Officials racing to perfect contact tracing
Possibility of virus resurging in the fall adds urgency
Four months after coronavirus swept into Connecticut and threatened to overwhelm hospitals, state and local public health officials are working the bugs out of a contact tracing program they hope will isolate and squash any viral hot spots that arise from the reopening of schools or a general resurgence in the fall.
“Contact tracing, right now, is like building the airplane while we’re flying it,” said Charles Brown, health director of the four-town Central Connecticut Health District south of Hartford.
“We really are trying to figure out what’s the best way to do contact tracing on a large scale and in ways we’ve never done it before. And we got lucky, because we actually have very few cases right now while we’re figuring it out.”
The purpose of contact tracing now, with the viral outbreak under control, is to prevent any resurgence — at least temporarily.
The goal for public health officers is to move quickly to identify people who test positive for a disease and persuade them — and those with whom they have had close, recent contract — to selfisolate until the threat they pose of passing on infection has passed.
The system that has evolved in
Connecticut after three months of fine tuning has as its leading edge the local network of 64 municipal and regional health directors that — although long underfunded and ignored politically — continues to be an essential element of state disease prevention efforts.
Under the evolving plan, whenever a state residents tests positive for a COVID-19 infection, the result is supposed to automatically load into a new software application acquired by the state, which in turn is supposed alert local health directors of new cases in their districts. The health directors then are expected to personally notify the newly infected people — known as cases — as well as all those on a list of recent close contacts provided by the cases.
Should a surge in infections begin to exceed the capacity of local directors to make notifications, the new state software application has the capability to alert new cases and their close contacts through telephone text and email messages based on questionnaires filled out by those testing positive.
The state also is recruiting volunteer tracers to work with the local directors on personal notifications in the event of a surge, although several directors question how effective the volunteer recruitment effort has been.
The challenges local districts are facing underscore how the state’s long-term financial shortcomings over the years have hurt the response — in part because the state’s information technology infrastructure is decades behind the times.
“The sad part of this is, you should not be building a statewide system in the middle of a pandemic,” said Jennifer C. Kertanis, director of the ten-town Farmington Valley Health District and president of the National Association of County and City Health Officials. “We should have been investing in an infrastructure that provided that from day one — for lots of other purposes as well.”
Kertanis said the sparsely staffed health districts are entitled to state subsidies set by law and based on district population, but in fact have received less for years. Several health directors said they were told their upcoming subsidies were further at risk if they failed to sign onto the new contact tracing software — software many were initially reluctant to adopt. What’s more, the directors complain they have been shortchanged by the state’s allocation of the tens of millions of dollars collected from the federal government for virus remediation.
In spite of short staffs and budgets, the directors are at the forefront of contact tracing because of their intimate knowledge of their communities and constituencies. While contact tracing, they are working with school districts to complete reopening plans by the end of the month and continuing to do an array of routine duties, from septic inspections to food safety inspections.
Something everyone in public health can agree on is that the current low rate of coronavirus transmission in Connecticut has given public health officers at all levels a lull during which to work out the deficiencies in the contact tracing plan. The rate of viral spread has been increasing recently but has been hovering around 1.0 over the last week or so. Below 1.0 means it is contracting rather than expanding.
“I think when you are trying out something new, the less pressure you are putting on a system the better because that gives you more time to devote to each case in learning how to use the system,” said Kristen Soto, the state health department epidemiologist who has been the administration point person on contact tracing.
The Lamont administration began scrambling to put together a contract tracing program in midMay, when public health officials were beginning to gain control over the virus through a statewide shutdown, but remained concerned that a resurgence could again threaten hospital capacity.
The state obtained, at no initial cost, the Microsoft Corp. contact tracing software known as the At Risk Investigation and Alerting System, or ARIAS. After just a hurried week of testing, the state rolled out the software and pressed local health directors to sign on and train staff to use it.
Positive test results from medical labs and health providers were to be entered into the state Department of Public Health electronic disease surveillance system, a continuously updated data bank of reportable diseases that includes COVID-19. Positive results were to transfer automatically to the ARIAS platform for distribution to the appropriate health districts.
The software gives local directors a choice between notifying those who test positive with a personal telephone call or by relying on the system’s text or email function to deliver notifications and ask for completion of questionnaires about recent close contacts.
Most local directors prefer making personal calls to people who they knew by experience are usually frightened and confused. They said the “personal touch” also is proving more effective in persuading people to answer questions about their personal interactions and close contacts.
The experience reported so far by the health directors suggests personal calls are more effective. Several said 90% or more of the text and email notifications delivered in their districts have been ignored.
In the weeks since the rushed, mid-May roll-out, the software has been tweaked, debugged and modified in ways that the health directors said has made it a more effective tool.
“We provided feedback to the state,” Brown said. “And they finally got it to the point where I think it is a workable system. It is still changing. But I think they are managing those changes a lot better.”
Among other things, software modifications have allowed the collection of more detailed data, such as infections among family members and symptomatic versus asymptomatic cases. The Department of Public Health also is designing a caller identification element that lets recipients know that text messages and emails are not spam, but official health department notifications. Soto said the governor’s office had discussed a public service campaign to let the public know about potential coronavirus calls and notifications.
Officials also continue to work on decreasing the time between when a person is tested for the virus and when positive results are entered into the system and available to local health directors for notifications. The longer a person is unaware of a positive test, the more time the person has to infect others. Local directors said they are still experiencing unacceptable lag times of as much as a week between test and data entry.
There is also concern about how many volunteers will be available to assist local health districts should the need for tracing pick up in the fall. Lamont spoke in the spring about recruiting hundreds of student volunteers from state medical schools.
Soto said last week that the state health department identified 935 people who are trained and ready to help trace in the fall — about 150 of whom are student volunteers. The local health directors are largely skeptical of the state’s numbers and several are trying to arrange their own pools of volunteers.
In general, local health directors say the system is working for them. Soto said it gives epidemiologists at the state level a broad, evolving view, in real time, of what is happening across the state in terms of infection patterns and the efficiency of the public health response.
“What this software allows us to do is communicate seamlessly across jurisdictions,” Soto said. “We are still working and making additional improvements as suggestions come in. But are also really confident right now that we are in a good place where we are able to meet all of the minimum criteria needed to effectively conduct contact tracing. Anything else we are doing is really fine tuning to make things work a little bit better, both for members of the public as well as for local health departments and state volunteers that are actually using the system.”