Contact tracing hampered by testing delays, lack of trust
WASHINGTON - Contact tracing may be the last, best hope short of a vaccine to stop the spread of the novel coronavirus. But the time-tested method of containing infectious diseases has been hobbled by testing delays, a lack of money and official support, and poor cooperation from a public wary of giving information to authorities.
Those challenges are preventing public health professionals in many places from reaching enough newly infected people to reduce transmission, raising the specter that more states will be forced to close businesses again.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, conceded in a late June news conference that nearly half of the people whom contact tracers call don't answer the phone because they don't trust the government.
The effort has not been helped by President Donald Trump, who has shown indifference and hostility toward the recommendations of public health authorities, including those within his own administration.
In recent days, he shared a tweet by a former game-show host accusing the federal Centers for Disease Control and Prevention of lying about the pandemic. Trump also stripped the agency of its authority to collect crucial data on the virus from hospitals.
Public health officials say the president's broadsides are making contact tracing even harder.
"The best thing people can do is at least answer the phone," Cleveland Public Health Director Merle Gordon said in an interview. "Please answer the questions and understand we are calling for a reason. Cooperation and a little kindness is so appreciated."
A bill in Congress, approved by the House but stalled in the Senate, would provide $75 billion for testing and contact tracing and call on the CDC to develop a national evidence-based strategy for testing, surveillance, contact tracing and mitigation of the virus.
In the meantime, city and county health departments have been left to hire and train thousands of disease investigators on their own, even as case numbers shoot upward. In many states, funding and support from governors have been lacking.
Despite these challenges, public health professionals contacted by Stateline said they remain committed to reaching every resident who tests positive for the virus within 24 to 48 hours, learning whom they have been in close contact with and reaching them to ask that they isolate before they infect others.
Overstretched public health officials contacted in Arizona, Maryland, Ohio and Texas said they were working long hours with no breaks, while hiring and training more and more contact tracers and support staff to battle a pandemic that is not abating.
"The problem is that in many places, elected officials reopened too early, when contact tracing was not fully up and running," said David Harvey, executive director of the National Coalition of STD Directors, which represents state and local contact tracers. That forced local health departments to quickly hire legions of new disease investigators, many of whom lacked training, he said.
At the same time, the promise of digital contact tracing - in which cellphones would be used to alert people who come in contact with a person who has tested positive for the virus - hasn't panned out.
Three states - Alabama, North Dakota and South Carolina - have announced plans to use the smartphone technology developed by Google and Apple, and experts predict privacy concerns will limit their success. Nearly three in five Americans say they are unwilling or unable to use the smartphone alert system, according to an April poll by The Washington Post and the University of Maryland.
So far, only seven states - Alaska, Massachusetts, Montana, New York, Oregon, Vermont, West Virginia - and the District of Columbia have managed to hire and train the recommended number of disease investigators to curtail community spread of the virus, according to a July survey by NPR.
The country needs at least 30 trained disease investigators per 100,000 residents to tamp down transmission of the virus while allowing people to move about in the community, according to the National Association of County and City Health Officials.
Nationally that equates to roughly 100,000 contact tracers. When the pandemic squarely hit the United States in March, only about 2,000 federally funded and few state or local disease intervention specialists were conducting contact tracing on other infectious diseases in the nation's more than 3,000 health departments.
Now some 40,000 people with varying levels of training are on the job - still under half of what's needed. Massachusetts and New York reached 30 per 100,000 through contracts with large private organizations.
That's a strategy that some public health experts cautioned could create administrative confusion and lack of trust, because many new hires are unfamiliar with local communities, and the information systems used by large private organizations often don't work with old technology used by local health departments.
Nationwide, a recent shortage of testing supplies combined with scorching heat in much of the country - which limits the number of hours public health workers can stand in parking lots filled with idling cars - means not enough people, particularly those who are asymptomatic, are being tested.
On top of that, test results are often taking seven to 10 days or longer. Those delays, and the failure of respondents to answer public health department calls, push back contact tracing, sometimes to the point where it no longer does any good.
At a minimum, lengthy delays between the onset of infection and when tracers reach infected patients strains people's memories of where they were and whom they encountered.
That is among the challenges occurring now in Arizona, which is experiencing one of the sharpest increases in new cases, said Will Humble, the former director of the state's Department of Health Services and now executive director of the Arizona Public Health Association.
Not only is there a shortage of tests in Arizona, but some labs aren't reporting results for more than a week, often after those testing positive are no longer infectious.
"With slow turnaround times, none of your case investigations or contact tracing will be effective because eight days have gone by, and they've already infected their roommates and friends," Humble said. "It won't do any good because you're conducting it after it matters."
Dr. Kristen Pogreba-Brown, an assistant professor of epidemiology who runs a contact tracing program at the University of Arizona that is assisting Pima and Maricopa counties, agreed.
"Our biggest challenge in contact tracing in Arizona is delays in testing," she said. "When you don't get results for two weeks, contact tracing can't reach its true purpose."
In Houston and surrounding Harris County, test results are not only delayed, but many are also incomplete, according to Sam Bissett, the agency's communication specialist.
Many test results have no phone numbers, addresses or demographic data, he said, which severely hampers epidemiological sleuthing. Test results for children are of particular concern, he said, because most contain only the child's name and birth date, with no phone number or address for the parents.
Dr. Letitia Dzirasa, Baltimore's health commissioner, said that testing turnaround times hadn't been a problem for the city until recently, when the labs the city used began receiving many more test kits from areas of the country experiencing surges. Wait times for results have now stretched from two to three days to five to seven days.
People with symptoms are typically given priority. That means too few tests are being conducted on pre-symptomatic or asymptomatic people who may be unwittingly infecting others, said Dr. Abdul El-Sayed, a Michigan epidemiologist and a former Detroit health commissioner.
As many as 40 percent of those infected with the virus have no symptoms, representing a huge number of people who may not be reached by contact tracers. "Those are the people whose tests would tell us the most if we're really concerned with stopping the spread," El-Sayed said.
"Contact tracing is an art form," said Dr. Georges Benjamin, director of the American Public Health Association. "If you want people to do things they may not want to do, such as provide personal information, you have to create an environment of cohesion and oneness.
"If you create an environment where people are at each other's throats and have huge differences in their views about the causes and solutions to the pandemic, people aren't going to trust the government," he said. "Clearly a lack of trust has been created by elected leaders in some places."
Often that lack of trust is expressed in the most basic way.
"Many people are just not answering a call from an unknown number," said Baltimore's Dzirasa. In addition, many of those reached by tracers are wary of giving information.
"Maybe they're concerned about privacy or talking about their whereabouts or who they were with," said Darlene Bhavnani, an epidemiologist at the University of Texas at Austin who runs a contact tracing program in heavily affected Austin. "That is an ongoing challenge."
To gain the public's trust, health departments have put out messages assuring confidentiality and explaining why contact tracing is crucial to stemming the pandemic.
Pennsylvania is using Twitter and other social media to warn people about scammers, informing them that legitimate contact tracers will not ask for certain data, such as Social Security numbers or financial information. Some places, like Maricopa County, Arizona, are using text messaging, hoping it will be more effective in reaching young people.
California, Georgia and Pennsylvania have created animated videos.
Language barriers also can be a problem. Bhavnani said she's working to hire more Spanish-speaking tracers, not only because people are more likely to give information to someone who speaks their own language, but also because it's quicker.
"When you use translation services, it can double the length of a call," she said.
Early on, Bhavnani's tracers made at least six attempts to reach people by phone, but because of expanding caseloads they've had to cut that to three. Still, Bhavnani said that her contact tracers have been able to reach 70 percent to 80 percent of those with positive test results and 75 percent of the people they came into contact with.
Adriane Casalotti, chief of government affairs at the National Association of County and City Health Officials, said, "A lot goes into building trust with the individual.
"You're talking to them and giving them critical information at a very vulnerable moment. We know people are dying from COVID. It's very scary."
The recent surge in cases in Arizona, Florida and Texas is outpacing the capacity of contact tracing to achieve its promise of containing the virus.
It's a numbers game, Arizona's Humble explained. "Let's say you have 300 people engaged in contact tracing, which is enough to cover, say, 750 cases a day. But you have 2,000 cases a day. It's just pure capacity. You've planned for 750 cases, but now you have 2,000."
That is what is happening now in northeast Texas, said George Roberts, head of the Northeast Texas Public Health District. "By early June, we had only 250 cases in Smith County," Roberts said. "Last Tuesday, we had that many in a single day."
The district is now trying to ramp up its contact tracing to keep up.
Even if they may be losing the numbers game when community spread is severe, contact tracing can still save lives, Bhavnani of the University of Texas said. "Any chain you can stop is making an impact."