Confronted with a shortage of test kits, rising COVID-19 cases, and pressure to reopen, many states are designing innovative contact tracing initiatives that use private and public health expertise, volunteers, and traditional phone calls to reach individuals who have been exposed to the coronavirus so they can self-isolate to stop the spread of infection.
Without an effective vaccine and with strict social distancing and stay-at-home practices waning as regions gradually reopen, states are expanding their contact tracing workforces – ranging from adding 10,000 workers in California to 700 in Kentucky – to reduce infections as outbreaks continue in nursing home, prisons, and meat-packing facilities. The National Association of County and City Health estimates 30 contact tracers are needed for every 100,000 residents to curb the pandemic.
While a combination of robust testing, contact tracing, personal protective equipment for caregivers, and high-quality medical care are needed to properly respond to the COVID-19 crisis, contact tracing by itself can help states more effectively target their interventions, keep potentially infectious individuals in quarantine, and allow them to gradually reopen.
But contact tracing is costly and states are facing unprecedented losses in revenues. In late April, the Centers for Disease Control and Prevention (CDC) announced it was awarding $631 million of Coronavirus Aid, Relief, and Economic Security (CARES) Act funds to 64 jurisdictions for testing and contact tracing programs. Congress is currently deliberating additional coronavirus aide that would provide additional funds specifically for contact tracing, but it is not clear how much will be designated to help states expand contact tracing in the face of rapidly-diminishing tax revenue. A recent Johns Hopkins report concluded the public health workforce needs to add about 100,000 “paid or volunteer” contact tracers at an estimated cost of $3.6 billion to state and local public health departments.
Massachusetts Designs a Collaborative Program
Massachusetts has designed a contact tracing program using private, local, and state health resources that makes use of an army of volunteers.
In early April, Massachusetts Gov. Charlie Baker announced a statewide COVID-19 contact tracing program that features a Boston-based nonprofit that has led community responses to infectious disease outbreaks internationally for decades – Partners in Health. Joining the effort is the state’s Department of Public Health, municipal health departments, a virtual support center that includes more than 1,600 volunteers and paid staff, and the Commonwealth Health Insurance Connector Authority, which provides technical expertise.
How the Tracing System Works
- When an individual tests positive, the results are entered into the Massachusetts Virtual Epidemiologic Network (MAVEN) and given to that individual’s local board of health. The board can decide to trace the individual’s contact or forward the case to the statewide Contact Tracing Collaborative (CTC), run by Partners In Health.
Within two hours, a case investigator (a paid staff person) calls the individual to discuss symptoms, medical care, and explain the need to self-isolate for at least 10 days after symptoms appear. The investigator also explains self-isolation requirements and offers more information to protect family and roommates.
- If the person can’t isolate at home or doesn’t have a home, investigators provide information about state isolation sites. In addition to counseling the individual, the investigator requests a list of everyone he or she has been within six feet of for more than 15 minutes within at least two days of their positive test result.
Massachusetts officials expected to get about 10 contacts per case, however to date the number of contacts has been close to two, indicating that social distancing has been having a positive effect.
Investigators report some people have been relieved to talk to them and are happy the state was involved. Paul Farmer, a Partners in Health founder, told The New York Times, “Somebody needs to say to people who are worried and not feeling well, ‘We got you,’” he said. “…And we’ll look out for your contacts, your spouse, and your family.”
Experts also point out that apps and technology alone can’t take the place of this traditional detective work, especially in an environment where there will be numerous outbreaks at different stages that need to be addressed locally and culturally appropriately. However, technology may one day assist these efforts. Apple Inc. and Alphabet Inc.’s Google are working together to create contact tracing technology that allows users to opt into a system that catalogs other phones they have been near so they can be notified if they were in close contact with someone infected with the coronavirus, but privacy concerns about this high-tech tracking approach persist.
- Once they have the names of contacts from an infected person, contact tracers, who may be either volunteers or paid staff, reach out to them individually within 48 hours, using a prepared script. They first text the individual and call back three times in succession to convey how important the call is, and also leave voice mail messages.
Once connected, they tell the contact about their possible exposure, ask about symptoms, help them get tested if needed, review the 14-day quarantine requirement, and help coordinate food or housing assistance if the individual can’t quarantine.
Results to Date
Tracers reported that about 50 percent of contacts have not answered their phones when they were called, probably assuming the calls were spam, so state officials, including the governor, have exhorted people to respond to the calls and publicized messages on social media: “Just answer the call. Help us help you. To stop COVID in Massachusetts answer this call.”
To help boost response, major phone service companies in Massachusetts agreed to let contact tracing calls go through without blocking them as spam. The state also secured two prefixes for all contact tracing calls – 833 and 857 – which should show up as MA COVID Team. But that name only shows up if an individual has paid for call ID. The state worked with phone service providers to waive caller ID fees, ensuring cell phone users see “MA COVID Team” when they get a call on their mobile device.
Quickly ramping up a team of trained tracers is challenging for any state. Massachusetts has recently averaged about 2,000 new infections daily, and its initiative needs to hire and train many more tracers as the state begins to reopen this spring and summer. Recently the Massachusetts League of Community Health Centers have allocated staff to join the effort, including employees who were recently furloughed, and local health boards have even pulled in school nurses to help with contact tracing and public health student volunteers. Additionally, Blue Cross Blue Shield of Massachusetts repositioned 100 of its call center employees to work with the Community Tracing Collaborative.
As of May 7, 2020, the Massachusetts initiative has reached 14,000 individuals infected with COVID-19 and reached out to 7,500 of their contacts.
“As we wait for science to develop a vaccine, contact tracing and the investigation of cases is how we interrupt chains of infection and control an epidemic,” said Monica Bharel, MD, MPH, Massachusetts Commissioner of Public Health at a recent state press conference. “Case investigation and contact tracing will continue to be some of our most powerful public health tools.”
