UPDATE: President Trump announced Friday that he and the first lady tested positive for the coronavirus. Their close contacts may have been exposed to the virus. The public health technique of contact tracing is used to map the possible chains of transmission and prevent further spread. Here’s how it works and what would it take to scale it up.
A birthday party held during the coronavirus pandemic might as well be the stuff of mystery novels.
“When you have a larger party, then that’s when we start talking about outbreak management,” said Angel Algarin, a public health and epidemiology doctoral student at Florida International University. “You almost feel like Sherlock Holmes, doing that investigative work.”
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Until April, Algarin was helping chart the story of virus spread as a contact tracer for the Broward County Department of Health. For eight hours a day, six days a week, he called people who tested positive for COVID-19 and asked them several detailed questions about symptoms, recent travel and their close contacts — generally the partners, family members, caregivers and other people whom we frequently encounter.
“Our first line of defense is up to the people. Wearing those face masks. Keeping that social distance,” Algarin said over Skype. “When that fails, you go to that second level, and that’s us. We’re just trying to mitigate further spread.”
Between Florida reopening, and recent protests against police brutality, more people are sharing the same space. That means more opportunities for COVID-19 to spread, which the state needs to mitigate.
One classic technique is contact tracing.
It’s not new to COVID-19. It’s been done all over the world throughout the year for all kinds of contagious diseases. It’s based on the idea that someone who’s sick will infect a certain number of people. With the coronavirus, it’s likely two or three, according to the World Health Organization .
The goal of contact tracing is to protect other people from getting sick. If an infected person potentially transmits a virus to other people, then those close contacts are monitored and advised to isolate at home — for 14 days in the case of COVID-19.
Dr. Robert Redfield, director of the Centers for Disease Control and Prevention, has said that contact tracing is key to slowing the spread of the virus and, in turn, keeping local economies running.
A study by The Lancet Infectious Diseases found that isolation and contact tracing helped control the spread in China.
“In order to stop this virus, we need to make sure we can identify those infectious individuals, get them to stay home and break that transmission cycle,” said Caitlin Wolfe, an infectious epidemiology doctoral student at the University of South Florida, who’s also a contact tracer for the Polk County Department of Health. “Anytime that you have diseases that can easily move from person to person, contact tracing comes into play.”
Wolfe did similar work with the World Health Organization’s Ebola Surveillance and Response Team during the 2014-15 outbreak. In Liberia, she helped train other contact tracers to track down people who might have the virus.
In Polk County, Wolfe and her fellow tracers make as many calls as there are positive COVID-19 cases recorded by the state. She said the call volume per day varies and depends both on the number of close contacts and the length of an investigation.
Contact tracers also teach people how not to get other people sick. They would recommend that someone who’s sick should stick to one bathroom in their house, if possible, avoid utensils and wear a mask in common spaces, among other things.
The human factor complicates the process, too. Tracers are required to build trust so people access their memories of being in public spaces more accurately.
“If somebody went somewhere, when they weren’t feeling good, and they’re ashamed to tell us, we’re going to be missing those chains of transmission,” Wolfe said.
Wolfe and other contact tracers speak in generalities because of strict patient privacy laws. They protect people’s personal information — and a sick person’s identity isn’t revealed to close contacts.
As communities reopen, capacity is going to play a more important role, Wolfe added.
“You need to make sure that you have enough people to make all the phone calls that need to be made,” she said. “Epidemics don’t take a day off.”
Public health agencies across the country have discussed hiring more tracers. New York, which has suffered one of the worst COVID-19 outbreaks in the country, wants to hire as many as 17,000 contact tracers. One requirement for that job is to take and pass a free online course made by Johns Hopkins' Bloomberg School of Public Health.
The state of Florida is working on expanding its contact tracing efforts, according to Dr. Shamarial Roberson, Deputy Secretary of Health for the Florida Department of Health. She said the agency recently hired a third-party call center, Maximus, to bolster the state’s contact tracing workforce. The state of Indiana hired the same company for this purpose.
In the coming weeks, Florida is expected to have about 2,000 people doing that work, Roberson said.
Before the pandemic, Roberson said Florida had about 200 disease epidemiologists who were on call in every county to monitor infectious diseases. As the number of positive COVID-19 cases grew, in coordination with the CDC, the agency began hiring and training health care workers and folks from public health schools for contact tracing.
The National Association of County & City Health Officials (NACCHO) recommends at least 100,000 front-line contact tracers nationwide. In April, it gave a baseline estimate of 30 tracers per 100,000 people to respond to the outbreak.
By that math, Florida would need around 6,000 tracers.
“As we reopen, we have a very comprehensive plan, including hiring additional employees. So we have the ability to bring people in as short as less than 24 hours and get them trained,” she said when WLRN asked her about NACCHO’s recommendation. “We can move contact tracers across the state to target the areas of need. So we’ll watch the numbers, and based on the cases we have, we’ll make changes accordingly.”
Contact tracing goes beyond re-starting the economy. Increasing those efforts helps communities prepare for an expected second wave of the virus this fall.
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