SALT LAKE CITY — There’s a rumor that public health has given up on tracing the contacts of people infected with COVID-19 because there are so many of them. It’s untrue.
Instead of giving up, local health department workers are revved up, working exhausting six-day weeks to make sure they call, assess and educate everyone who is known to be at risk of infection through contact with someone who has a confirmed case of the novel coronavirus.
The need is so great that workers from other county health divisions have been pulled in and trained to lend a hand.
It’s a scenario playing across the nation as public health officials try to stymie spread of the infectious disease that has most of the country staying home. Dr. Robert Redfield, director of the Centers for Disease Control and Prevention, this week told NPR that “very aggressive” contact tracing will be needed along with a lot more testing for Americans to safely resume their normal routines.
This is contact tracing in a nutshell: Every positive test means monitoring or quarantining that person’s contacts and if they develop symptoms or test positive for the virus, doing the same to their contacts, on and on, until transmission stops. It’s a vital part of being able to reopen businesses, schools, theaters and parks. Only then can people hug again.
Without contact tracing, it’s nearly impossible to prevent “multiple community outbreaks that can spiral up into sustained community transmission,” Redfield said.
The Deseret News went inside to see how contact tracing works in Salt Lake County, where the ranks of contact tracers swelled from 31 staffers in the Infectious Disease and Epidemiology bureaus to more than 130 people, most reassigned from entirely unrelated tasks. While investigating cases and tracking people who might have been exposed to COVID-19, they are working long hours six-day weeks at three Salt Lake County locations.
The need is great: In Salt Lake County alone, 1,071 had tested positive by Saturday for COVID-19 and 94 of them had been hospitalized. Some died. More than 2,206 have tested positive statewide and 18 Utahns are dead from this coronavirus.
In Salt Lake County, health employees who usually do community education around chronic disease prevention are temporarily on the disease surveillance teams, as are environmental health scientists. Administrative staff is joining in.
Redfield said the process is so important that 600 CDC staffers have been dispatched around the country to help and guide efforts — including some in Salt Lake County.
A daunting task
Friday morning, the ground-floor lobby of the county’s downtown public health center was nearly empty, entered by a door plastered with notices that tuberculosis testing and even getting a birth or death certificate are by appointment only. The lobby chairs, carefully arranged at least 6 feet apart, were empty. The ghostly feeling continued on the second floor where contact tracing takes place, but only because workers were distanced from each other behind closed doors in every available office to work the phones and notify people they might have been exposed to the virus. Duos worked in a few offices, masked and at least 6 feet apart, as contact tracing experts trained those who never expected to be tasked with such a job.
Mackenzie Bray, who normally does STD contact tracing, was training Dan Moore, whose specialty is solid hazardous waste. In a nearby office, Chantel Ikeda, an infectious disease nurse, was making sure Shawn Gonzales, expert in air pollution and emissions, was comfortable opening a conversation about COVID-19, providing the right counsel, then documenting the case.
Each worker will make dozens of calls a day. Some end up coming in a little earlier than their nine-hour shift or staying late or both. Within 24 hours of the index person’s positive COVID-19 test, they hope to have reached everyone that person could have exposed.
Tara Scribellito, a nursing supervisor, said they try to identify everyone a person who tested positive for COVID-19 was within 6 feet of for at least 15 minutes — from two days before symptoms until that “index person” was hospitalized or went into isolation.
County public health staff divvy the contact lists. On the phone, they’ll ask questions, assess risk and suggest either quarantine or isolation. Quarantine is for those with no symptoms and means staying home and away from others not in your household. They’re told to take their own temperature twice a day and call the health department if anyone develops fever. Those with symptoms not severe enough to be hospitalized can manage the illness at home, but must isolate even from family members or roommates.
People are sometimes scared when they get the call, Scribellito said. But they are also usually grateful to know that they’ve been exposed and have someone tell them what to watch for and what precautions they should take.
Reassigning assets
Originally, the Salt Lake County Health Department tracked hospitalizations of COVID-19 patients on vast white boards, adding another board as each one filled. The boards listed patients by initials, the names of the person doing contact tracing, where one was hospitalized, some underlying conditions and other information available at a glance. The black erasable writing was punctuated periodically with a notation in red that the patient died.
Over time, there were simply too many hospitalizations to keep adding white boards and they moved the records to spreadsheets.
Those alone in rooms with doors closed don’t have to wear masks, though some do. Rooms and work surfaces are carefully cleaned at the beginning of shift, said Lee Cherie Booth, a public health nurse who gave the Deseret News a tour. At shift’s start, each worker’s temperature is taken, then they move into their work space, where they wear gloves to clean the desk, keyboard and phone with antiseptic wipes, then put on masks if they’re sharing space or want to work with the door open.
Many of them are multitasking all day long, doing some of their regular public health jobs, then picking up their contact lists again. Around noon, infectious disease nurse Travis Langston and Booth stopped to don more sophisticated personal protective equipment, including face shield/respirator masks, gowns and gloves so they could swab people who were driving up for testing appointments out front on 200 East. Langston said it would take them several minutes to get ready to do the tests, and even longer to clean up afterward.
COVID-19 has put many normal public health efforts on the back burner, said Tair Kiphibane, Infectious Disease Bureau manager. But some efforts continue, because life has continued during the pandemic. People still have STDs and tuberculosis and need public health services, though what’s available is limited and has all been scaled way back.
Dr. Dagmar Vitek, Salt Lake County Health Department medical director, said one of the biggest challenges is taking time out from each worker’s own surveillance work to train others.
The surveillance work is never done because there are so many people to trace, so many case investigations to do. Recruited workers may need help to hone basic surveillance skills. Kiphibane said some pulled from other specialties are not used to talking to people on the phone. Getting someone to open up and answer the kind of questions that must be asked can be quite challenging. How to approach that is part of the training.
Surveillance requires finding out where all those contacts have been, too, if the person has any symptoms, as well as who they might have exposed to the virus.
The April 8 CDC Morbidity and Mortality Weekly Report showed how big the web can be. In one case, an index person referred to as A.1 went to a funeral for someone whose death was unrelated to COVID-19. No one was yet warning of COVID-19 in the United States and he didn’t have worrisome symptoms. A.1 was only tested for COVID-19 as part of a broader community surveillance a short time later, not because of concern A.1 was sick. But A.1 had shared a meal with two family members the night before the funeral and at the funeral hugged grieving friends and relatives. At least four of A.1’s close contacts from those events developed COVID-19 a few days later. A.1 also went to a family birthday party. Seven from the party developed symptoms. Two of them died, as did one from the funeral. Some of the others also unknowingly spread COVID-19 to others. That’s how infectious disease spreads through a community.
Those doing contact tracing must have have broad, deep knowledge of a community’s resources and how the public health response to the pandemic works. They may be asked tricky questions, like how someone is supposed to distance himself from family in a tiny abode or when he’s the caregiver to multiple children. Contact tracers end up explaining the need to sanitize doorknobs and clean shared bathrooms or what a person can do to get groceries now that they’re not supposed to leave the house at all.
When people can’t isolate because of their living space or have no place to quarantine, the county health department can send someone to a quarantine site set up for precisely that need. They can even, in some circumstances, send a mobile testing van over, though most people are told where to go to get testing, if it is needed.
Ilene Risk, Epidemiology Bureau manager, said people sometimes balk at the restrictions they’re given. But when surveillance staff explains the “why” to them, she said, they seem more accepting.
Different ways to track
Not all communities are asking patients to provide lists of everyone with whom they had contact, sometimes dating back a couple of weeks or more. Some countries, like China, have used cellphone and other surveillance technology to trace contacts and view where a person who developed COVID-19 has been. That tactic has raised real privacy issues in the United States.
Apple and Google, though, are betting that people will want to be able to look at their own contacts to see if anyone has exposed them to the virus. The Washington Post reported that the two tech companies “unveiled an ambitious effort Friday to help combat coronavirus, introducing new tools that could soon allow owners of smartphones to know if they have crossed paths with someone infected with the disease.” Their technology would let public health officials use an app that can sense smartphones in the area.
“If a person learns they have coronavirus, they could indicate on their app they’ve been infected — and people whose smartphones have been in their vicinity would be notified, regardless of whether their devices run on Apple or Google software,” the article said.
For now, local health departments are doing the informing — and providing tools and guidance to help people figure out what to do.