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 With the pandemic claiming about a thousand American lives a day,
many city and county departments say they lack the money and staff
to expeditiously identify people who have been exposed, according to
a Reuters survey of 121 local agencies, as well as interviews with
dozens of state and local officials, epidemiologists and tracers.
The United States badly lags other wealthy countries in contact
tracing, including South Korea and Germany, which ramped up their
programs months ago. Contributing to the faltering U.S. response is
the government’s failure to provide accurate and timely diagnostic
testing, something other countries were able to roll out much faster
and more broadly.
On Alabama’s hard-hit Gulf Coast, health department staffers are
stretched so thin they are directing individuals who test positive
to notify any contacts themselves, said Rendi Murphree, director of
Mobile County’s Bureau of Disease Surveillance and Environmental
Services.
“Everything is overwhelmed,” she said.
Adding to the challenge has been a sharp politicization of the
COVID-19 response, with many Americans, from President Donald Trump
on down, often portraying mask-wearing and other measures as an
infringement of personal liberty.
The United States has by far the world’s largest COVID-19 caseload,
with over 4.6 million confirmed infections and more than 155,000
deaths. Yet public health measures during the pandemic have been
largely decentralized, coming down to patchwork efforts by state,
and especially local, governments. Federal funding has proved
unreliable, caught up in fierce debate over the crisis.
Now, as part of log-jammed negotiations over new relief legislation,
Republicans and Democrats in Congress are arguing over funding
proposals for testing and tracing that are tens of billions of
dollars apart. As of June, U.S. Centers for Disease Control and
Prevention director Robert Redfield said the country had 27,000
contact tracers – about a quarter of what has been recommended.
Although some local health departments told Reuters their efforts
have proved successful – and many said they were worthwhile –
several researchers described U.S. contact tracing overall as too
little, too late.
“You don’t clean up an oil spill with paper towels,” said Marc
Lipsitch, a professor of epidemiology at the Harvard public health
school.
On this point, the Trump administration does not disagree. Admiral
Brett Giroir, Assistant Secretary for Health at the U.S. Department
of Health and Human Services, told Reuters that given the spread of
the disease, mask wearing and other prevention measures are more
effective.
"It is really impossible to contact trace," Giroir said, until the
numbers come down.
The agencies responding to the Reuters survey serve at least 27
million residents in large cities such as Minneapolis, Boston, and
Cleveland, as well as smaller communities including Allentown,
Pennsylvania, and Dare County, North Carolina. Collectively, as of
last week, they accounted for at least 230,000 COVID-19 cases and
7,300 deaths. The responses cover the week ending June 22. Reuters
followed up in late July with several departments, such as Las Vegas
and Kansas City, Kansas, where officials said circumstances had not
improved.
Among the findings:
• The 40 local health departments with the highest caseloads have
fallen far short in their efforts to reach patients who tested
positive. Only about half the departments with more than 1,000 cases
had reached close to all infected people at the time of the survey.
The CDC recommends that newly positive cases be interviewed within
24 hours.
“It’s just impossible with the kind of numbers that we are seeing,”
said Devin Raman, a senior disease investigator at the Southern
Nevada Health District, including Las Vegas.
• Nearly half of the local departments said they lacked sufficient
staff and funds. In Missouri, many said they hadn’t received any
additional money for contact tracing. “Some of them are literally
running out of money right now,” Diane Weber, executive director of
the Missouri Association of Local Public Health Agencies, said in
July.
• Local health officials in six states complained that efforts to
create statewide contact tracing systems have been hampered by
issues including technical problems and poor coordination. In some
cases, this has led to tension and a costly duplication of efforts,
with state and local tracers calling the same people.
“We’re not going to drop the ball on tracing in our county and leave
it to the state. If we did that, we’d probably all be dead,” said
Joni Wise, administrator of the Vigo County Health Department in
Indiana.
A spokesperson for the Indiana Department of Health acknowledged
that people are more likely to answer a local call from a municipal
health department than an “833” number from the state’s centralized
call centre.
• More than three dozen public health departments said they were
hindered by some residents’ failure to answer their phones or to
provide accurate information when they did. Several departments said
people they called had objected to contact tracing as an
infringement on their privacy rights.
“We get a variety of responses from yelling and hanging up, to those
telling us that they have already contacted all of their friends and
will not give us those names,” said Kenosha County health director
Jen Freiheit in Wisconsin.
'A LAME EXCUSE'
From the early days of the pandemic, public health experts
emphasized the importance of contact tracing, a decades-old strategy
aimed at interrupting infectious disease transmission. It involves
interviewing infected people, identifying people whom they may have
exposed to infection and trying to keep those individuals from
passing the virus to someone else.
“If any country is saying contact tracing is difficult, it is a lame
excuse,” World Health Organization Chief Tedros Adhanom Ghebreyesus
said in June. He pointed to the WHO’s success in halting an Ebola
outbreak in eastern Congo by tracing 25,000 contacts a day in a
remote area, where some 20 armed groups were fighting.
Under the best of circumstances, contact tracing is not a panacea.
It is only one of many public health tools commonly deployed against
infectious disease. The approach is particularly challenging during
a fast-moving epidemic in which people may be infectious but don’t
fall sick right away. In addition, a culture of individualism and
legal protections inhibit U.S. authorities from forcing people to
stay inside and divulge their social relationships.
Still, some other democracies have devised a more coordinated
testing and tracing strategy than the United States.
In Germany, a country with about 400 public health offices, contact
tracing early on was part of a collaborative effort. Workers from
other municipal government offices lent a hand. The national Robert
Koch Institute said it deployed hundreds more “containment scouts” –
mostly medical students – to help. Daily confirmed cases in Germany
now number in the hundreds. Deaths per day are down to the single
digits, from a peak of over 300 on April 16.
In the United States, daily case counts that had been falling since
mid-April began climbing again in July, reaching a peak of 77,299
July 16.
The federal government has largely taken a hands-off approach to
contact tracing, as well as other public health measures during the
pandemic. Though the CDC has issued guidance for contact tracing, it
is not deeply involved. And though Congress authorized billions of
dollars in aid that could pay for tracing, the money is not required
to be used that way.
Trump and many of his fellow Republicans in Congress have often
downplayed the threat posed by COVID-19. In July, the White House
tried to block new funding for testing and contact tracing –
something the White House later disavowed amid opposition even from
Trump's own party. Since then, Senate Republican leaders have
proposed a relief bill that would dedicate $16 billion for the
effort, while a bill passed by the Democrat-dominated House would
provide $75 billion for testing, tracing and hospital support.
Negotiations are at a crawl.
A senior CDC official told Reuters in a statement that the agency
has provided more than $12 billion across the country to address the
COVID 19 crisis, including a recent grant of $10.25 billion for
testing and other activities such as contact tracing. In addition,
the official said, the CDC has provided staff and extensive
technical support to states.
“Contact tracing is most effective when local communities embrace it
and drive it,” said the official, who declined to be named. “The
Administration has empowered states with funding to lead these
efforts."
REALITY SINKS IN
A few days before Las Vegas casinos reopened in June, state health
officials in Nevada predicted a wave of coronavirus cases.
[to top of second column] |
The state should have as many as 700 people working on contact
tracing to meet the surge, the officials wrote in a May 29 COVID-19
“plan of operations,” which Reuters obtained under a Freedom of
Information Act request. Referring to the roughly 100 tracing
staffers then aboard, the plan said staffing “falls short of what is
needed to effectively manage the need.”
It took two months to staff up. As of July’s end, Nevada had 744
staffers statewide, a Nevada Health and Human Services department
spokeswoman said.
Still, Las Vegas and surrounding areas have struggled. The Southern
Nevada Health District (SNHD) saw about 1,000 new cases a day by
mid-July, up ten-fold from the first week of June (although new
cases have dropped precipitously in recent days).
A SNHD official told legislators last week that the district had
less than half the tracing staff needed to serve Clark County, home
to Las Vegas.
Raman, the senior investigator in the southern district, estimated
in mid-July that her department was able to interview between 25%
and 40% of people who recently tested positive.
“Right now, unfortunately, we are just trying to keep our heads
above water.," she told Reuters.
It was a similar story in other hotspots. Health officials for
Harris County, Texas, who serve the Houston suburbs, have reported
about 550 cases a day since July 1, up from about 200 a day during
the first half of June.
Harris County reported reaching about 60% of the newly positive
people to interview about contacts. In general, epidemiologists told
Reuters, the goal should be at least 75%.
Martha Marquez, a county spokesperson, described the 60% figure as
“good” but said the county was “looking into how to grow our success
rate.”
Other departments struggle to keep potentially infectious people in
quarantine. Ideally, a tracer notifies contacts, refers them for
testing and advises them to stay home and away from others. Then
someone in the department follows up to see if they need anything to
stay indoors – house-cleaning supplies or food, for instance. It’s
no guarantee they won’t go out, but tracers say it can make a
difference.
In Alabama's Mobile County, with case counts exploding to more than
1,000 cases a week by mid-July, follow-up was next to impossible.
“It is not going well,” said Murphree, the disease surveillance
director.
For months, the health department in Mobile relied only on existing
health staff for contact tracing – as well as a few volunteers. It
took until mid-July for the department to hire two people dedicated
to that work, positions that the federal government has promised to
fund, Murphree said.
The county has not yet received the money, she said.
This lack of resources is being felt across the country.
Despite pleas for assistance, local health departments in Missouri
have received little to no COVID-19 funding from the state.
Meanwhile, the state recently announced a $15 million package to
help support tourism, using funding from the federal CARES Act – a
$2.2 trillion COVID-19 relief package passed by Congress in March.
"Tourism is a major employer and a major boon to the economy of
Missouri,” said Scott Clardy, assistant director of the
Columbia/Boone County Department of Public Health and Human
Services. “That being said, here we are not being able to
investigate cases, but we're giving $15 million to the tourism
industry to bring in more people."
Clardy said, however, that he was expecting almost $1.8 million in
CARES Act funding for contact tracing and testing to become
available as early as this week.
Contact tracing efforts are strained not just by the sharp rise in
cases but by the long delays in getting COVID-19 test results back.
David Holcombe, the director of the Louisiana Department of Health
for the central portion of that state, said that, as of mid-July,
the turnaround was as long as 14 days.
The lag time makes “contact tracing virtually useless,” he said.
That’s because by the time positive results come back, the infected
person has potentially had many more contacts, who have potentially
infected others themselves.
KEEPING UP
Not all contact-tracing efforts are in disarray.
In San Francisco, cases are rising but not spiking to the level seen
in other places in the country. So far, contact tracers say they
have been able to keep up – largely through the efforts of
redirected city workers.
Before the pandemic, program manager Jana De Brauwere could be found
at San Francisco’s main public library, using one of the four
languages she speaks to help patrons without computers apply for
jobs and other services online.
Since April, dozens of librarians, attorneys and other San Francisco
city workers have been redeployed to trace COVID-19 contacts –
though at some cost to the city’s other public services.
After about 20 hours of training, De Brauwere started calling people
exposed to the disease, arranging for supplies to help them
quarantine, and referring them for testing. Soon she was promoted to
team leader.
A typical shift now starts at 7 am, when De Brauwere parcels out
roughly 100 contacts for her eight-tracer team to interview that
day. De Brauwere has given up all her library work. “This is the
priority,” she said.
The city’s contact tracing program, which is getting help from
nonprofit organizations, reported reaching over 80% of people with
positive tests through the third week of July, an exceptionally high
rate. Similarly, health officials in Vigo County, Indiana, report
being able to interview nearly all positive cases. Wise, the county
health administrator, said local contact tracers have been more
successful at reaching people than those at the state level.
The state’s tracers often are contractors who don’t understand the
area, she said. That unfamiliarity can alienate residents and make
them less likely to share critical health information, she said.
'A THREAT TO OUR PRIVACY'
Even with sufficient money and staff, health departments often have
trouble convincing people to pick up the phone and cooperatively
answer questions.
Playing into that problem are political divisions throughout the
country over how seriously to take the pandemic and what
responsibilities the government should or should not impose on the
public.
In Texas, a Republican state representative in June called for
ending the contact tracing program as “a threat to our privacy and
individual liberties.” The Republican-controlled Kansas legislature
in June passed a COVID-19 bill with bipartisan support ensuring that
no civil or criminal penalties would apply to anyone who refuses to
provide information to a tracer. Such penalties, to the limited
extent they are allowed under public health laws, are rarely
enforced.
People may be reluctant to engage with tracers for a variety of
other reasons, including embarrassment for exposing themselves to
infection or fear they’ll lose their job.
Sometimes, contact tracers are hindered by misunderstandings.
In early June, in Berrien County, Michigan, contact tracer Karen
Kortebein received a call from a public health nurse in a
neighbouring county. An employee of a long-term care facility there
– a resident of Kortebein’s county – had contracted the virus.
Kortebein knew the woman. She'd been speaking with her since her
husband tested positive in May.
Kortebein had asked the woman then if she was working outside her
home. The woman said no. But in reality she had been working –
possibly while infectious – with a particularly vulnerable
population until her husband became ill, something contact tracers
needed to know as soon as possible.
It turned out the woman, whose first language is not English, had
misunderstood the question. Also, she was confused about the risk
she posed because she’d had conflicting test results and had yet to
develop symptoms.
For Kortebein, it was a lesson in how easily wires can get crossed.
“I was kind of blown away,” she said.
(Benjamin Lesser and Andrea Januta reported from New York, Dan
Levine from San Francisco, and Jaimi Dowdell from Los Angeles.
Additional reporting by Douglas Busvine in Berlin and Alexandra
Alper in Washington, D.C. Editing by Michele Gershberg, Janet
Roberts and Julie Marquis)
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