Rick Bowmer / AP
An NPR survey of state health services shows that the national coronavirus contact troop has tripled in the past six weeks, from 11,142 to 37,110 workers. Yet, given their current number of cases, only seven states and the District of Columbia are staffed to the level that public health researchers deem necessary to contain epidemics.
Contact tracers are public health workers who contact each new case of coronavirus positive, find their contacts, and connect both the sick person and those exposed to the services they need to be able to isolate themselves safely. It is essential to eradicate emerging epidemics.
To understand how this picture had changed since the first NPR contact tracing survey in late April, NPR again contacted all state health departments, as well as D.C. and the United States. In total, NPR journalists were able to collect data from the 50 states as well as from D.C., Guam and the Northern Mariana Islands.
Many states are still planning to hire more contact tracers, reassign existing government personnel, or train outside volunteers. Some already have a bank of qualified staff or volunteers on standby, capable of turning to finding contacts in the event of new positive cases. Many of them rely on the National Guard, AmeriCorps, volunteers or part-time workers to fill these ranks. With plans to hire and reserve staff, the national workforce grows to 68,525 contact tracers.
“I think it’s amazing that the scaling up of the workforce has gone this far in such a short time,” said Crystal Watson, senior researcher at the Johns Hopkins Center for Health Security and lead author of contact center white paper. tracing capacity. “But I am also – at the same time – concerned because we are seeing these increases in the number of cases in many different states. ”
Former CDC director Tom Frieden agrees that the NPR results show progress, but that it is “not enough and not fast enough”.
Public health experts say tracing contacts for each positive case and asking them to quarantine is crucial to allow communities to reopen safely – those who are sick or who have been exposed stay at home while the rest of the public begins to resume a normal life. If communities do not have enough tracers to call and promptly investigate each positive case and to ensure effective follow-up of contacts, this strategy of reducing transmission fails.
Many places in the United States are reopening before fully establishing the robust tracking system that public health leaders demanded months ago. “We reopen before we have the system ready to prevent cases from becoming clusters and clusters from becoming epidemics,” said Frieden.
How many tracers are enough?
To estimate the number of plotters sufficient for each state, NPR analyzed each state’s current needs based on the number of cases in each state in the past 14 days, using the Contact Tracing Workforce Estimator developed by the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University.
The analysis assumes that workers call 10 contacts per case and that contacts are followed up every other day. Ten contacts may be a conservative estimate, as many places have started to ease social distancing, and when people go to restaurants or shopping, the number of contacts can increase rapidly. The analysis also assumes that tracers reach 45% of contacts, as it is sometimes not possible to find people – this is the middle of three strategies described in a workforce contact finder recently published by the Centers for Disease Control and Prevention.
These entries are designed to represent the real challenges that contact tracers may face in reaching all possible contacts. “It’s hard to get hold of people,” says Watson. “There are many other factors that can make people unwilling or unable to do so, including its historic problems of trust in government […] I think any contact tracing is helpful. ”
The results of the NPR analysis show that several states have enough contact tracers deemed necessary to investigate their current burden of recent cases. Seven states – Alaska, Massachusetts, Montana, New York, Oregon, Vermont, and West Virginia – as well as DC, and the territories of Guam and the Northern Mariana Islands, currently have enough tracers, taking into account local transmission. Six other states – Colorado, Connecticut, Idaho, North Dakota, South Carolina and Washington – are fed up when reserve personnel are included in their personnel counts. According to NPR, thirty-seven states do not have enough contact tracers.
However, many states have indicated that they believe they have enough tracers to reach quickly. With 1,500 contact tracers, a spokesperson for the Florida Department of Health wrote to NPR: “This is successfully responding to current operational demand, which is being reassessed daily as new cases are confirmed. ”
According to NPR’s analysis, Florida would need about three times the current number of contact tracers to be able to investigate and track contacts for each case of coronavirus. Florida is one of more than a dozen states where COVID-19 cases are currently on the rise.
Each location is different – a county with only a few new cases of coronavirus per week may be able to manage contact tracking with only a few part-time employees. But with a highly infectious virus, this configuration is risky, warn public health experts – a spike can occur suddenly and get out of control without proper contact research.
Testing is also essential – it is the first step in the testing, tracing and isolation strategy that public health leaders have stressed the need to put in place. If a community does not test enough, positive cases cannot be identified and traced.
Consolidate a workforce
States cited a range of creative strategies for strengthening the workforce. Some have turned to private philanthropy, such as New York, which has the support of Bloomberg Philanthropies to hire workers. Others have partnered with universities, bringing in graduate students to help them. Others, like California, train and reassign public servants who perform other duties.
A number of states have cited volunteers as part of their strategy to manage workload, turn to service groups like Americorps, or recruit individuals willing to help. Michigan, for example, relied primarily on volunteers and hired a contractor to manage this workforce. They’ve recruited 9,500 people ready to help, and 422 volunteers are currently calling, who “make contact with about 90 percent of all contacts within 24 hours,” Lynn Suftin, Michigan news manager Department of Health and Human Services wrote to NPR.
Epidemiologist Abdul El-Sayed has criticized Michigan for relying on volunteers. “What we are saying is – implicitly – that we do not value this enough to pay for it,” he said. “This is a place where you need the kind of responsibility, you need the kind of sensitivity and you need the kind of training that professional staff can give you. ”
And he adds, with more than 40 million people claiming unemployment benefits, “it’s not like we don’t have the workforce available for employment.”
A patchwork system
One of the reasons why it is difficult for the United States to have a coherent contact tracing strategy is that the public health system is a mosaic of different systems of governance. In most states, “local health services are independent of the state health service,” says Adriane Casalotti, head of government and public affairs at the National Association of County and City Health Officials. . Some states have fully centralized public health services, and others are a mixture of the two.
In many of these local health units, a small team of public health workers performs many different tasks – and now adds tracking of contacts with coronaviruses. Wyoming County staff, for example, “does a lot of the work but also has other responsibilities, so it’s not just a count of staff,” wrote Kim Deti of the Wyoming Department of Health in an email. at NPR. “I don’t have a number for that. ”
However, in Montana, where public health services are independent and local, the state public health service recently conducted a survey to determine the number of employees across the state and found more capacity 500 employees who could turn to find contacts if necessary. .
Candice Chen, a health policy professor at George Washington University who worked on the contact troop estimation tool, hopes that other local control states will follow the example of Montana and ask, ” Can we do what Montana has done? prepared if we start to see cases in some counties that had not seen cases? ”
Another complexity is that the task of finding contacts is generally divided into several different roles, for which different degrees of expertise are required.
“The way we think about it is this contact tracing system,” says Casalotti. There are front-line workers who phone to investigate new cases and contact contacts. In addition, you need supervisors, and she says, “We also need epidemiologists – not only at the state level, but also at the local level – who can then take the data in real time” to identify the possible peaks.
A call to federal leadership
The total reported by states is far below the more than 100,000 contact tracers that some influential public health experts have claimed.
Part of the reason for this discrepancy is clearly a lack of funding. A group of former federal officials who wrote a letter to Congress calling for increased support for contact tracing estimated that $ 12 billion in federal funding would be needed to pay for the hires. The HEROES law, which was passed in the House last month, includes $ 75 billion for testing and contact tracing, but should not be passed in the Senate. It is not at all certain that a new bipartisan rescue bill would include federal funding specifically for contact tracers.
The CDC provides staff to support local contact tracing efforts. Director Robert Redfield told NPR in April that the agency had about 500 employees currently deployed to assist local and state health services, and that it would support another 650 positions with $ 45 million in Foundation funding CDC.
It is not known how many of these hires have been made. In a statement, CDC spokesperson Scott Pauley told NPR: “The CDC’s efforts to support contact tracing with states are underway and hiring through the CDC Foundation continues,” and noted the provisional communication and orientation toolbox available on the CDC website.
Many public health leaders have called for more leadership – if not funding and staff – from the federal government to support contact tracing efforts by state and local health departments.
“We have needed a federal response on this since day one and we have not had one,” said El-Sayed. “We need federal funding for contact tracers and we need it now. ”
“I hope we can keep this at the top of our national agenda – to continue to increase our membership and our commitment to contact tracing,” said Watson of Johns Hopkins. With the increase in cases in many states and the loosening of social distancing measures, she said, “it will only become more difficult to find contacts in the future.”
Caroline Kelly, Connie Hanzhang Jin, Sean McMinn, Ruth Talbot, Julia Wohl and Carmel Wroth contributed to this report.