Answer your phone!
While many of us in recent times have stopped answering calls from telephone numbers we don’t recognize, these days the unknown caller may be a contact tracer trying to talk to you about coronavirus.
In the absence of a vaccine, the challenging effort to reach people who have tested positive for COVID-19, persuade them to self-isolate – and then to track down anyone they may have exposed to the disease – may be the last remaining hope of containing the pandemic short of another lockdown.
The people making these calls – 33 in Indian River county and 1,600 in Florida – are employed by the Health Department as contact tracers. Six hundred more investigators and tracers are expected to be hired by a private company engaged by the state.
When a person is tested for coronavirus, they put their phone number on their testing form, and labs are required by law to pass these on to the Health Department, along with results.
The head of the CDC, Robert Redfield, testified before a congressional subcommittee last week that 100,000 contact tracers are needed nationwide, four times the current number, to do what’s needed with those who are testing positive.
In Florida, that means the battalion of 1,600 tracers needs to be expanded to 6,500. And that’s just a starting point. For Wuhan, China, to bring COVID-19 under control, it took one tracer for every 1,000 people. That translates to 21,500 for Florida alone.
With the rise in cases statewide, hospitals at the brink and six-hour waits for testing in some places, the contact tracing effort appears woefully inadequate for the task at hand, but local officials dispute that.
In Indian River County, the number of contact tracers at the Health Department has more than doubled since the end of May. That puts the ratio of tracers to residents at 1 per 4,500, three times more than the state’s ratio of 1 per 13,400, and local health officials say they are sufficiently staffed at present.
“Department of Health-Indian River has enough staff to meet the current need for contact tracing,” said spokeswoman Stacy Brock. “Should the need arise for additional staff, the Department will reassess.”
The department “makes contact with every positive COVID-19 case,” Brock said, adding that cases are updated as new data is uncovered during the investigation.
But the most immediate concern, as an investigation opens, is to find out who may have been exposed to the infected person, which means asking them to recall what they did and who they saw starting two days before their symptoms began.
Just as important is finding out how to reach those close contacts, the start of an effort to “box in” the virus until it dies out for lack of new victims.
The triad of identification, isolation and contact tracing is considered critical to limiting spread, the next best step after social distancing and mask wearing. But so far, it is failing, according to Dr. Anthony Fauci, who addressed the issue of contact tracing in a federal task force briefing Friday.
Fauci blames the public’s distrust of the government for a lack of cooperation in at least half the calls tracers make, and suggests more tracing should be done door-to-door – a far more expensive and risky proposition.
The CDC considers a “close contact” anyone who was within 6 feet of the infected person for at least 15 minutes – regardless of whether either was wearing a mask (unless it was an N-95 respirator) – starting from two days before illness onset, or, if the positive case is asymptomatic, two days prior to getting tested.
The closer the contact and the longer the exposure time, the greater the risk, the CDC says. Risk also goes up if the positive person had symptoms like coughing.
The CDC suggests tracers use everything from license plate records to social media – even frequent shopper cards, though it doesn’t explain how that would work – to help locate those close contacts at risk of disease. The aim is to find them quickly and help them self-quarantine without infecting anyone else, including family.
Many of the new hires in the on-going contact tracing expansion are students earning degrees in health-related fields. After a brief training period, the HIPAA-certified tracers are deployed to areas with surging COVID-19.
Some, like Victoria Johnstone, a master’s degree candidate in public health at the University of Florida, have been staying for weeks in hotels at state expense.
In Palm Beach County, “we’re very short staffed,” said Johnstone, who called the crush of new cases there “insane.”
After arriving in May, Johnstone, who says she can manage 80 to 100 cases a week, said last week she was looking at a backlog of “four, five, six days.”
That delay is tacked on to delays at labs recently overwhelmed by testing. By the time case investigators are calling the patient, it could be two weeks since the COVID-19 swab was taken – too late to prevent exposure when the person was the most contagious.
“Sometimes they’re not getting their results back at all,” says Johnstone. “So, they’re not even isolating.”
Building trust is key to the work of a contact tracer. The patients need to be reassured that their identity won’t be revealed to the people they name as contacts.
The contact tracer is trained not to be judgmental. Often, COVID-19 positive patients are embarrassed that they didn’t follow social distancing rules, or took a risk they shouldn’t have taken, or have been somewhere they shouldn’t have gone. “Depending on how you ask the question, most of them will only say they’ve been to Publix,” says Johnstone.
They are also afraid of being stigmatized for potentially infecting others. “And people don’t want to throw their friends under the bus.” If any of those concerns means they won’t talk to investigators, the contact tracing is over.
“All aspects of case investigation and contact tracing must be voluntary, confidential and culturally appropriate,” CDC guidelines say.
Overall, Johnstone estimates she reaches 70 percent of the people on her list. That’s despite a lot of disconnected numbers and incorrect information on the lab’s form.
She lays out a typical contact tracing call. “If they haven’t already tested positive, we say, ‘Someone you have been in contact with in the last 14 days has tested positive.’
“Typically, they already know who it is. It’s usually not secret in their friends’ group. So, we have to ask, ‘Have you gotten tested?’ And if they say no, we’ll ask, ‘How are you feeling?’ If they say fine, we may say, ‘Well, I recommend quarantine.’
“At this point, since their lives haven’t been affected, that’s kind of where it stops. They’re locked in. And I get it. No hard feelings.
“We can only ask so much from them,” she says. “We can’t force them to do anything. We have to respect people’s boundaries.”
There are incentives for cooperation, though.
People isolating with COVID-19 and their close contacts who are quarantining at home may be eligible for paid leave; the contact tracers can help them find out about that. They may be offered help with grocery delivery, laundry services and sometimes even housing.
Johnstone told of a case in which a woman who tested positive was kicked out of her apartment by her roommate. Homeless, she was found a room to stay in by the health department.
“You have to have a level of emotional intelligence, especially when they haven’t seen your face before,” says Johnstone. “I have had a hard time with the population in south Florida. There are people in agriculture who are undocumented that don’t want to talk because they don’t feel comfortable. Our interpreter tells them absolutely contact tracing isn’t going to expose you. No one’s going to come after you, but it’s hard for them to understand that.”
While identification of cases has greatly expanded through increased testing, the investigation into cases is stalling because “the dots are not connected,” as Fauci put it.
People are being infected through community spread, but many are asymptomatic – their dots don’t even get noted without widespread screening testing. Those who are tested may not be responsive to the contact tracer’s call.
“Maybe half of the people don’t even want to talk to someone who they think is a government representative,” said Fauci. “If you live in a community that is mostly brown or black … maybe 70 percent of them don’t want to talk about it.”
Another problem Fauci pointed out is that even when a close contact is identified, “you don’t isolate them because you don’t have the facility to isolate them. That is what’s not working.”
