Early in the COVID-19 pandemic, public health officials had a mantra: test-trace-isolate. The idea was to weather the storm while we waited for scientists to produce the therapies and vaccines that would allow us to end the current pandemic and return to something approaching normal.
Once widespread tests were available (which took far longer than most of us would have liked), attention turned to contact tracing: the epidemiological detective work by which public health authorities interview everyone who tests positive for a communicable disease to map their whereabouts and close contacts when they were likely contagious. Those contacts are then notified that they may have been exposed to the virus so that they can get tested, self-quarantine, and arrest the further spread of COVID-19.
Critics say that contact tracing is outdated and won’t change the impacts of COVID-19. As the United States enters its second (or third) wave of COVID-19 in fall 2020, case increases in nearly every state, we’ll be able to get an indication of whether that’s true by comparing outbreaks between states based on their contact tracing programs.
On a good day, contact tracing is a challenging dance requiring the public health tracer to establish instant rapport with a stranger in order to deliver unwelcome news of exposure to a potentially deadly virus. Initial shock is followed immediately by the news that they’ll need to quarantine for the next two weeks until they are determined to either have the virus or be free of it, at which point they can return back to society. For many, this means making quick plans to isolate from family or roommates, miss work, and quickly arrange for food delivery and the other accoutrements of isolation. Many more don’t have the economic means or public support programs to access food, shelter, and protected leave from work that make quarantine possible.
The key to contact tracing is the public health investigator. Before COVID, public health departments across the U.S. employed small teams of investigators, mostly to track down sexually transmitted infections like HIV and chlamydia. Cases numbered in the dozens or even hundreds for a large metropolitan area in a hopping week. But then came the coronavirus, with hundreds or thousands of cases coming in every day to quickly overwhelm the small case investigator forces of most health departments. Some departments staffed up quickly, like New York and Massachusetts, with massive hiring pushes targeted to reach the most vulnerable residents. Other states like Indiana outsourced much of their contact tracing to phone banking companies. And still others, like Utah, counted on technological solutions using text messaging or novel apps that use Bluetooth sensors to do the work of contact tracing.
By June, public health experts across most of the United States declared that the first wave of COVID-19 had overwhelmed any meaningful contact tracing capacity. Contact tracing, after all, is designed to stop the spread of a localized outbreak. In the face of widespread community transmission, contact tracing is about as effective as bailing out a rowboat using teaspoons. But no matter, said public health experts. We can use this time to build the contact tracing workforce so that we will have the full capacity in place to stop a new wave from spreading.
Some states, like New York, have already demonstrated wins in this area. For instance, an outbreak an apple processing plant in Western New York that was quickly identified by testing, characterized by contact tracing, and stopped in its tracks through effective isolation of contacts. However, not every state is New York.
According to COVID ActNow, which has compiled the findings of reporting efforts from TestTrace.com and NPR, most states have failed to hire the contact tracing workforces that they need to arrest a new wave of COVID, based on an algorithm that calculates the time it takes to complete a contact tracing case and the expected number of cases that will need to be traced. Whereas New York and Vermont have hired 100 percent of the contact tracers needed to trace every new COVID case, Washington has only 61 percent, Maryland has 44 percent, and South Dakota has 8 percent. As of Oct. 18, only seven states have hired even half of the contact tracers they need, and 26 states have hired less than one-fifth of the workforce to keep up with their COVID cases.
Why has America failed to build the contact tracing force it needs? As it turns out, there are significant systemic challenges. The workforce needed varies day to day based on how many new cases are identified, which in turn stems from the access and uptake of COVID-19 testing. Further, the administrative aspect of hiring contact tracers is highly variable from state to state. In some states like New York and Massachusetts, contact tracing is run directly by the state’s health department. In others like Arizona, public health is delegated to counties or municipalities. In some places, including parts of California and Arizona, contact tracing depends on the services of volunteers. Depending on where the work is located and how it’s carried out, accounting for contact tracers can be difficult to decipher. The various systems may be working from state to state, but because there is a lack of consistency and transparency, we have no way to know exactly what’s going on.
There’s another big problem with contact tracing in America. There is no unified reporting about it—no way to really know how much or how well the work is being done. Some states and counties are incredibly transparent about their hiring and activities, going so far as to post dashboards showing the numbers of cases traced and closed like Los Angeles County and the Maryland. This is the ideal, in line with what experts at some of America’s leading public health institutions like the Johns Hopkins Bloomberg School of Public Health recommend. Other places are not so forthcoming, limiting reporting on contact tracing to the odd press conference. Illinois has largely simply refused to respond to queries.
Here’s what we know. It appears that America’s contact tracing workforce is still insufficient, hampered by poor data, low trust in public health authorities, and a fragmented workforce rather than the coordinated army of tracers that experts called for in the early months of the pandemic. Many have criticized public health authorities for wasting the opportunity to build a contact tracing program that could prevent or at least mitigate the effects of the wave of COVID that is building now across the United States.
On the other hand, a lot of organizations, including companies and schools, are taking it upon themselves to conduct limited tracing to at least protect their own work or school environments and hopefully offsetting the impacts of what some have deemed a public health failure.
As America enters the flu season with the possibility of a so-called twindemic, we’ll be able to see just how effective New York’s robust hiring program is to quell broad outbreaks, as it did smaller ones in the past few months. We’ll also be able to see how well the assertions of the public health leaders who eschew traditional contact tracing stack up when cases start mounting again. Early signs are that contact tracing works when you make the investment to do it right. By the end of October, New York’s positivity rate was 1.4 percent with 100 percent of their needed workforce hired for contact tracing. In contrast, South Dakota reported a 43.4 percent positivity rate with just 8 percent of the contact tracers that it needs.
We’ll also be able to see how effective some of the COVID tracker apps are, like the one that the state of Utah invested in heavily early in the pandemic and the shared Google-Apple exposure notification app that several other states are using. These exposure notification apps use the Bluetooth technology in a cellphone to detect and alert users when they have been within the definition of close contact with someone who has tested positive for COVID-19. So far, it appears that uptake of location-enabled contact tracing apps has been minimal, causing Utah to abandon the location data components of its app after three months.
When the pandemic ends—and it will, though it may not seem like it now—it may be useful to compare America’s experience with contact tracing in 2020’s technological age as compared to 1918’s distinctly manual experience. So far the public health outcomes have been quite the same despite a century’s opportunity to learn. Heading into the next wave, I hope we can do better.