Why Contact Tracing Couldn't Keep Up With The U.S. COVID Outbreak
Despite a massive hiring push last year, health agencies around the U.S. failed to contain the pandemic through contact tracing. Health leaders reflect on lessons learned and what's next.
Here's one (more) sign the COVID-19 pandemic is on the decline in the United States.
NPR's latest survey of state health departments with the Johns Hopkins Center for Health Security finds many are winding down the contact tracing programs they scrambled to grow last year. More than half of the 36 health departments that responded to the survey in late May had fewer tracers than in December, and the vast majority isn't planning to hire more.
In a way, that makes sense. With coronavirus infections tapering off in most parts of the country, public health experts said a smaller workforce may be able to keep on top of current outbreaks.
But there are some big questions as these programs transition from full-throttle crisis mode to something new. Why, despite furious efforts to ramp up the workforce last year, was the U.S. not able to use testing and contact tracing to control the pandemic?
And how can the country be better positioned for the next public health emergency?
The Biden administration recently allocated $7.4 billion in funding to hire public health workers, potentially infusing the system with resources. Now state and local health departments, along with the Centers for Disease Control and Prevention, have to figure out how to build on the success and learn from the failures of the past year.
"What's coming next — with all this funding from the federal government to scale up public health workforces — is really critical," said Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security and collaborator with NPR on the contact tracing survey.
"It has to go beyond, how do we sustain this specific workforce very focused on contact tracing, to how do we make sure that we have the workforce we need to do better public health every day?"
The rush to ramp up
Early in the pandemic, with no vaccine in sight, contact tracing seemed like one of the best options to halt the burgeoning pandemic. Places such as Hong Kong and Singapore initially contained their outbreaks by deploying thousands of public health workers to track down every positive case, figure out their contacts and quickly get those people to quarantine.
But in the U.S. in April 2020, state health departments told NPR they had only about 11,142 contact tracers, which clearly wasn't enough to do something like that in a country of 330 million people. Public health experts told Congress the country needed to increase the workforce tenfold to 100,000 or more.
"We are going to need a substantial expansion of public health field workers," then-CDC Director Robert Redfield told NPR in April 2020. "We can't afford to have multiple community outbreaks that then can spiral up into sustained community transmission. So it is going to be very aggressive — what I call 'block and tackle,' 'block and tackle.' "
Local and state health departments responded with a massive hiring and training effort.
Over the course of 2020, NPR and the Johns Hopkins Center for Health Security surveyed state and territorial health departments on their contact tracing programs five times. From 11,000, the contact tracing workforce grew to a peak of more than 70,000 in December.
By the time cases started to spike dramatically last winter, it was clear "we still did not have enough people to respond and deliver case investigation and contact tracing," said Dr. Melanie Taylor, an epidemiologist at the CDC who's currently a senior advisor on contact tracing in the agency's COVID-19 emergency response.
The dream of an army of contact tracers who would stop the spiral into sustained community transmission had largely fallen through.
''Trying to build the plane while flying it''
One reason the U.S. wasn't able to hire enough contact tracers to handle the winter surge — even with millions of Americans unemployed — is because health departments had to staff up after decades of cuts.
"Scaling up contact tracing was a larger task because you weren't just starting from zero, you were starting from a deficit when it came to the workforce," said Adriane Casalotti of the National Association of County and City Health Officials. "Local health departments entered the pandemic down over 20% of their workforce capacity."
"We didn't have a deep bench — we didn't have a bench at all," she added.
Katherine Feldman, contact tracing program manager for Maryland's Department of Health, said the problem wasn't just finding people to hire — it was much more complicated.
"It takes a minute to recruit qualified staff and train them up and get them going," she said. Then, she said, because of the intensity of the work, contact tracers might only work part time or leave after a few months.
When the virus spread out of control, staffing got even more complex. She had to figure out, "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 challenging," Feldman said. "I think we actually did a pretty good job in the face of all of that."
But perhaps the biggest reason that the U.S. wasn't able to scale up enough, Casalotti said, is that communities began to open up in the spring and summer of 2020 before hires were trained and ready to go. Once cases surged, there was no way contact tracers could keep up.
It was kind of like "trying to build the plane while flying it," she said. "The system was not in place in advance, and that really made it a lot harder for contact tracing overall to be as successful as it could have been."
An absence of federal leadership
Although Redfield, the CDC director at the time, made ambitious promises about potential federal collaborators such as the Peace Corps or the Census Bureau to scale up a national contact tracing army rapidly, those plans didn't materialize in any large-scale way.
And even when it came to funding the states' efforts, the federal government left things open-ended. There were tranches 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, so the amount devoted to contact tracing varied a lot from place to place.
"There was just a general lack of communication from authorities — particularly CDC or the White House — early on about contact tracing and its importance," said Watson of Johns Hopkins.
The lack of federal leadership made it hard for different contact tracing programs to learn from each other, Watson said. "They didn't even really have a chance to gather together and try and understand what other jurisdictions were doing so they didn't have to reinvent the wheel," she said. "That federal role for guidance and coordination and advice is really important, and there probably wasn't enough of that over the last year."
As the months went on, health departments had to deal with exploding case counts and vaccination campaigns. "So at a time when contract tracing probably needed more resources and more focus, there was big competition from other parts of the response," she said.
A deficit of trust
For contact tracing to work, first of all people need to answer the phone. In the U.S. contact tracing effort, that proved to be a big problem.
A CDC analysis of 14 contact tracing programs from June to October 2020 published Thursday in JAMA Network Open found that "no contacts were reported for two-thirds of persons with laboratory confirmed COVID-19 because they were either not reached for an interview or were interviewed and named no contacts."
The authors assessed that, during this period, "contact tracing activities were not sufficient for reducing SARS-CoV-2 transmission in most communities." In other words, it didn't work very well.
"The trust aspect has been an uphill battle throughout all parts of the response," said Nicole Roberts, who runs the contact tracing program in Utah. As cases grew and the pandemic became more and more politicized, that distrust grew stronger, she said.
A recent poll by the Harvard T.H. Chan School of Public Health and the Robert Wood Johnson Foundation found only 52% of Americans really trust the CDC; the numbers for state and local health departments were even lower. The distrust was especially strong among Republicans — 27% of Republicans greatly trust the CDC, compared with 76% of Democrats.
"Before we had people who were not getting vaccinated because of political reasons or under the guise of freedom, we had people who weren't going to pick up the phone when a contact tracer called," Casalotti said.
Sometimes that distrust turned ugly. Dozens of public health leaders have resigned or been forced out, Casalotti noted. "Some of them were physically threatened, their families were threatened, others who were politically scapegoated," she said.
Trust is a challenge, agrees Feldman in Maryland. "We don't want to be public health police," she said. "We want to be perceived as service deliverers and connections to resources and [able] to provide guidance and help for these difficult times."
Digital tools were not shortcuts
Distrust got in the way — not only when it came to connecting with public health workers — but also when it came to the technology that was part of contact tracing's success in other parts of the world.
"Earlier on in [Utah's] response, we had an app called Healthy Together that used GPS location and was supposed to be a really amazing tool for contact tracing — kind of similar to what we were seeing in South Korea," Roberts said.
The app, she said, was a "disaster." She said the first challenge was getting people in Utah interested and willing to download the app. "Then, once people found out that the app was tracking where you had been through GPS, there was a huge outcry," she said, and many people turned the GPS feature off.
Utah — and many other places — now use the "exposure notification" platform from Apple and Google, which lets Bluetooth anonymously track proximity and alert people if they have been near someone who tested positive, without tracking movements. "It works a little better," Roberts said, but the ways that it protects privacy also limit how much it can tell the health department about what's going on with the virus.
Feldman said in Maryland officials are still evaluating how much these digital tools helped. "I can't give you a quantitative measure of its impact," she said. "But I am very glad to have it as another tool in the toolbox."
Looking ahead: Breaking the boom-bust funding cycle
It was hard work for health agencies lacking resources to scale up to face the pandemic last year without an infusion of funding. Now that funding has arrived at what experts hope is the tail end of the COVID-19 crisis.
The Biden administration's new funding is designed to put state and local health departments on stronger footing to do both the bread-and-butter work of public health — restaurant inspections, rabies control, HIV outreach — and to be better prepared next time an infectious disease outbreak or pandemic hits.
But state and local leaders are not sure what to do with the money that's now available. "We're just being inundated with so much funding that it's almost like you're scrambling, trying to figure out what all to use it on," Roberts said.
In Utah, they're having to move staff around. "Cases dropped pretty drastically, and so then we had a ton of people and we were wondering what to do with everyone," she said. Some contact tracers transitioned to helping with mobile COVID-19 testing teams or vaccine clinics.
Watson of Johns Hopkins hopes the federal government will provide guidance about the best positions to hire, for instance. In NPR's latest survey of state health departments, "there were very few respondents who had some concrete idea of how they would use those American Rescue Plan funds," she said.
"The funds are so new," the CDC's Taylor noted, that it'll take time for health departments to figure out what they'll need. "I do say that CDC is standing by to assist states to implement those funds."
This funding represents a huge opportunity to reverse the years of disinvestment in the public health system, said Casalotti of the National Association of County and City Health Officials. She hopes the funding makes it to the local level. "Local health departments are really that front line of the federal, state, local partnership," she said.
The new funding is on a timeline. "There is a lot of concern — rightly so — that this money is still temporary," Watson said. After it runs out, there's no guarantee it will be replenished.
So there's a fear that after the current funding feast, "a few years from now, we might be hitting famine," said Roberts of the Utah Department of Health.
Then, if there are new political leaders with different priorities, health departments will be in the difficult position "where we've built all of these programs and we have all of this capacity, and then the funding will dry up because the pandemic response is no longer sexy."
Watson and other public health experts said they hope the U.S. will break this cycle so that — in the next pandemic — the country won't have to build the contact tracing plane while flying it.
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