Short Wave - Lessons Learned From Hindered Contact Tracing Efforts In The U.S.

Episode Date: June 28, 2021

Early in the pandemic, contact tracing was viewed as one of the best options to quell the spread of coronavirus infections. The idea was to have public health workers track down people who tested positive, figure out whom they'd been in touch with and quickly get those people to quarantine. Places like Hong Kong and Singapore made headlines for their success stories. The U.S. aimed to replicate this, but came up short. Today, health reporter Selena Simmons-Duffin explains what went awry and the lessons learned.Reach the show by emailing [e-mail] pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences.NPR Privacy Policy

You're listening to Shortwave from NPR. Early in the pandemic, with no vaccine in sight, contact tracing seemed like one of the best options to get the coronavirus under control. There has to be a substantial augmentation of the public health work or CDC. That's former CDC director, Robert Redfield, talking to NPR in April 2020. Back then, stories were coming out about how Hong Kong and Singapore were able to contain their COVID-19 outbreaks by deploying thousands of public health workers to track down every positive case, figure out whom they've been in contact with, and quickly get those people to quarantine. If everyone who has been exposed stays home, then the virus can't spread. The centerpiece of our response needs to be the tried and true, proven to work, public health response of early case recognition, diagnosis, isolation, and contact tracing.

But contact tracing takes a lot of time, a lot of public. health manpower, something that the U.S. did not have. CDC Director Redfield was adamant that the U.S. could scale up. He talked about partnering with the Census Bureau or the Peace Corps to build an army of contact tracers big enough to cover the U.S. 100,000, 300,000. I don't know what the exact number is, but we're prepared to expand the public health workforce for contact tracing and to the extent that we need it.

And Selena, those comments got you curious. as a health policy reporter, right? Yes. When I heard that, I wanted to know how many contact tracers the U.S. had in the first place. Because public health workers do contact tracing all year, including when there's no pandemic, usually for things like sexually transmitted infections and tuberculosis. I asked a couple different national public health groups for this number, and no one had it. So I tried to figure it out.

I basically sat on the bed in my sister-in-law's childhood room with my laptop. and track down emails and phone numbers for the health departments in every state and asked, how many contact racers do you have? Selena, this is some of that thrilling, high excitement reporting we see in the movies. Yes, absolutely. Producers contact me. So I was doing all of this painstaking spreadsheet work in late, April 2020. I ended up getting help, I should say, from NPR's researchers and our absolutely incredible editor, Carmel Roth. and a whole bunch of member station reporters from all over the country.

And how many did the country have at that point in late April of 2020? 11,142. Wow, wow, wow. So definitely not 100,000 people. Not even close. And keep in mind that the U.S. has 330 million people in it. So I kept asking health departments every few months. And states did scale up.

There was a massive hiring effort. the most contact tracers the country ever got, according to our survey, was just over 70,000 in December of 2020. So more than a sixfold increase from the initial number. But not as many contact tracers as we needed. That's right. And many public health experts I talked with say it is clear even that record-setting number was not enough to keep up with the winter surge. So today in the show, we talked to Selena about her year-long project to check in with health departments around. the country about contact tracing.

What went well, what didn't, and what's next. I'm your host, Maddie Safaya. And I'm NPR Health Policy Reporter, Selena Simmons-Duffin. This is Shortwave, the Daily Science podcast from NPR. Okay, Selena, so I want to dig into the why, like why the U.S. wasn't able to scale up this public health workforce. But first, can we just explain what contact tracing is, like what's the job? Right.

So contact tracing is kind of an umbrella term for a whole process. that involves a few different roles. And the first person involved is called a case investigator. So that's the person who calls you when you test positive and says, hi, you're positive. Let's think through everyone you may have exposed, starting two days before symptoms. So hopefully out of that you get a list of names and phone numbers. And then the contact tracer's job is to call those people and say, hello, you've been exposed. You need to quarantine for two weeks from the date of exposure.

Okay, okay, got it. So all of that needs to happen pretty quickly, right, to avoid more exposures. Yeah, the goal is to reach out to cases and contacts within a day or two of the test result coming back. And then there is a third leg of the contact tracing stool, and that is a role called Care Resource Coordinator. So a lot of people can't quarantine. They need to work to pay bills, get groceries, get medications. So Care Resource Coordinators help connect those people to programs that they're eligible for that can meet those things. needs like grocery delivery or utility and rent assistance. Okay, so how did states find people

to do these jobs? The short answer is it was a total grab bag. Some states used private call centers, some used volunteers, some created centralized state contact tracing programs, and some left it to local health departments. Adrian Casillotti of the National Association of County and City Health Officials points out that the context here was decades of funding and staffing cuts. Local health departments entered the pandemic down over 20% of their workforce capacity. And so scaling up contact tracing was a larger task because you weren't just starting from zero. You were starting from a deficit. The problem wasn't just finding people to hire. These are actually complicated jobs. Catherine Feldman runs the contact tracing program for

Maryland's Department of Health. Your contact tracing also is a skilled job. And it takes a a minute to recruit, qualified staff, train them up and get them going. And then she says, because of how intense the work is, contact tracers might only work part-time or leave after a few months. They get burned out. Some describe the job to me as being like 911 dispatch. A lot of the people you call are stressed and sick and scared. So Feldman and the other people running these programs had to juggle all of these variables. How many staff are you going to actually need on a certain day? How long is it going to take to recruit those folks and get them trained up and ready to go. It's very challenging. And so I think

we actually did a pretty good job in the face of all of that. But maybe the biggest reason that the U.S. wasn't able to scale up enough, Casillotti told me, is that communities began to open up in the spring and summer of 2020 before hires were trained and ready to go. Wow. I did not realize that. That is no good. Right. So, once. cases surged, there was no way contact traces could keep up. It was never supposed to contain the pandemic on its own. Casillotti told me it was kind of like trying to build the contact tracing plane while flying it. People saw the utility of contact tracers, but opened up communities before the contact tracers were in place and the systems were in place at the levels they needed to be.

And so we kind of set up contact tracing. I wouldn't, I go probably too far to say we set it up to fail, but we certainly didn't set it up for success. Hmm. Okay. Okay. So that's the timing, which was bad. But can we talk about the numbers? Like, why didn't we ever get that army of contact tracers, Selena? Yeah, that big national army really never materialized in any large-scale way. And even when it came to funding states' efforts, the federal government left things really open-ended. There were buckets of money for contact tracing that came in various congressional bills, but they were always lumped in with funding for testing or other pandemic response measures.

And that meant that the amount devoted to contact tracing really varied from place to place. Some states got more money than others. Some really wanted to invest in another aspect of the response. Some were focused on surveillance or making vaccination plans. Wow. So this is just another example of how this patchwork response to the pandemic in the states really hamstrung us, right? Yes, absolutely. Okay.

So you talked to a lot of contact trace. throughout the past year. What are some of the stories that you heard? Yeah, the first contact tracer I talked to last spring was Malachi Stewart. He works at the Washington, D.C. Department of Health. He pivoted to COVID-19 contact tracing early on, and he helped me understand what the job was really like. No two interviews should ever sound the same. Building a rapport with people and sort of creating a safe space for people to be able to express, to know that what they tell you is confidential and make that. conversation not feel like a cold call where somebody's just checking boxes, but it felt like a

conversation where the person's actually, you know, taking interest, actually concerned and prepared and willing to give you information. In order to build that kind of rapport, I heard from a lot of people that it's incredibly important that this workforce is coming from the community that they're trying to serve. And that includes speaking the languages needed to reach everybody. So Eustacia, John, a contact tracer and care resource coordinator for the Navajo Nation in Gallup, New Mexico, made her calls sometimes in her native Navajo language. And when I talked to her, she mentioned a grandma she'd called recently. I did her initial interview and I explained to her what I'm doing. Do you need food? Are you okay? Do you need help with like medical services? And then she would say,

no, I have no family or friends. Nobody's going to help me bring food over. So Eustacia helped get her request in for food and followed up with her day after day during her isolation period. She was really grateful of it. Like she was crying and said, you know, you're, you sound like you're the only person that cares for me right now. You call me every day and you check to see how I'm doing. So that is how it works when it works. It can be an incredibly useful tool to both support individuals and to stop transmission at the community level. Right. But I'm guessing it doesn't always go that smoothly. That is true. So one theme that came up again and again was the lack of trust. This is Nicole Roberts, who runs the contact tracing program in Utah. Unfortunately, as the disease became more and more politicized,

that trust with the health department started to go down. So case investigators would call and people wouldn't answer, or they would hang up, or they would refuse to give any names. Sometimes people were afraid that they would cause someone to lose a job by giving their name. I mean, that's a very legitimate fear, I think, for some people. Right. And public health needs to address that lack of trust for a lot of reasons. It is clear it really hurt this aspect of the pandemic response. CDC even did an analysis of 14 contact tracing programs from June to October 2020 that found that, quote, no contacts were reported for two thirds of persons with laboratory confirmed COVID-19, because they were either not reached for an interview or they were interviewed and named no contacts.

Wow. Wow, Selena. Okay. So you kept surveying health departments six times over the past year. The most recent one was just last month. What's happening now, Selena? Right. I want to first shout out the Johns Hopkins Center for Health Security, especially Crystal Watson and Lucia Mullen, because they partnered with us to send out the surveys after the first few. and they're like actual public health professionals. You know what they're doing. They were really incredibly helpful with this. So the most recent survey went out to state health departments in May, and almost all of the departments told us

that they're either not hiring more staff or they're letting staff go. And the worry is if one of these variants of concern continues to take off in unvaccinated populations and there start to be larger outbreaks again, the country will be back to square one with a few thousand contact tracers and no coordination on how to scale up. Yeah. Wow. Okay. All right. Selina, you have been following this for a long time now. And so I want to ask you, do you think the government has actually learned from this? Like, will they do things differently in the future? I mean, we're still not out of this pandemic. And the U.S. will certainly experience another one. I know the Biden administration has said this is a priority, right? That's true. And there's $7.4 billion.

in the latest COVID-19 relief package for the public health workforce. Because even if there's not a big demand for COVID-19 contact tracing at the moment, there is definitely a need for more public health workers, like doing everyday things like restaurant inspections and animal control and HIV outreach and then pivot to do contact tracing in an emergency. But all of this new funding is temporary. It's a big infusion of money that can be used for the next few years. And then what?

So I want to believe that the country is going to come away with this with good lasting lessons, but I'm not convinced that it will. The U.S. has a habit of only funding public health when there's a crisis and then slowly siphoning money away as the memories fade. A lot of public health experts are advocating for the U.S. to break that cycle and create something more sustainable and stronger. that's what would need to change for us to be better prepared for the next pandemic. That's NPR's Selena Simmons-Duffin. Selena, thank you. We appreciate you. Thank you. This episode was produced by Rebecca Ramirez, edited by Giselle Grayson, and fact-checked by Indy Kara.

The audio engineer for this episode was Marcia Caldwell. I'm Maddie Safaya. Thanks for listening to Shortwave, the Daily Science Podcast from NPR.