By Tara Gibson - July 1, 2020
Prior to the coronavirus COVID-19 pandemic, only a very small proportion of the public health workforce was engaged in contact tracing. Now, as states start to reopen, the race is on to hire tens of thousands of disease detectives.
Contact tracing is a strategic mitigation tactic that, in the past, has been used to track outbreaks of infectious diseases such as tuberculosis and Ebola. As infectious diseases of this nature are rare in the US, most public health departments employ only a handful of epidemiologists to detect, identify, and respond to emerging health threats. According to data collected in 2017, of 3,369 epidemiologists employed by public health departments, only 55% were engaged in infectious disease control.
Consequently, when the first reported U.S. case of coronavirus COVID-19 was confirmed in Snohomish County, Washington, the sole epidemiologist assigned to control communicable diseases in the county’s public health office was quickly overwhelmed. Although the patient lived alone and drove to work, he had shared lunch with seven colleagues when his symptoms first manifested, and thirty-eight other patients were waiting for consultations when he attended his local health clinic.
Colleagues quickly pitched in to help the epidemiologist trace as many of the patient's contacts as possible to advise them to self-isolate and get tested. Healthcare workers who had been in contact with the patient before his test was confirmed as positive - and other patients they had treated - also had to be contacted; and soon 30 of the Snohomish Health District's 133 employees were engaged full-time in contact tracing and follow-up calls - all because of a single infected patient.
However, the success of contact testing in the fight against the coronavirus COVID-19 pandemic is reliant on the fast identification of people who have been in contact with an infected person, and testing them to see whether they have also contracted the disease. Due to the speed at which cases multiplied throughout February, and due to the non-availability of reliable testing, the resources simply didn't exist for contact tracing to have any impact on the transmission of the disease, and the tactic was abandoned.
The subsequent locking down of communities in most states reduced rates of transmission; and, although the reliability of COVID-19 testing is still questionable, many states believe the best way to prevent further waves of infections is to resume contact tracing at a scale never before seen. For this reason, states are recruiting and training tens of thousands of disease detectives - although experts believe the number required nationwide could be as high as 300,000 due to projected infection rates.
The number of contact tracers required by each state is fluid depending on the population of the state, the intended number of contacts per case (i.e. interviews, notifications, follow-ups, etc.), and the number of COVID-19 cases per 100,000 population reported in the past fourteen days. To help states determine how many disease detectives are required at any given time, the George Washington University has developed an easy-to-use Contact Tracing Workforce Estimator.
The manner in which disease detectives work will also be subject to the state in which they are located and the technology being used. For example, the states of Alabama, North Dakota, South Carolina, and Virginia have indicated they will by running contact tracing operations around exposure notification apps developed by Apple and Google, while states such as Utah have reduced the workload of contact tracers by developing their own location tracking apps.
Nonetheless, the work is not easy. The initial interview call can take up to thirty minutes according to the script given to contact tracers in Massachusetts, and contact tracers providing notifications of positive test results will have to be sensitive in how they deliver the news. It will also involve a steep learning curve for non-medically trained tracers, as epidemiologists at public health departments usually undergo a year's training, whereas COVID-19 contact tracer training can be as short as a day.
While some state health departments are centralizing contact tracing operations - so there is one operation covering the whole state - others are delegating operations to county health departments; and it is at this level that issues such as inadequate recruitment, inadequate testing, and inadequate technology are more evident. For example, some counties in California have only recruited and trained two contact tracers per 100,000 population - way below the state's requirement of 15 per 100,000.
Although it may not be important how many contact tracers a county has if the rate of infection remains low, it is essential each county has adequate testing capabilities. Again, many counties in California are failing to meet the state's minimum benchmark of 150 tests per 100,000 residents per day; and, as the testing rate is a contributory factor for counties progressing into later phases of reopening, the failure to test populations for coronavirus COVID-19 may also be damaging the health of local economies.
With regards to technology, the scale of contact tracing required to prevent further waves of infections means it is not feasible to rely solely on phone contacts and manual caseloads. The state of California is planning on rolling out a platform that will “facilitate communication between state and local contact tracing teams and allow ongoing, automated monitoring of cases and contacts” - but it hasn't arrived yet.
Possibly more of an issue across all state and local health departments, is the public's lack of willingness to be contact traced. According to an Axios-Ipsos survey, only 51% of Americans would voluntarily participate in a contact tracing program if it was administered by the CDC and/or public health officials, with 35% or less Americans willing to participate in a contact tracing program if it was administered by a cell phone/Internet service provider, tech company (i.e. Google), or the federal government.
Over time, the issues of inadequate recruitment and inadequate testing will likely be addressed as CARES Act funding filters down from state governments. It is also likely procedures will be introduced to redeploy trained contact tracers from well-covered counties to less well-covered counties as localized outbreaks occur. However, for contact tracing programs to be effective, there needs to be scalable communication solutions in place that are easy to use and that people can trust.
A comprehensive mass notification solution overcomes the issue that 20% of the population doesn't own a smartphone (and are therefore unable to download contact tracing apps) by sending messages via multiple communication channels. State and local leaders should look into platformsdesigned for ease-of-use, and that has advanced reporting capabilities to provide public health teams with the level of monitoring required to keep on top of cases and contacts.
Geo-targeting capabilities within a mass notification solution can be used to overcome trust issues. Where contact tracing programs are already up and running, scammers have been posing as contact tracers to extract personal information and sensitive data. Consequently, the public has become more reluctant to engage with genuine contact tracers. With a mass notification system, public health departments can alert communities to a localized outbreak and advise that genuine contact tracers may be in touch.
With regards to privacy, our solution has been developed by the same team that developed the Smart911 system, which securely maintains the data of more than 45 million citizens. State and local governments will find it easier to engage with community members that are already using Smart911 safety profiles to protect themselves and their families when it comes to notifying them of an infected contact, encouraging them to self-isolate, and get tested. Contact us today to find out more.
Tara is a Marketing Coordinator on the Rave Mobile Safety marketing team. She loves writing about all things K-12, State & Local, Higher Ed, Corporate, and Healthcare, and manages the Rave social media channels. When she's not working, she's taking care of her smiley, shoe eating, Instagram-famous fur baby, Enzo!
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