Quickly tracking the contacts of COVID-19 patients is vital for reopening Washington, Gov. Jay Inslee has said, but his administration can’t tell you if it’s meeting its own goal to reach people within 48 hours of a positive coronavirus test.
Three months into the pandemic, state officials have drafted and trained a small army of workers who are now finally ready to make phone calls — but they’re mostly just waiting as counties instead have staffed their own investigators.
Those who are doing the work have found that more than 40% of phone numbers and other key information is missing, due in part to gaps in reporting from laboratories and illegible handwriting. They are often filling out paper forms because the state’s central database for tracking disease is inadequate.
And people who test positive aren’t always responsive when investigators call.
Despite these glitches, counties across the state are largely able to track their individual cases, and some, including King County, are at or near their goals.
Unlike some peers across the country, Washington’s largest counties abandoned full contract tracing in the earliest stage of the pandemic. And now, as pressure grows for a return to normalcy, a drawn-out effort to fully restart the critical of work of contact tracing is running into setbacks.
“We’ve never had to do something of this magnitude before,” said Maria Courogen, the state Department of Health’s branch director for disease containment. “Some of these things are us making up for lost ground from even before COVID.”
Contact tracing may be simultaneously at its most relevant and irrelevant point in the pandemic. Public health experts have been warning for months that the U.S. cannot reopen without effective contact tracing. But recent nationwide protests over racial injustice and the police killing of George Floyd have created opportunities for mass transmission that can’t practically be traced.
Still using paper forms
Think of local epidemiologists as the equivalents of paramedics. How quickly they respond to a report of an emergency — here, the notification of a positive coronavirus test — can determine how many lives are lost.
When a laboratory reports a test result, local health investigators have two pressing tasks: Interview the person who tested positive, and then call their close contacts, who are asked to quarantine for two weeks. The system is meant to reduce transmission and prevent future outbreaks.
“When we get a disease that is deadly, and if it gets to low enough incidence or prevalence in the population, we have a chance to actually stop that onward transmission before more people get infected,” said Dr. Neil Abernethy, associate professor of biomedical informatics and medical education at the University of Washington School of Public Health.
Like fire departments, health departments track their response times. The state has set coronavirus targets: In 90% of cases investigators should reach the person who tested positive within 24 hours of receiving the lab result. Also, 80% of their close contacts — those who’ve been within 6 feet of an infected person for about 15 minutes — should be reached in 48 hours.
State and county health departments have a computer system to track initial case investigations, but it’s not designed to monitor contact tracing, state DOH spokeswoman Amy Reynolds said. Instead, local agencies have developed their own processes, and sometimes still rely on paper forms.
Investigators at Public Health – Seattle & King County, the state’s largest local health agency, still document some interviews on paper.
Counties are calculating their own coronavirus response times and reporting those figures to the state when they want to advance to the next stage of Inslee’s “Safe Start” reopening plan. But that reporting is sporadic, and doesn’t allow state officials to actively monitor progress.
Because of the limitations, the Department of Health can’t say how quickly investigators are reaching COVID-19 patients or their contacts.
State health officials, trying to fix the data problem, recently launched a pilot program with just two local health agencies, in Pierce County and in the state’s far northeast corner. The counties can record both case investigation and contact tracing data using a Microsoft tool. It is being used by at least nine other states for COVID-19 tracking, but be won’t be fully ready in Washington until late summer.
“The fact that we can’t consistently track it doesn’t mean it’s not happening,” Reynolds said. “We believe that counties are doing their best to meet their measures.”
When a Pierce County resident tests positive for COVID-19, the first person they might hear from is Kimberly Steele-Peter.
Steele-Peter supervises a group of contact tracers with the Tacoma-Pierce County Health Department whose job includes, in some cases, delivering the news of a positive test, and then teasing out sensitive information that can help public health officials better understand and contain the disease.
“You pause, let them react,” Steele-Peter said. “They may say, ‘Why are you calling me, why isn’t it my doctor’s office?’”
There were 164 new cases of the virus in Pierce County in the last two weeks of May, but those people reported only 190 close contacts, just over one per person. That ratio will surely change as stay-home orders are lifted and more people begin to return to normal routines. Indeed, the county’s projections for how many contact tracers it will need assume each case will have eight close contacts that need to be reached.
Getting people to answer the phone in the first place has been an obstacle, said Courogen, from the state Department of Health. The state is trying to raise public awareness so people know they may be reached during an investigation. “We really need people to understand that they will be getting calls,” she said.
Sometimes the process breaks down even before then.
Phone numbers and other key contact information appears to be missing for roughly 43% of COVID-19 cases entered by testing labs or local public health staff into the state’s central database, called the Washington Disease Reporting System, according to a recent review by state health officials, Reynolds said.
In some cases, the labs don’t provide the needed information to public health agencies. In others, the health care provider doesn’t collect the right info or provide it to the lab. Still other issues stem from human error, like illegible handwriting.
The state is working with labs and health care providers to improve their reporting, said Courogen.
“Putting out fires”
It’s understandable that the public would be unfamiliar with contact tracing, as some local agencies essentially stopped doing it right after COVID-19 cases emerged here in March.
Public Health — Seattle & King County was overwhelmed nearly immediately, Dr. Jeffrey Duchin, the department’s health officer, wrote in an email obtained by The Seattle Times through a public records request.
“We quickly became unable to follow up on contacts because all staff were constantly putting out fires and the investigations were taking hours each and we frequently did not even have contact info for contacts,” he wrote to a New York City official on March 8.
Duchin wrote that he didn’t know exactly how many COVID-19 cases King County had when it stopped contact tracing, but estimated it was between 10 and 20. On March 2, only three days after the county’s first positive test result, King County broke the 20-case mark.
Kate Cole, a spokeswoman for Duchin, said in an email recently, “It was unclear how effective contact tracing would be” at that point. Test results were slow, and people were waiting a long time to receive medical care, so when the county finally compiled a list of contacts, it was impossibly long.
State workers took over the county’s initial case investigations, and King County only followed up when a patient lived in or worked at a high-risk facility, such as a nursing home or homeless shelter.
The shift allowed King County to “focus on broad prevention strategies to reduce transmission” and managing the health care system as the virus spread, another spokesperson wrote in an email.
In Washington, King County was not alone. Snohomish and Pierce counties switched to so-called “mediated” contact tracing in mid-March, where investigators ask patients to notify contacts themselves.
“Sure, in an unlimited resource world, they would continue to do contact tracing,” said Rebecca Katz, a professor and director of the Center for Global Health Science and Security at Georgetown University Medical Center in Washington, D.C. “They were running in a hundred different directions, trying to respond to the high-risk populations.”
Health agencies in some other major cities, however, managed to keep conducting full contact tracing throughout the pandemic.
“We never stopped,” a San Francisco Department of Public Health spokesperson said in an email. The city/county health agency trained librarians, city attorney employees, and UC San Francisco medical students. By early May they had 276 people trained, with 120 conducting contact tracing.
The public health agencies that cover the cities of Austin and Portland also never stopped contact tracing, according to spokespeople at each department.
Counties handle the load
Washington state announced a contact tracing plan on April 21 and said its reinforcements would be up and running by the middle of May. The state trained more than 700 National Guard personnel, nearly 800 Department of Licensing staffers, and 130 Department of Health workers to fill in for local staff.
As of last week, only 103 of the state-trained workers were conducting case and contact-tracing calls. Most counties, it turns out, are now able to meet the demands with their own workers, particularly because the state has been on partial lockdown, and COVID-19 patients have had very few close contacts. The rest of the trained contact tracers could be used if there is a second wave of infections.
The state has been assisting seven counties, including King and Snohomish. King County reported on June 3 that it was exceeding the state’s goals for quickly reaching both the patient and their contacts, but Snohomish was still behind on both measures. Pierce County is behind on one target but ahead in the other.
The task will get more difficult as counties continue to reopen their economies.
Pierce County, for instance, needs only about 20 contact tracers to track the disease today, but county health officials believe “a surge of cases is likely to occur as Washington opens.” Their surge scenario envisions a staff of 200 contact tracers who would need to reach 1,400 close contacts each day.