OFF TO THE TRACES: Health officials gear up to track thousands of COVID-19 cases

In this Tuesday, May 19, 2020, photo, Salt Lake County Health Department health investigator Mackenzie Bray points to a board showing a hypothetical case that serves as a training tool to teach new contact tracers how to track all the people they need to reach out to after a person tests positive for COVID-19. Some cases involve just a few family members, while others require health investigators to alert dozens of people who might have been exposed. (AP Photo/Rick Bowmer)

Picture this: After months spent pent up inside your Aurora home, you venture to a casual gathering in early June. While you endeavor to maintain social distance, you inadvertently lean in to chat with a friend of a friend while you both nurse beers.

Days later, your phone rings. On the other end is an official who tells you that you have been in contact with a person confirmed to have contracted COVID-19. You’re instructed to quarantine in your home for 14 days after your exposure to the fellow partygoer and possibly seek out a viral swab.

Such could be the case for an increasing number of Coloradans this summer as the economy winds back up and a growing cohort of COVID-19 case investigators dial phone numbers of the exposed.

While calls for wide-spread contact tracing have cascaded down the chains of government in recent weeks, the system in Aurora and the surrounding area remains in its infancy.

The Tri-County Health Department, which oversees all public health decisions in the three counties encompassing Aurora, does not currently have any dedicated contact tracing positions, according to department spokesman Gary Sky. However, some 40 workers at the public health entity are currently investigating new COVID-19 cases in the area and performing “limited contact tracing,” Sky said.

Ashley Richter, communicable disease epidemiology manager at Tri-County, told the Sentinel earlier this month that number, ideally, would expand to about 80 people on hand to investigate COVID-19 cases.

The department has split up its tracing efforts to focus on large health facility outbreaks, small public outbreaks — like those that are tied to workplaces and retail stores — and then the general public. So far, the department is pulling from other departments to help, but it’s only a short term solution.

County officials so far have been largely focusing on case investigations, which center on monitoring a virus patient’s symptoms and movements, as opposed to tracing, which focuses on contacting and alerting anyone who a positive patient has been in contact with two days before their symptoms emerged and 10 days after the onset. The Centers for Disease Control and Prevention define a contact as any interaction for more than 15 minutes within 6 feet of a person who tests positive for the virus. The contact window extends to 48 hours before the patient begins exhibiting symptoms.

Tri-County Health isn’t currently hiring any contact tracers, Sky said. However, the department is currently seeking various volunteers to buoy COVID-19 relief efforts 16 hours a week for at least three months, according to an online job posting. More job listings for additional tracers in the county are forthcoming, officials have said.

Still, the proportions are not in officials’ favor. County case investigators take on about 10 cases every day, according to Sky, with the tracing process often taking about a month to complete. Investigators follow-up with contacts after two weeks to ask about any possible symptoms and confirm whether they were able to quarantine. Each case involves an average of 10 to 15 contacts to call and monitor, officials say.

“Currently we do not get in touch with all contacts,” Sky wrote in an email. “We are performing limited contact tracing.”

At the state level, health department officials have pledged to hire more contact tracers to better portray the web of viral transmission and ideally stem the disease’s spread. Still, the numbers remain woefully short of federal requests for tracers. Officials have called for hundreds of thousands of tracers to be hired across the country.

But the state currently only has about 50 workers helping county health officials perform contact tracing, though plans to hire more tracers — primarily currently enrolled public health students — are in the works, according to a spokesperson for the state health department.

The goal is for state tracers to be able to handle as many as 500 cases a day, officials have said. That’s as roughly 300 confirmed cases are still being reported in Colorado every three days, according to current averages reported to the state health department. About 70 to 100 new cases are coming just from the three county region Tri-County oversees, according to county data. Those numbers are about half of what they were at the end of April.

Until tracing efforts in the state are bolstered, many business leaders are instructing their workers to continue working from home. That’s the case for Bryan Leach, CEO of Denver-based tech company Ibotta, which employees some 500
people.

“Without testing and without tracing, all 500 of our employees will definitely remain working outside of the office until there’s a vaccine,” Leach said. “And we don’t know. That could be, you know, months or years away.”

 


 

Health officials have to work down the chain of contacts that starts with someone who tests positive with COVID-19.;

BEEN THERE, DONE THAT

While you likely haven’t heard of contact tracing before the current coronavirus crisis, it’s far from a new idea.

Professor Glen Mays, who chairs the health systems, management and policy department at Colorado School of Public Health, said it’s a strategy dating as far as the 18th century, when a researcher tracked a cholera epidemic ravaging London.

In the modern era, public health staff contact trace a slew of illnesses and afflictions. A sexually active person might get a call from a clinic informing them a sexual partner tested positive for HIV or gonorrhea, Mays said. Or, contact tracers identify and isolate people with measles during outbreaks.

It’s a strategy rooted in the belief that, by informing someone of their possible exposure to an affliction, you can shift their behavior and limit a disease’s spread.

But Mays said the current task is a much bigger one: contact tracers will now have to glean how many people may have been exposed to a highly contagious virus in a densely-populated metro area.

“We know how to do it, but we have never done it before on this scale in the U.S.,” Mays said of contact tracing.

Add Aurora’s language barriers — Aurorans speak more than a hundred languages and dialects, according to city estimates — and the basic communication needed to trace cases could be strained or totally blocked. As nearly all tracing occurs over the phone, questions and responses could quickly become lost in translation, Mays fears.

He said Tri-County will have to consider how to tackle this issue. They might hire translators or work with members of the community willing to volunteer. Or, the staff could pre-record messages in different languages that would play for non-English speakers.


 

Medical workers conduct coronavirus testing at a drive-through testing program at STRIDE in Aurora April 24, 2020. PHOTO BY PHILIP B. POSTON/SentinelColorado

THIS IS A TEST

The entire process starts with testing, which is slowly becoming more available in Colorado. Gov. Jared Polis earlier this month urged anyone who is experiencing COVID-19 symptoms, including shortness of breath, fever and cough, to get a test. That’s a pivot from earlier messaging that encouraged only the sickest patients with life-threatening symptoms to get tested, and often told patients to arrive at test sites with a doctor’s note. Such documentation is no longer needed.

“Three weeks ago, the message was that if you have COVID-19 and you’re not deathly ill, just curl up in bed and don’t get tested and don’t go to your doctor,” Dr. John Douglas, executive director of Tri-County Health told the Sentinel earlier this month. “Now we want more people to get tested … We want to try to reverse some of that earlier message as best we can.”

STRIDE Community Health Center in Aurora continues to provide discounted tests at its Del Mar Circle location in Aurora.

To further help tracing, the state has launched a symptom tracker tool that encourages people experiencing COVID-19 symptoms to input how they’re feeling into a state database. To date, nearly 1,900 people have self-reported their symptoms, including 186 people in Arapahoe County and 153 people in Adams County, according to state data. Only about 9% of people who have reported symptoms said they had a contact with a confirmed COVID-19 patient, and 16% of reporters said they suspected they were in contact with a viral carrier.

Such efforts have earned the state accolades from federal officials.

Gov. Jared Polis, who traveled to Washington D.C. earlier in the month, said he had side conversations with Dr. Deborah Birx, the White House coronavirus response coordinator, about Colorado’s efforts to contain the virus, including contact tracing. Polis said Birx was “very complimentary” about the state’s work, which has included ramping up the number of epidemiologists and bolstering the number of COVID-19 tests the state has in its arsenal against the virus.

Gov. Jared Polis and state officials at the White House Wednesday May 13 before a meeting with President Donald Trump. PHOTO FROM TWITTER FEED OF GOV. JARED POLIS

But building up an army of public health workers to track the spread of COVID-19 will be expensive. Initial reports from the state health department put the price tag somewhere between $30 million and $100 million. The Center for Disease Control granted $160 million this month for “Colorado to develop, purchase, administer, process, and analyze Coronavirus Disease 2019 (COVID-19) tests, trace contacts, and related activities.”

It’s not clear yet how those dollars are being divided up. A contact tracing plan is in the works, according to state health officials and staff in the governor’s office, but it isn’t public yet. Earlier this month, Arapahoe County announced it is slated to receive some $114 million in federal relief funds to buoy the economy and combat the virus. About $63 million of those funds will be used to improve modeling abilities, testing, and hiring contact tracers.

A steep increase in recruiting public health workers is something all levels of government are now concerned with. Last month, Sen. Michael Bennet and Aurora Congressman Jason Crow  announced bills to “create the Health Force, which would recruit, train, and employ hundreds of thousands of Americans to expand our public health workforce for … COVID-19 response and strengthen our capacity to meet America’s longer-term public health needs,” according to a news release.

Bennet’s legislation to create a national “Health Force” is two-fold in its approach, the senator said on a recent virtual roundtable. First, it seeks to combat a highly-infectious virus and prepare for whatever the U.S. might encounter next. Second, it could employ hundreds of thousands of out-of-work Americans.

“The federal government would fund the program and provide assistance through the Centers for Disease Control,” Bennet said of his ideal health force. “But importantly, state and local health departments would be empowered to do the training and day-to-day management since they know better than anybody else what their communities need.”

This is particularly important for places like Colorado, he added, where health departments are largely decentralized and local agencies lead the way in decision-making for their communities.

Leaders in communities outside of the metroplex see the need for more public health workers as a necessity, for public health, of course, but also for the economy.

“We’ve got roughly 4 million students graduating from some level of college in 2020. It is the most diverse college graduating class in history. They were headed into, as we know, one of the strongest economies in recent memory and now they’re facing an unemployment rate greater than the Great Depression. That happened, obviously, all in a matter of months,” said Colorado Mountain College President Carrie Besnette Hauser. “Too many of them their job offers have disappeared, internships have been pulled back, entry level positions have been the first to be cut. We certainly understand that our lower income students of color will be the most hard hit and miss and it also presents probably the most amazing opportunity, the health force and a concept like this.”

This May 13, 2020, photo taken with a fisheye lens shows a list of the confirmed COVID-19 cases in Salt Lake County early in the coronavirus pandemic at the Salt Lake County Health Department, in Salt Lake City. Health officials later moved to tracking the cases in an online database, but the white board remains in the office as a reminder of how quickly the coronavirus spread. (AP Photo/Rick Bowmer)

In spite of the funding and logistical labyrinths, Mays with the Colorado School of Public Health thinks it’s possible for Tri-County and other public health authorities to craft a fully-fledged contact tracing operation. He said the system will benefit from a relative respite from the pandemic during the warm summer months, when transmission might be reduced with continued social distancing and sunshine.

While the overall number of cases in the state has continued to rise, officials have optimistically pointed to a decrease in hospitalizations as evidence of an impending summer trough. Daily infection rates, too, have reportedly plummeted since Polis ended the statewide stay-at-home order April 26, just after a surge of positive COVID-19 cases. According to data compiled by the Colorado Department of Public Health and Environment, more than 970 cases were reported to the state health authority on April 30. That number has generally declined in the last month to 222 reported positive cases on May 26.

As of May 26, the state had tallied 24,565 confirmed cases, and 1,352 deaths, according to state health department data. Aurora alone has recorded 3,159 cases and at least 151 deaths as of last week, according to Tri-County Health statistics.

But, like most public health officials, Mays is expecting a second wave in the fall. That’s when advanced contact tracing will be key.

“We’ve been under-investing in this infrastructure for so long, and now we all depend on it,” he said.