Public health nurse Lee Cherie Booth conducts a test for Covid-19 outside of the Salt Lake City Public Health Center. When a swab test comes back positive, contact tracing starts. | Scott G Winterton/The Deseret News via AP
The country only has a fraction of workers needed to trace the coronavirus, as health departments are scraping together a rag tag army of graduate students, workers from a city attorney’s office and even librarians.
Before the pandemic, state and local health departments had fewer than 2,000 workers carrying out contact tracing — the detailed investigatory work to track and stop outbreaks of everything from syphilis to measles. The real number needed could be somewhere between 100,000 and 300,000 — an astronomical figure that seems near impossible to reach without a massive national program to build a highly trained public health workforce.
Here’s how contact tracing works: Using test results and in some cases, just hours of training, the newly drafted workers must interview infected people, identify those with whom they’ve come into contact and convince those people to self-quarantine. The recruits will be tracking a stealthy disease many times more virulent than the flu that can be transmitted before people show symptoms. And one missed case can lead to a new hot spot and stamp out weeks of benefits from social distancing.
“Learning contact tracing is not easy,” said Tom Frieden, the former CDC director and New York City health commissioner. “Training is very important. Listening to someone, understanding their concerns, helping them remember.”
The National Association of State and Territorial Health Organizations estimates that the country may need to hire as many as 100,000 such “disease intervention specialists” at a cost of $3.6 billion. Frieden thinks the number could be as high as 300,000.
Arkansas, among the handful of states that never imposed a stay-at-home order, has expanded its contact tracing team from three to more than 150, some of whom are focused exclusively on outbreaks in prisons and nursing homes.
Many of North Dakota’s newly enlisted 300 contact tracers are graduate students earning credit toward their masters in public health. The state is contacting health care workers who have been furloughed due to canceled office visits and elective surgeries, as well as tapping members of the National Guard, and is still looking for another 200 disease trackers.
Hundreds of Utah public employees have volunteered to reach out to close contacts of infected patients and are receiving about two hours of online training from epidemiologists. San Francisco is aiming to train more than 250 recruits over the next two weeks — assembled from a pool that includes librarians, staff from the city attorney’s office and retired health workers.
The guidance the White House released last week to states seeking to reopen their economies says contact tracers are needed, but included no information about how many or how states and workplaces should monitor the spread of the virus. In the aftermath, public health groups are mobilizing to develop crash courses.
Later this week, the Association of State and Territorial Health Officials and the National Coalition of STD Directors will release a one-day online tutorial for lay people to learn the basics of contact tracing — a seminar they hope local governments will supplement with their own state-specific information.
David Harvey, the executive director of the STD directors group, noted that disease investigators at public health departments usually get at least a year’s worth of training and mentorship.
“Obviously in this emergency, that has gone out the window,” he said.
Public health experts credit aggressive contact tracing for limiting the damage from the coronavirus pandemic in Taiwan, Singapore, New Zealand and South Korea — all of which have seen far fewer cases and deaths per capita than the U.S.
Senate Democrats last week proposed a plan to spend $30 billion on measures like disease surveillance and contact tracing. Sens. Ed Markey and Chris Van Hollen have a separate plan that would expand FEMA and Americorps to bolster contact tracing efforts in the states. But with Congress gridlocked over the latest rescue package, states are forging ahead and improvising with buddy systems and on-the-fly training.
Utah’s volunteers are being assembled into eight to 10-person teams with a supervisor who can provide on-the-job training. Vermont is giving new contact tracers 90 minutes of training, followed by three days shadowing an experienced disease investigator and another 90 minutes of training.
There are also concerns that the rush to deploy workers will overlook minority communities that have been hit especially hard during the pandemic and may not be getting enough resources because of inadequate data collection. Harvey said that while STD contact tracers are already familiar with communities of color and skilled at asking sensitive personal questions, they are not being given leadership roles in tracking coronavirus.
“The existing workforce who has been doing STD contact tracing since World War II is once again being overlooked,” he said.
The speed and scale of the project is additionally leading many states to rely on digital tools, which raise a host of new privacy concerns.
Apple and Google announced last week that they will roll out technology that will use Bluetooth on people’s phones to detect when they have come into contact with individuals diagnosed with the virus.
The technology could be a critical tool, reducing the number of people needed to track the spread of the virus. But civil liberties groups already have a long list of concerns.
“While some technology-assisted contact-tracing systems may offer public health benefits, they may also cause significant risks to privacy, civil rights, and civil liberties,” said ACLU senior staff technologist Daniel Kahn Gillmor. “We need a sober consideration of the risks and tradeoffs.”
But such concerns may take a back seat as the coronavirus sweeps through the South and farm belt, forcing states to scramble a response.
“Rural health departments have never attempted anything on this scale,” said Tennessee Health Commissioner Lisa Piercey, who has recently added more than 150 contact tracers across her state.
Arkansas’ health secretary credits newly hired teams of contact tracers with keeping the state’s death rate far lower than most. But Jennifer Dillaha, the state epidemiologist, told POLITICO that Arkansas is still “not where we’d like to be,” and more staff and resources are needed. She said they are “repurposing” nurses who are now working in local health departments and partnering with the University of Arkansas and other schools to have students assist with contact tracing.
The situation is particularly tough in states whose health departments have seen funding and staff slashed in recent years. In the last decade alone, local health departments have shed more than 55,000 jobs.
Frieden said technology can’t replace human contact in a crisis like the pandemic. That puts more of an onus on the new recruits to paint an accurate picture of who’s sick and where.
“It’s not clear that phones can say who is in contact with who and when at a high enough or accurate enough rate to be useful,” he said. “This is fundamentally a person-to-person process. It’s about talking to someone earning their trust, and helping them remember who they were in contact with.”