May 12, 2020 -- As more states reopen businesses, beaches, and parks, COVID-19 cases are expected to rise. Many states are focused on an aggressive contact tracing program as part of a comprehensive public health strategy to contain the virus.
Public health experts worry that states are easing restrictions before infection rates have significantly declined and without the support in place to control new outbreaks.
Until a vaccine or effective treatment is developed, they recommend traditional public health strategies, including contact tracing, that have been used to contain other epidemics, including Ebola and Zika, says Ingrid Katz, MD, associate faculty director of Harvard University’s Global Health Institute and an associate physician at Brigham and Women’s Hospital.
The idea behind contact tracing is simple. “In an epidemic, infection isn’t passed from one person to another in a simple chain; it spreads more as if in a web. If just one chain of transmission in this web is missed, the virus can continue to spread through the community,” Tom Frieden, MD, former CDC director and president and CEO of Resolve to Save Lives, said at an Aspen Ideas Health 20/20 media briefing this month.
“Every time contact tracing results in an infected person’s being isolated or a contact’s being quarantined when that person develops infection, a web of transmission is broken,” he said.
Contact tracing involves interviewing the infected person, ideally within 24 hours, to find out who they have spent time with recently and the nature of the contact, and then alerting the contacts to the exposure, says Katz. “Efficiency is the name of the game -- you need to get to people quickly and isolate anyone who tests positive,” she says.
Katz and Frieden agree that contact tracing has to go hand-in-hand with widespread testing, isolation of cases, and quarantine of contacts to stop transmission chains of the virus. These are the four components of Frieden’s “Box It In” strategy.
“In order to go back out and reopen, we need to put the virus in a box. We do need to scale up testing capacity, but we don’t need to wait for that to do other things -- isolation, contact tracing, and quarantine -- these four aspects all go together. The more we focus on other sides of the box, there will be less of a need for testing and fewer outbreaks,” says Frieden.
Experts at the Johns Hopkins University Center for Health Security and the Association of State and Territorial Health Officials (ASTHO) estimate that each infected person can, on average, infect two to three others. This means that if one person spreads the virus to three others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections.
Public health groups recommend a workforce of 10 to 30 contact tracers for every 100,000 Americans. The Johns Hopkins center and ASTHO estimate that an additional 100,000 contact tracers are needed, while Frieden and the National Association of County and City Health Officials (NACCHO) recommend a total workforce of 300,000 during a pandemic. The association says that is double its usual workforce recommendation of 15 health workers per 100,000 people.
Meanwhile, a group of influential bipartisan health leaders has called on Congress to fund an additional 180,000 contact tracers at a cost of $3.5 billion, part of a $46.5 billion request. The remaining money would allow states to book blocks of vacant hotel rooms where Americans sick with COVID-19 could self-isolate, and provide up to 18 months of income or $50 a day per person while they can’t work, according to a letter obtained by NPR.
“The existing public health system is currently capable of providing only a fraction of the contact tracing and voluntary self-isolation capacity required to meet the COVID-19 challenge. The country must establish a workforce and support investments to track and contain the spread of the virus, which in turn, would have the added benefit of acting as an economic stimulus and creator of new jobs,” the leaders say.
They point to contact tracing efforts in Massachusetts that show that lay people can quickly be hired and trained, with 15,000 applications submitted for 1,000 positions within 2 weeks.
The CDC told NPR that it would support another 650 positions with $45 million. This would be in addition to about 500 staff who are currently deployed to help state and local health departments.
States now have several tools they can use to estimate the contact tracing workforce they need. George Washington University’s Milken Institute School of Public Health unveiled its new calculator last week in partnership with local and state health organizations, estimating that 184,000 contact tracers are needed. Resolve to Save Lives also published a staffing calculator last week.
State Report Cards
Forty-four states and the District of Columbia now have plans to expand their contact tracing workforce, reaching a total of 66,197 workers, according to NPR data released May 7. This is an increase of about 30,000 planned workers from when NPR first released the results on April 28 of a survey that asked about the contact tracing workforce in all 50 states, Puerto Rico, and Washington, D.C.
Of the projected planned total of 66,197, states reported having at least 11,142 contact tracers working as of May 7.
“If the goal is 30 contact tracers per 100,000 people and we’re currently at about 11 per 100,000, we still have a long way to go. It’s not surprising that rural states like North Dakota met that goal first, given the state is less densely populated,” says Katz.
North Dakota and Alaska were the first states to reach and surpass the goal of 30 contact tracers per 100,000 residents. After the planned hiring surge, North Dakota will have 66 contact tracers per 100,000 residents, and Alaska will have 68, according to NPR.
Six other states are close to reaching that 30 workers per 100,000 threshold: California, the District of Columbia, Illinois, Michigan, Nebraska, and New York, NPR reports.
Among the recent updates to states’ plans, California announced a partnership with the University of California, San Francisco, to put 3,000 people a week through its 20-hour contact tracing training, with a goal of ultimately having 20,000 contact tracers. New York state also announced a plan to hire as many as 17,000 workers, in partnership with Bloomberg Philanthropies, the Johns Hopkins School of Public Health, and the nonprofit Resolve to Save Lives, according to NPR.
Several states that fall short of the threshold are shoring up their existing contact tracing workforces. The Virginia Department of Health has staff numbering in the 100s doing contact tracing across 35 local health districts, including reassigned staff from other programs or departments, state Health Commissioner M. Norman Oliver, MD, said during a news briefing last month.
Oliver also said CDC guidance recommends 15-30 contact tracers per 100,000 population. To meet the lower threshold, Virginia would need to hire approximately 1,000 contact workers to “supplement the existing local health department staff already in place and performing contact tracing. Work is currently under way to determine how best to move forward in hiring individuals for this position.”
Katz said with so many people unemployed, it’s a good time to hire contact tracers. She recommended hiring people from similar backgrounds and communities who speak the same language. “The biggest piece is trust -- if they speak to someone who they can trust and who understands them, it will be easier to help them access the care they need, including testing and isolation.”
Isolation Important, Too
Isolation is “often a seriously neglected piece of the effective strategy. In addition to testing and contact tracing, you need to be able to isolate everyone who tests positive,” says Katz.
But some people lack a safe space -- meaning a separate room and a bathroom -- to recover from the disease. “This is particularly challenging for low-income families that share small spaces,” says Katz.
She supports the public health leaders’ request to Congress that part of the stimulus money be used to open up new spaces in hotels, university dorm rooms, and convention centers for people who cannot safely isolate in their homes.
"You should not share a connected space as long as you’re infectious. If people bring you food, they have to be prepared to wear a mask and gloves.”