Statewide contact tracing set to launch
WASHINGTON — Every day over the past week, hundreds of people in Massachusetts received phone calls alerting them they may have been exposed to someone who now has tested positive for coronavirus. They were advised to isolate themselves and referred to testing.
This process is known as contact tracing,
and it's a standard public health tool to limit the spread of infectious diseases. But it's costly, time and labor intensive. Massachusetts is now the only state conducting contact tracing on a statewide basis for COVID-19.
Now, other states are making plans to follow suit as they prepare new strategies to tamp down the virus and slowly reopen their economies. Connecticut has already started crafting its new contact tracing plan, in conjunction with Gov. Ned Lamont’s Reopen Connecticut Advisory Group, said Matthew Cartter, state epidemiologist.
China and South Korea have used cell-phone apps that track people's movements and notify them instantly if someone tests positive for coronavirus who they have been in close proximity to. The apps have come under public scrutiny for data protection and privacy issues. Singapore has also launched an app.
Although slower, the U.S. is opting for the manual, human approach. Dr. Deborah
Birx, White House Coronavirus coordinator, said Thursday night while the new White House guidelines on reopening, the Centers for Disease Control and Prevention will be sending staff to "every single state" to partner with state and local officials to ensure that all of coronavirus cases are "immediately identified and contact traced."
"We do have enough testing capacity to do both that surveillance piece, as well as the diagnostic piece and contact tracing," Birx said.
Connecticut was doing contact tracing at the start of the state's outbreak. But as the state's coronavirus cases skyrocketed into the thousands, state and local health officials were overwhelmed and too understaffed to keep up.
Contact tracing has continued in pockets of Connecticut, where local resources and cases numbers permit, Cartter said.
“It is very difficult to do contact tracing when there is widespread community transmission of COVID-19 and COVID-19 testing remains limited,” Cartter said.
“Widespread community COVID-19 testing and contact tracing will happen once we pass the peak of COVID-19 transmission — on the downward slope of the pandemic curve. This will be needed to drive the curve to close to zero.”
One of the active large contact tracing efforts in Connecticut is in New Haven, where the Yale University School of Public Health is helping the city of New Haven and Yale New Haven Health locate people who have been near confirmed coronavirus patients.
The Yale School of Public Health started its contact tracing efforts three weeks ago and has trained about 100 faculty and students, including public health, nursing and medical graduate students, to do the work, said Sten Vermund, dean of the School of Public Health.
“We have a group called the Emerging Infection Program,” said Vermund. “This has been going on for at least 20 years and is a partnership between the state of Connecticut, Yale School of Public Health and the CDC in Atlanta. Because they have been working with the state Department of Public Health and CDC, they have had contact tracing experience, particularly for food-borne outbreaks.”
The Yale contact tracers interview COVID-19 patients to make a list of people with whom the patients interfaced for more than five minutes within six feet distance in the past few days. The interviewing process can be difficult and sometimes impossible if the patient is too ill to communicate, Vermund said.
Then, the contact tracers must gather or find contact information for the listed people and then call them to warn them they may have been exposed to the virus. The exposed individuals are counseled on testing and quarantine, as well as local resources. Yale students and faculty created a standardized script for the contact tracers to use and developed a data collection system.
As of Monday, the team had interviewed 73 Yale New Haven Health coronavirus patients and contacted 78 of the people they may have exposed, data shared by Vermund indicates. They also interviewed 208 patients referred by the city of New Haven and contacted 173 individuals who may have been exposed.
Massachusetts launched its statewide contact tracing operation on April 3 by engaging Partners In Health, a Boston-based international health nonprofit that works on health systems and disease control in poor countries. The state contracted Partners in Health for $44 million to lead Massachusetts contact tracing effort, with Accenture and Salesforce providing support center capabilities.
Partners in Health is hiring 1,000 people to do contact tracing in Massachusetts, a few hundred of which are already working. Vermund predicted Connecticut would need about 1,000 contact tracers for a statewide operation as well.
In Massachusetts, contact tracers are paid $27 hour to work on their personal computers from home. They follow very similar procedures to the Yale contact tracers. The Massachusetts teams started this work on April 11.
Currently, only 2,200 disease investigation specialists are employed throughout the U.S. in local and state health agencies, according to the Association of State and Territorial Health Officials. The Centers for Disease Control has staff to assist with disease investigation efforts, but the work is generally led by employees at the state and local level.
"We need substantially more contact tracing staff at the local, county, state and national level," said David Holtgrave, dean of the School of Public Health at the University at Albany. "As the economy is reopened, this need will increase rather than decrease because there will be a pressure to identify new cases of COVID-19 very rapidly and to fully get in touch with all persons who may have been exposed to the persons just diagnosed and substantially more staffing will be needed to do so. This will be a major public health challenge to address at all levels as we move forward."
Based on preliminary research generated by Johns Hopkins University, it’s believed an additional 100,000 contact tracing employees are needed to address COVID-19 in the immediate future, ASTHO advised members of Congress in an April 10 letter. Moreover, a minimum of 1,200 more epidemiologists are needed across the country, ASTHO said.
States are unlikely to be able to afford on their own to build contact tracing operations of the size needed for coronavirus. They already face other inflated health care, emergency response and unemployment costs, at a time the epidemic is driving tax revenues down. Due to state revenue shortfalls, some state health departments have been forced to furlough staff, ASTHO said.
ASTHO asked Congress to supply $3.6 billion in emergency funding for contact tracing, although with amping up CDC funding by $4.5 billion a year to improve disease surveillance, laboratory capacity and preparedness. The Association also requested that the federal government wave student loans for people working for or hired at state and local health department to help expand the workforce.
Congress is still negotiating and drafting its next coronavirus legislation and it's unclear whether these measures will be included.
Some public health experts have also advocated for states to stand up temporary facilities where individuals whose housing situations do not permit them to isolate can quarantine or where people can receive moderate health care, as a step down from hospitals. People who are contacted by contact tracers could be referred to such facilities on a voluntary basis.
Hotels and college dormitories that are now empty, or temporary facilities in convention centers and gymnasiums could be deployed in such an effort. It's not yet known if Connecticut will use the strategy as a complement to contact tracing.
Developing contact tracing operations, expanding testing and creating patient quarantine and monitoring options will be important not just for reopening, but for a possible resurgence of the virus in the fall or winter, prior to the development of a vaccine, public health officials agree.
"Will we better prepared?" asked Vermund. "Will we able to surge in our ICU potential? Will we be able to do widespread testing and contact tracing? Will we have drugs that are available that can mitigate the severity of disease? ... if we don't have these measures prepared for the next wave, we may find ourselves in an analogous situation."