If you tested positive and the contact tracer never called, here's why

When the coronavirus pandemic began, the health department in Teton County, Wyo., went all in on contact tracing. Everyone at the health department stopped their regular jobs to join the effort, and each person who tested positive in the county — home to Jackson and Grand Teton and Yellowstone national parks — got a call.

But when the omicron surge hit this winter, "the numbers were just staggering," says health director Jodie Pond. At one point in early January, the county had the highest case rate in the country.

When the health department got too overwhelmed to call everyone, she says, the community noticed right away.

"Our phone lines were just ringing off the hook the week before Christmas, because people were like, 'I haven't heard from you!' " They went on local news to tell residents what was going on. "We had to make sure they understood that they wouldn't be getting a call from us," Pond says.

With one full-time and four part-time staffers, the health department had to prioritize who would get a call. They decided to focus on people over age 60, people who might not have access to medical care, and those who tested positive in group settings like daycares.

"It was hard because we didn't want to let our community down," she says. But, as a small health department in a rural county with – at the peak – more than 275 cases in one day, she says, "we just had to make the pivot."

Perfect world, meet messy reality

With omicron, the sheer number of cases was completely unmanageable for contact tracing programs in many places. In Fulton County, Ga., chief epidemiologist Fazle Khan says, they have 130 people on their contact tracing team – as many as they've ever had. It still hasn't been enough.

"We ended up – in Fulton County alone in this omicron surge – with more than 44,000 cases that have not been investigated," Khan says.

In Maryland, during the omicron surge, "we really were only able to reach out to 11% or 12% of the cases," says Marcia Pearlowitz, chief of the Maryland Department of Health's contact tracing unit. Before omicron, they had reached 76% of residents on average, she says, even during previous surges.

In a perfect world, when an infectious disease started spreading, there would be plenty of testing and plenty of public health staff to reach out to people who test positive and their contacts, and share guidance about isolating and quarantining. Doing this quickly, over and over, would keep the virus in check.

This ideal was especially beguiling at the beginning of the coronavirus pandemic. Places such as Hong Kong and Singapore initially contained their outbreaks by deploying thousands of public health workers to track down every positive case and all of their contacts. In the U.S., the director of the Centers for Disease Control and Prevention at the time called for an army of 100,000 contact tracers to contain the virus.

At one point, the U.S. got close. Surveys by NPR of state health departments found there were 70,000 public health staff working on contact tracing COVID-19 cases in December 2020 – up more than six fold from when the pandemic began.

But the efforts were still far from what was needed. Public health experts – including CDC officials – agree: the country never had enough staff doing contact tracing to contain the rapid spread of the SARS-CoV2 virus.

And now, many of those programs have scaled back. Omicron's flood of cases was the final blow to the dream that contact tracing could keep up with the spread of COVID in the U.S. Many state and local contact tracing programs are taking stock and trying to chart a new strategy for the rest of the pandemic. And that's raised a question: If health departments can't realistically keep on top of every case – or even most – what good are their efforts?

Part of the answer seems to lie in targeting tracing toward those most vulnerable. Many public health experts insist that contact tracing for COVID-19 remains valuable, even if it must now prioritize who to reach and how to reach them.

"It's still important and can still save lives in the midst of a surge," says Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security.

Contact tracing's new phase

In late January, several important public health organizations endorsed the move away from universal contact tracing. In a statement, the groups, including The Association of State and Territorial Health Officials and the Council of State and Territorial Epidemiologists, call for "a revised public health approach."

"We urge a refocus of our public health efforts and resources, with an emphasis on targeting investigations in higher risk settings serving vulnerable populations and other critical measures to better protect the public's health," the statement reads.

The statement, explains Dr. Marcus Plescia, chief medical officer of ASTHO, came after many jurisdictions were already beginning to make this kind of shift.

"There was just a feeling that somebody needed to lay out an explanation of that for the public and for policymakers," he says. "The concern would be that the public would view it as another place where we've not been capable of doing what needs to be done. And so that's why [the statement could] at least be the first step towards trying to change social expectations."

Hemi Tewarson, Executive Director of the National Academy for State Health Policy (NASHP), which tracks state contact tracing programs, says it is time to acknowledge that we're in "a different phase of the pandemic." When the pandemic started, there were few tools to contain outbreaks, she says. "We really had to rely on contact tracing very heavily. I think now we're in a very different place."

To be clear, she adds, "I don't think this is a failure" for health departments to move away from trying to contact trace as many people as possible. And after two years of doing this work, "there's a lot of good lessons learned."

Scaling back and adapting

While some states have reduced or stopped contact tracing, according to Tewarson, others are pivoting to a variety of lower-resource approaches. One particular model seems to be taking off among red and blue states alike, she says. While contact tracing is still conducted for high-risk populations, for the rest, "there's a whole bunch of states that have said, 'Okay, public, you should reach out to your own contacts or enter information into the portal online.'"

Right now, about 20 states are using this model, she says, including Alaska, Colorado, Michigan, Nebraska, and Vermont.

Even if born of necessity, the move to ask the public to participate more may be a smart, pragmatic shift. Many people don't answer public health workers' calls; even those who answer often don't provide phone numbers for their contacts. So when people reach out to their own contacts, it spares public health workers the hard work of tracking people down, and the contact is more likely to take the call.

There have also been innovations since the scrappy early days of COVID-19 contact tracing.

In Maryland, people are encouraged to report their positive at-home test result in the state's self-report portal – and when they do that, or get a positive lab test result – they receive a link to an online survey that gives them personalized guidance about how long they need to isolate and mask and a work or school excuse letter. The information they provide in the survey then helps the department flag people who are at higher risk and might need to receive a follow-up call.

"We really have put the tools in place that will allow us to ensure that we're still attempting to reach out to everyone, but doing it in an automated way," Maryland Health Department's Pearlowitz says. A few other places, like Washington D.C., and local health departments in California, New York and North Carolina have similar self-reporting platforms.

Even when contact tracing programs can no longer reach everyone, they still serve a critical role in their communities, says Watson of Johns Hopkins.

"It may be really important for the nursing home where there are many people who are severely at risk for bad outcomes from getting COVID and need to be more protected," she says. "It's still important for workplaces that don't want large outbreaks and absenteeism. I think it's important for individuals – you may reach somebody through contact tracing who really hasn't thought to notify their contacts."

Contact tracing can also connect people to antiviral medications during the vital few days after diagnosis when they can be used most effectively. It can connect people who need help with local resources, like rent or utility relief programs if they have to miss work due to illness.

It can also give public health officials and policymakers insight into where outbreaks are happening – for instance, Washington D.C. tracks the number of outbreaks in restaurants and gyms and schools and more using data from the District's contact tracers.

Funding issues

In Teton County, Wy., as elsewhere around the country, the omicron surge seems to be retreating as quickly as it arrived. But even when her department has a chance to catch its breath after the surge, says Jodie Pond, they'll continue to focus on contact tracing only those who may be at higher risk from COVID-19. "I think we stay the course on this pivot," she says.

Even the scaled-back version of contact tracing that many places have moved to is limited by budget concerns, and could be reduced even further without additional funding.

When contact tracing was one of the only ways to stop the spread of the virus, that's where a lot of resources went. Now, much of the funding has been spent, and health departments have other priorities, like running vaccination campaigns, notes Khan of Fulton County, Ga. Of course, there's also the everyday work of public health as well, like animal control and HIV prevention and helping people quit smoking and more.

Pond in Teton County says her small local health department has received some federal grants, and did receive funding through the CARES Act, one of the early COVID-19 relief bills. But she says she hasn't felt the impact of the $7.4 billion appropriated in the American Rescue Plan last year for building the public health workforce. That funding is designed to meet a lot of needs, from school nurses, to data infrastructure updates, to the laboratory workforce.

As for contact tracing? "It's a funding issue," Pond says, noting that public health in the U.S. is chronically underfunded. If Congress and the Biden administration "want to continue to fund us for contact tracing, we will need additional appropriations," she says.

The work goes on

Despite the pivots and the challenges, all over the country, public health workers are still making calls every day, giving advice – and sometimes comfort and clarity – to people who may feel sick and stressed and scared.

A few weeks ago, one of the people who got a call from a public health worker in Maryland was Crystal Watson – the scholar at Johns Hopkins who researches public health and was an early voice advocating for contact tracing in the first months of the pandemic.

"I was glad to have that experience, having talked about it so much," she laughs. It was fast, too. "I think it was within 48 hours of my positive result." She also uploaded her result into an app designed to automatically notify people she'd been close to, and her husband got notified.

"So for us – for our household – it worked," she says.

She thinks it's understandable that people would want to declare the end of COVID-19 contact tracing — but it's too soon.

"I think people are very eager to move to the place where we don't have this ramped up public health response that's different than what we see for seasonal respiratory viruses," she says, and contact tracing is a part of that. "But I don't think we're there yet, and we do have to be vigilant about what's coming next."

NPR's Allison Aubrey contributed to this report.

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