The cost of doing too little
Underinvestment in contact tracing can do more than just leave some people hanging. Much of the data that city officials cited to inform their process for new targeted closure efforts came from information collected during case investigation interviews — but with so few positive cases being reached by tracers, the data collected may have created an incomplete picture on which to base those closures.
On Oct. 20, for instance, Health Commissioner Dr. Farley reported that the number of positive cases interviewed who reported going into an office increased by about 10%, prompting him to remind people to work from home whenever possible. But with data derived from such a small fraction of cases, it’s hard to know whether those trends are reflective of actual transmission patterns.
It can also undermine trust in government if tracers aren’t equipped with tools to be able to deliver real support. When contact tracing has been used for other diseases, like syphilis or tuberculosis, there has been an incentive to participate, said Bruce Davidson, who worked as Philadelphia’s tuberculosis czar in the 1990s. In those cases, he said, tracers had something to offer the patient.
“You meet the person confidentially, and you say, `Look, I’ll test you, no charge, if you have this, I will cure you, no charge, and if you do have it, I’ll test the people you know … and make them safe,’” said Davidson, who is a pulmonologist now based in Washington state.
“So everyone we contact-traced for TB, they said, what’s to lose? For this disease, all you can say is you have to quarantine for 10 days. And everyone you know and have been around has [to] too.”
Case managers, not just case trackers
A contact tracer in the Philadelphia region, whose identity WHYY News agreed not to reveal because they were not authorized to do interviews, said the caseload has recently exploded. Back in the summer, their team would have a meeting before the start of a shift, and sometimes the leader would say they haven’t had a lot of new cases, so most calls would be contacts or follow-ups. Those meetings have since stopped because there are so many calls to make.
“We used to start calling at 9 a.m. and stop calling at 8 p.m., and now we start calling at 8 a.m. and finish calling at 9 p.m.,” the tracer said. “I certainly have worked into the evening, and I’ve never had a situation where I didn’t have any cases to work recently … I rarely hear anything recently about, ‘Oh, we finished.’”
The calls can sometimes be difficult, such as when the contact tracer is the first to tell people that they most likely have COVID-19.
“I’ve definitely had people who needed a moment after they heard they were positive, to digest and deal with it: people who’ve practically been crying on the phone, or even people who are crying on the phone, realizing that they’ve exposed friends or family members who could get sick,” the worker said.
Aside from contacting people who may have gotten the virus from someone who tested positive, contact tracers can be critical resources for people who have to quarantine but need help with groceries or rent, mental health support, or an official letter from the state to show their employer why they need to stay at home.
Contact tracers also sometimes work as case managers, said Kailee Leingang, a contact tracer for the North Dakota Department of Health and a nursing student.
“You are the person that they call before they go into the hospital trying to figure out if they should go. A lot of times I’ve been the one that has told them, ‘You need to go into the hospital, call ahead, tell them you have COVID 19,’” she said.
Right now, she is managing about 50 cases. Like Philadelphia, the number of cases in North Dakota has surged so much recently that as of last month, she and other contact tracers no longer call people who may have been in touch with people who tested positive.
“It is scary, because it puts a lot of responsibility on that positive case,” she said.
She worries about people who have such horrible symptoms they don’t want to make calls, or people who don’t want to deliver the news to their friends that they have to quarantine too.
In part because of the support tracers offer in interactions like these, epidemiologist Emily Gurley argued it would be far worse if contact tracing stopped altogether.
“We always have to remember: Even if cases are increasing, that doesn’t mean it couldn’t be worse; it could certainly be worse.”
Gurley created a free online course and helped develop tools for public health officials and people managing contact tracing programs to learn how to estimate the impact of their programs, and how to improve them.
In Philadelphia, Katz understands that health departments are cash-strapped and cases are surging, but for him it’s about trusting leaders to stand by their word and keep people safe, which includes investing in public health and contact tracing.
“Not to be trite, but we are all in this together,” he said. “Individuals need to wear masks in public places, and government is part of that bargain — they need to do what they’re supposed to be doing.”