fact, testing, tracing and isolation is our only route, other than a vaccine, to getting life something closer to normal and saving the economy.”

Pinal County does not have enough testing — both diagnostic and antibody — available because of supply chain issues. The state has provided some diagnostic test kits, but it hasn’t been enough, Daniels said.

Other counties, such as Yavapai, have been boosted by the state’s weekend testing blitz program, but still lack the ongoing test kit supplies needed to address outbreaks in certain locations.

The outbreak at Mingus Mountain Academy would have benefited from more test supplies, for example, said Terri Farneti, a spokeswoman for the Yavapai health department.

In Gila County, symptomatic people are able to get tested, but there are not enough supplies to test close contacts or others who may have come into contact with a positive case, Beck said.

“We are not anywhere close to being able to test according to the current standing orders,” he said.

La Paz County is able to stay afloat with its contact tracing and can monitor the symptoms of contacts for 14 days. There’s worry that if case numbers increase because of the testing blitz, the county could become overwhelmed. La Paz also expected to receive an Abbott rapid test machine from the state, but it never arrived, spokeswoman Jenna McDaniel said.

Graham County Supervisor Danny Smith said he was surprised when the county got its first case that the state health department didn’t seem to be emphasizing contact tracing as much as it has with other outbreaks in the past, such as tuberculosis or whooping cough.

“In this situation, I believe there seemed to be a ‘the cat’s already out of the bag’ belief or approach” from ADHS, Smith said in an April 24 interview with The Republic.

It seemed like the state health department thought the county’s plan for extensive contact tracing was beyond what was needed and may not be fruitful, he said, but the county continued its efforts.

Smith said the county contacted the parents of about 160 fifth- and sixthgraders because of possible exposure at an elementary school. The Graham County Health Department held a clinic to evaluate and test students at this school, a Facebook post from the county shows. The county asked the students to voluntarily stay at home.

Smith said he believes the county’s efforts on contact tracing and testing people who may have been exposed prevented further spread. He said it has been interesting to see increased discussion of the importance of contact tracing in recent weeks, given the earlier message. But Smith acknowledged that people and agencies around the world were caught off-guard and were overwhelmed by the new coronavirus.

“It just felt like we were talking to a different agency, someone we had never talked to before, in their approach to contact tracing in the beginning,” Smith said. “It was like, who are these people and what have you done with the Department of Health Services? I think they were just overwhelmed.”

The Graham County Health Department and the Arizona Department of Health Services did not respond to requests for comment on Smith’s claim.

The Department of Health Services announced last week a new statewide system to aid contact tracing at the county level. Contacts will be able to report symptoms for their 14-day period through a secure electronic system by phone, text or online.

“This will allow our health departments to work efficiently to collect this information,” the department wrote in a blog post.

The department said it was also beefing up its contact tracing workforce by training state employees, working with universities to use faculty, staff and students and partnering with the CDC Foundation for attracting and training new contact tracers. The plan is to staff up to 40 teams of “public health investigators that can be deployed statewide” to help local health departments, according to the blog post.

A number of counties said the state has been helpful in providing some supplies such as testing materials and personal protective equipment, but that they haven’t yet seen any progress with the contact tracing system or assistance.