POST 36. July 2, 2020. CORONAVIRUS. “There’s just a handful of interventions proven to curb the spread of the coronavirus. One of them is contact tracing, and “it’s not going well,” (Dr. Anthony Fauci)..

“Contact tracing occurs when trained personnel contact infected people to investigate where they might have been infected and who they might have exposed to the virus. Along with widespread testing and ability to isolate potentially infectious people, tracing is an age-old public health intervention now being ramped up at an unprecedented scale.

“It’s not going well. I have to tell you, it’s not going well,” Fauci said in an interview with CNBC’s Meg Tirrell that was aired by the Milken Institute. “What we need to do is we need to rethink, and we are right now, the idea of many more tests getting into the community and even pooling tests.”

The White House advised states not to reopen until they had built the infrastructure to conduct widespread testing and contact tracing, though the federal government did not specify what a robust tracing infrastructure would look like. Rather than developing a coordinated national tracing plan, which some countries, such as Germany, have done, the Centers for Disease Control and Prevention has sought instead to support local efforts.

Earlier this week, CDC Director Dr. Robert Redfield testified that about 27,000 or 28,000 people are doing contact tracing work across the country. He later acknowledged that he estimates the necessary workforce to be about 100,000 tracers. Former CDC Director Dr. Tom Frieden thinks the country will need even more, up to 300,000.

“To just say you’re going to go out and identify, contact trace and isolate, that doesn’t mean anything until you do it,” Fauci said. “Not checking the box that you did it, but actually do it. Get people on the ground. Not on the phone. When you identify somebody, have a place to put them to get them out of social interaction.”

The CDC has allocated more than $10 billion for states to ramp up testing, tracing and isolation, but Fauci said he doesn’t see local officials making the kind of progress he’d like to see. He added that some states have done well in ramping up their programs. Getting more jurisdictions to do that work in preparation for the fall, when Fauci said he expects cases to surge again, will be key.

“When the fall comes, we better be ready that there will be surges in cases, and as I’ve said so many times now for months, we have a few months to prepare for that,” he said. “So when that happens, we have to be able to do the proper and effective way of identification, isolation and contact tracing.”” (A)

“Government virus expert Anthony Fauci told reporters in a press briefing on Friday that contact tracing efforts to contain the coronavirus are “not working.”

Why it matters: Without a vaccine, contact tracing of cases is the best tool available to stem the spread of an outbreak. But understaffed public health agencies, privacy concerns, disappointing technology, and the sheer size of the pandemic are limiting the technique’s effectiveness.

By the numbers: The public health standard is that a state should have at least 30 contract tracers — public health employees dedicated to investigating the contacts of positive cases — for every 100,000 people during a pandemic. According to a June 25 report by Nephron Research, however, just seven states have met that standard.

Another seven have near-term plans to sufficiently increase contact tracing capacity.

Even those states that have sufficiently beefed up their contact tracing systems are struggling to get people who have tested positive to report whom they were in contact with — or, in some cases, to even pick up the phone.

New York state currently has nearly 50 tracers per 100,000 people, the most in the U.S. But in New York City, long the epicenter of the pandemic, contact tracers were only able to successfully complete an interview with about half of all positive cases between June 1 and June 20.

That’s well below the 75% rate public health experts say is needed to keep an outbreak contained.

The situation is worse in other hard-hit cities like San Antonio, which has only received responses from about 300 of the 2,500 cases currently under review.

Context: The U.S. has had great success in the past controlling diseases like HIV and tuberculosis through contact tracing. But COVID-19 would present enormous challenges to even a well-funded and well-staffed national contact tracing effort — which the U.S. assuredly does not have.

Unlike tracing the spread of STDs, where contacts can be narrowed down to sexual partners, COVID-19 requires tracers to quiz a positive case for everyone they may have come into contact with, even for a relatively short period of time.

Early hopes that app-based smartphone contact tracing might help have largely gone unfulfilled….

The bottom line: More than four months after the first recorded U.S. COVID-19 cases, the virus is still outpacing our ability and willingness to track it.” (B)

“Dr. Anthony Fauci, the nation’s top infectious disease expert, said Friday that contact tracing simply isn’t working in the U.S.

Some who test positive don’t cooperate because they don’t feel sick. Others refuse testing even after being exposed. Some never call back contact tracers. And still others simply object to sharing any information.

Another new challenge: More young people are getting infected, and they’re less likely to feel sick or believe that they’re a danger to others.

While older adults were more likely to be diagnosed with the virus early in the pandemic, figures from the Centers for Disease Control and Prevention show that the picture flipped almost as soon as states began reopening. Now, people 18 to 49 years old are most likely to be diagnosed…

“Right now we have an insufficient capacity to do the job we need to,” Arkansas Gov. Asa Hutchinson said recently, announcing he wanted to use federal coronavirus relief funds to increase the number of contact tracers to 900.

Arkansas already has 200 doing the job, but infections have risen more than 230% and hospitalizations nearly 170% since Memorial Day. Businesses that had closed because of the virus were allowed to reopen in early May, and the state further eased its restrictions this month.

In addition to needing more staff to handle rising case numbers, contact-tracing teams also must build trust with people who might be uneasy or scared, said Dr. Umair Shah, executive director for Harris County Public Health in Houston, where an outbreak threatens to overwhelm hospitals.

That’s difficult to do if infected people don’t return calls…

Perry N. Halkitis, dean of the Rutgers School of Public Health, said COVID-19 spreads so fast that contact tracers need to get in touch with 75% of the potentially exposed people within 24 hours of their exposure to successfully combat the spread…

Contact tracing is key to avoiding worst-case outcomes, said Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention and current president and CEO of Resolve to Save Lives, a nonprofit that works to prevent epidemics. But the explosion of U.S. cases has made it nearly impossible for even the most well-staffed health departments to keep up, he said.

Contact tracing is “a tried and true public health function,” Frieden said. “If the health department calls, pick up the phone.” (C)

“Dr. Anthony Fauci, the nation’s top infectious diseases expert, raised a question Friday as to whether contact tracing is even worth the endeavor. And in Texas, a health official in Austin revealed this week that information about hundreds of new cases is pouring in daily across the state via an archaic form of technology: the fax machine.

That has made the confirmation of positive cases extremely time-consuming, the official said, which in turn has hindered contact tracing, a labor-intensive commitment that involves calling people who are confirmed ill with COVID-19, asking for their recent contacts and reaching out to those people to determine if they need testing and if they should self-isolate, all in the hopes of breaking the chains of infection.

“The cases we receive come in by fax machine,” Dr. Mark Escott, the interim medical director and health authority for Austin Public Health, told Travis County commissioners. “And sometimes those faxes are positives and sometimes they’re negatives. Sometimes they have information like the person’s phone number that was tested and sometimes they don’t. So we have a whole team of people who have to sort through more than a thousand faxes a day to sort out the positives versus the negatives.”

The system remains a “very manual and archaic process,” he added, because nearly all of the labs and the hospitals in the state report coronavirus cases through fax, and those results must then be manually entered into a computer…

“Right now, what happens when you call somebody that’s a positive and ask where they’ve been over the past week, they’ve been everywhere. They’ve been at grocery stores and restaurants and bars and friends’ houses. They’ve had contact with hundreds of people,” he said at a news conference Wednesday. “Contact tracing in that circumstance is not going to be as effective. So that’s why we’re asking people not to depend on contact tracing at this stage of the outbreak.”

Since the beginning of the coronavirus pandemic, public health experts and Democratic lawmakers have been vocal about the need for local and state health agencies to perform contact tracing, in addition to ramping up of testing for COVID-19, the disease caused by the coronavirus.

But a lack of consistent messaging from the White House, the Trump administration’s apparent delay in distributing billions of dollars in funding appropriated by Congress in April for testing and tracing, and the woefully inadequate number of contact tracers needed nationwide to appropriately handle the growing caseload have derailed the efforts to create a robust tracing program, experts add…

Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security, which released a report in April estimating the need to hire 100,000 contact tracers as part of a nationwide workforce, said there’s been a noticeable lack of a “top level embrace of contact tracing.”

While she said she’s “heartened” by states and local health agencies that moved to ramp up contact tracing efforts ahead of reopening their economies, including in Massachusetts and New York, she is “disheartened by the lack of support from our federal government on this.”” (D)

“Kimberly Jocelyn graduated from college last month as millions across the country sheltered in place to avoid the coronavirus pandemic. Looking for a pandemic-friendly way to connect with her community, she applied to be a New York City contact tracer.

After a FaceTime interview with New York City Health + Hospitals’ test and trace corps and a six-hour online course through Johns Hopkins University, Jocelyn joined the city’s team of roughly 3,500 in the effort to contact those who have tested positive for Covid-19 and identify who they might have exposed to the virus.

The work is crucial to cutting off chains of infection before they balloon into outbreaks. Along with social distancing and mask wearing, contact tracing is one of the only proven strategies in containing the coronavirus. It’s also difficult work, Jocelyn said, and it’s nonstop.

“My first call was with someone who was confused about how they contracted the virus,” she said, adding that it takes compassion and patience to do the job well. “We’re here to provide information about Covid, understand how they contracted Covid, and also to understand how they are, to see if they need any resources.”

Jocelyn, who’s now a supervisor of about 15 other tracers, said ideally, a tracer comes out of one of those conversations with contact information for family members, co-workers and anyone else who might have been exposed. Throughout a given day, a tracer on her team will contact between 30 and 50 people, tracking the virus around the city and trying to corner it off into identified chains of people…

“If you’re not doing mitigation, so closing things down, implementing social distancing, once you stop doing that, the only tool you have to keep people from transmitting to each other is contact tracing, isolation and quarantine,” said Dr. Karen Smith, former director of the California Department of Public Health. “It’s the only tool you’ve got and it’s a tool that works really well when adequately staffed.””  (E)

“New York City’s ambitious contact-tracing program, a crucial initiative in the effort to curb the coronavirus, has gotten off to a worrisome start just as the city’s reopening enters a new phase on Monday, with outdoor dining, in-store shopping and office work resuming.

The city has hired 3,000 disease detectives and case monitors, who are supposed to identify anyone who has come into contact with the hundreds of people who are still testing positive for the virus in the city every day. But the first statistics from the program, which began on June 1, indicate that tracers are often unable to locate infected people or gather information from them.

Only 35 percent of the 5,347 city residents who tested positive or were presumed positive for the coronavirus in the program’s first two weeks gave information about close contacts to tracers, the city said in releasing the first statistics. The number ticked up slightly, to 42 percent, during the third week, Avery Cohen, a spokeswoman to Mayor Bill de Blasio, said on Sunday.

Contact tracing is one of the few tools that public health officials have to fight Covid-19 in lieu of a vaccine, along with widespread testing and isolation of those exposed to the coronavirus. The early results of New York’s program raise fresh concerns about the difficulties in preventing a surge of new cases as states across the country reopen.

The city has successfully done contact tracing before, with diseases like tuberculosis and measles. But as with much involving the coronavirus outbreak, officials have never faced the challenge at this scale, with so many cases across the five boroughs.

The city’s program has so far been limited by a low response rate, scant use of technology, privacy concerns and a far less sweeping mandate than that in some other countries, where apartment buildings, stores, restaurants and other private businesses are often required to collect visitors’ personal information, which makes tracking the spread easier…

Perry N. Halkitis, dean of the School of Public Health at Rutgers University, which is guiding an effort to bring on thousands of tracers in New Jersey, called New York City’s 35 percent rate for eliciting contacts “very bad.”

He suggested that the poor showing stemmed in part from the inexperience of the contact tracers and insufficient hands-on training.

“This is a skill,” he said. “You need to practice.”” (F)

“For Lauri Jones, the trouble began in early May. The director of a small public health department in Washington state was working with a family under quarantine because of coronavirus exposure. When she heard one family member had been out in the community, Jones decided to check in.

The routine phone call launched a nightmare.

“Someone posted on social media that we had violated their civil liberties [and] named me by name,” Jones recalled. “They said, ‘Let’s post her address. . . . Let’s start shooting.’ ”

People from across the country began calling her personal phone with similar threats.

“We’ve been doing the same thing in public health on a daily basis forever. But we are now the villains,” said Jones, 64, who called the police and set up surveillance cameras at her home.

Public health workers, already underfunded and understaffed, are confronting waves of protest at their homes and offices in addition to pressure from politicians who favor a faster reopening. Lori Tremmel Freeman, chief executive of the National Association of County and City Health Officials, said more than 20 health officials have resigned, retired or been fired in recent weeks “due to conditions related to having to enforce and stand up for strong public health tactics during this pandemic.”

Although shutdown measures are broadly popular, a vocal minority opposes them vociferously. There have been attacks on officials’ race, gender, sexual orientation and appearance. Freeman said some of the criticisms “seem to be harsher for women.”

Marcus Plescia, chief medical officer with the Association of State and Territorial Health Officials, said attacks on health officials have been particularly awful in California, Colorado, Georgia, Ohio and Pennsylvania.

This month in California, Nichole Quick, Orange County’s chief health officer, stepped down after she faced threats and protests at her home for requiring face coverings in many businesses as cases rose. The mandate, issued May 23, was softened to a recommendation a week later.

Andrew Noymer, a professor of public health at the University of California at Irvine who is part of a county task force, said it was not the first time Quick had been undermined.

On March 17, Quick issued a strict lockdown order; a day later, it was amended to add exceptions.

“It was couched as a clarification, but it was a walk-back” because of pressure from business leaders, Noymer said.

Quick’s departure is part of an exodus of public health officials across the country who have been blamed by citizens and politicians for the disruptions caused by the coronavirus pandemic.” (G)

“Germany, a country of more than 83 million people, has flattened its coronavirus curve, dropping from a peak of more than 6,000 new cases a day to just around 600 now. Contact tracing by telephone is one tool the country has relied on.

“Public Health Authority, Pankow,” says an operator, answering her phone before the first ring is over and identifying the Berlin district where she works. “So,” she confirms with the caller, “you’ve had contact with someone who’s tested positive.”

She asks for the name of the infected person, types it into her computer, and the caller’s name appears on her screen as someone the contact tracers were about to call.

“Did you spend more than 15 minutes at close contact with this person?” the operator asks. The caller tells her they went for a walk.

Across Germany, there are about 400 call centers like this one, each filled with dozens of operators fielding calls from worried citizens, taking first steps at contact tracing and referring callers to medical personnel…

Merkel aims for the country to have one tracer per 4,000 people — nearly 21,000 tracers for Germany’s population of 83 million.

“We’ve recruited staff from other district authorities, including social services, but we also have traffic wardens and librarians working for us,” says Dr. Uwe Peters, director of the Pankow district health authority. “We’ve even recruited gardeners from parks and recreation. They all help man the hotline. We also have students helping out and we’re about to be allocated five soldiers as well.”..

“One teacher had contact with 400 students,” says Krummacher. “It could also be a midwife working at the hospital, having close contact to many, many women. There are all sorts of constellations.”” (H)

“John Welch, a nurse anesthetist with the nonprofit Partners in Health, was working at a clinic on the rural central plateau of Haiti when, in August of 2014, he got a call asking if he could fly to Liberia…

Liberia, a nation of five million people, eventually employed as many as ten thousand tracers. Welch recalled that, after he had been in the region for eight months, “if you told me there would be an outbreak in a particular region, I could tell you which village. If you told me the village, I could tell you which house.” … He told me, “I think we are at a similar point with covid-19 to where we were with Ebola when I first arrived in Monrovia.”..

Many states have also launched contact-tracing programs without what P.I.H. considers one of the most vital components—the care-resource coördinators who help solve the problems, like a need for food or medicine, that keep people from isolating. Mike Reid, an infectious-disease doctor at the University of California, San Francisco, who is helping design the city’s contact-tracing program, said that there was an active debate over whether to include care-resource coördinators. Reid believes that the role is “absolutely critical,” he told me, but because of funding concerns it was likely to be cut from the San Francisco program. “We’ve had plenty of states get on the phone with us, and you get to the care-resource-coördination part, and you can just see their eyes glaze over,” one P.I.H. staffer told me. “Like, ‘Wait, these aren’t contact tracers? Why do we have to pay for this again?’ ”

The answer, at least for the P.I.H. staffers, was that, without helping people to isolate, you would never persuade them to do so. The full contact-tracing process is “the bulwark of how we will reopen,” as George Rutherford, an epidemiologist at U.C.S.F., who is also working on California’s statewide program, put it. But contact tracing can’t easily solve the problems that are typical in the places where outbreaks tend to occur—prisons, nursing homes, and protests—or the policies that help determine who stays home and who doesn’t. What it has to offer, to try to insulate communities from the virus, is the attention of individual people: tracers, investigators, resource coördinators. The more of them you have, the better the odds…”” (I)

“But everywhere you look, tech has failed to deliver. In France, less than 3% of the population has downloaded StopCovid. The U.K. missed an initial rollout deadline and has chosen to start over using another platform. Tracing apps in the U.S. have been caught in a social media war about whether virus news is real or fake, while Australia’s COVIDSafe hasn’t detected a single case despite 6 million downloads. Singapore’s TraceTogether was an early entrant, but even its government began distributing portable tokens this week to complement the app. The one nation with a modicum of success has been China, but only because authorities made the technology mandatory and imposed privacy practices that would be unacceptable elsewhere.

The value of contact-tracing apps is “really questionable,” says Sean McDonald, a senior fellow at the Centre for International Governance Innovation, an independent think tank based in Canada. “The underlying science of proximity as a good indicator of infection relies on a whole bunch of other variables, like whether or not you’re wearing a mask, or whether or not you’re outside.”

Contact-tracing apps use smartphones to track a person’s whereabouts, alerting users if they’ve been in contact with someone who’s had the disease. They’re designed to help supplement the traditional, labor-intensive approach to contact tracing, which involves hundreds of people interviewing those who have been exposed and painstakingly piecing together information about what they did and who they may have come into contact with. In the absence of a vaccine, digital technology was seen as critical for getting people back to work faster and economies up and running…

One of the biggest issues is making sure there’s a critical mass of people signing up. The apps, most of which are voluntary, need a significant number of users if they’re ever going to be effective. A University of Oxford study published in April and based on a simulation of an urban population of 1 million found virus transmission could be suppressed if at least 80% of smartphone users—which amounts to about 56% of all people—participated. That’s a very high number. Even in Singapore, which has a largely compliant populace used to following government orders, only 35% of people have downloaded the app, among the highest take-up rates in the world….

Vivian Balakrishnan, the minister in charge of Singapore’s Smart Nation Initiative, said in a Facebook post that “we need to entrust human contact tracers with information during this crisis.” Contact tracing “remains a human endeavor requiring human judgment,” he said.” (J)

“As countries search for ways to exit lockdown and avoid or manage a second wave of covid-19 cases, many have turned to the promise held by contact-tracing apps. In a rare display of collaboration, Apple and Google recently joined forces to help the technology work effectively…

The principle behind contact-tracing apps is fairly simple. Once installed, they use Bluetooth low-energy (LE) technology to record when a phone has come into close proximity with anyone else using the app. If either person later reports coronavirus symptoms, the other party is notified, so they could self-isolate or seek health advice. An alert could also be sent if a medical authority certifies the other person tested positive for the virus – this would be one way to avoid users trolling the system by falsely claiming symptoms. In theory, the apps work anonymously and only store data temporarily, without collecting location…

There are a host of other questions. Key elements will be the level of trust between citizens and governments, how privacy is preserved, keeping the apps voluntary, and how to also protect people who might not have a smartphone or the ability to install an app – a group that is likely to include many vulnerable older people. The American Civil Liberties Union yesterday laid out a list of principles, including the need for an exit strategy for such apps, to avoid such systems being maintained for “surveillance creep” after an epidemic has passed.

Nevertheless, many countries are on the verge of deploying apps. Germany is expected to release one imminently, and Australia is working on one too. One of the most high profile existing apps has been Singapore’s TraceTogether app, built by the city state’s government. But even its creators admit that it is too early to tell how effective it is. Moreover, “every country will have to develop its own app” because of different situations and requirements, says a spokesperson at Pan-European Privacy-Preserving Proximity Tracing, a European technology initiative…

However effective the apps turn out to be, they cannot be a silver bullet for exiting social distancing measures, and must be part of a much broader effort of testing and contact tracing.” (K)

“As Texas becomes a national hot spot for the new coronavirus, the state is still falling short on the governor’s months-old goal to employ up to 4,000 contact tracers — and the number of virus detectives dropped recently when the state health agency reassigned hundreds of state workers.

Earlier this month, 400 Texas Department of State Health Services employees who had been temporarily assigned to contact tracing were directed to other roles, including other COVID-19 response jobs, because there were sufficient personnel to track all the cases they were covering, spokesperson Lara Anton said…

Now, about 2,800 contact tracers are at work in Texas, even as the state has routinely reported more than 5,000 new COVID-19 cases each day. In early June, the state’s contact tracing workforce numbered about 2,900, and it reached almost 3,200 later in the month before dropping again…

But experts say that a state with 29 million people where cases are climbing at an alarming rate needs as big a workforce as it can muster.

And health officials in some of Texas’ biggest cities — some of whom have already asked the state for assistance — said they are struggling to keep pace with contact tracing as cases skyrocket. Of the state’s 2,800 contact tracers, 1,250 are working in local health departments, Anton said…

And in a state where more than a third of residents speak a language other than English at home, just 112 of the state’s 2,800 contact tracers have indicated that they are Spanish speakers, according to the state heath agency. Tracers who speak only English have access to a translation service that helps reach more individuals, but that could mean each call takes twice as long, experts said.” (L)

“Imagine being given a list of 23 people and told that you need to track down and contact every person that each of those 23 people has come into contact with in the last two weeks. Time is of the essence because those contacts may have been exposed to COVID-19.

With nearly 50,000 newly confirmed cases of the coronavirus in Florida in the last seven days, that’s the one-week caseload for each of the state’s 2,200 contact tracers. And their caseload continues to grow.

According to the National Association of County and City Health Officials, during a pandemic, about 30 contact tracers are needed for every 100,000 people. The latest data show there are only eight states that meet the threshold.

In order for Florida to meet the same threshold, it would need to nearly triple its workforce to around 6,500 contact tracers.” (M)

“The Ingham County Health Department is asking patrons who visited Harper’s Restaurant & Brew Pub between June 12 and June 20 to self-quarantine and report cases of Covid-19, the department said in a statement…

Of the more than 100 positive cases, 12 are from secondary transmission, Ingham County Health Officer Linda S. Vail said Monday night…

“Our oversight of the line on our stairs has been successful, but trying to get customers to follow our recommendations on the public sidewalk has been challenging,” the statement read. “Because we have no authority to control lines on public property, we are left with the dilemma of staying open and letting this situation continue, or closing until we can devise a strategy that eliminates the lines altogether.”

The bar opted to close down temporarily to install air purifiers and to eliminate lines, according to the statement.” (N)


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