Contact tracing is inarguably one of the most important pieces of the puzzle when it comes to figuring out how to safely reopen our societies. In the absence of a vaccine, contact tracers are the people who do the essential work of figuring out how many individuals an infected person has come into contact with, and then notifying those people of their exposure and urging them to self quarantine. Contact tracers are detectives, social workers, and, occasionally, therapists all in one. And depending on who you ask, our country needs between 100,000 and 300,000 of them (there are currently around 8,000) before we can even start to figure out what our new “post-coronavirus” reality might look like.
The contact tracing workforce, known as Disease Intervention Specialists (DIS), is operated by individual state and local health departments and was in place long before coronavirus emerged. Currently, the DIS receives funding from the CDC's STD prevention program. During normal times, much of the group's work relates to tracing STDs, which involves notifying the partners of those who have been diagnosed with STDs such as AIDS. DIS has the largest contact tracing employee base in the United States, and the group has been deployed to help in previous outbreaks, including Ebola and Zika. According to David Harvey, the executive director of the National Coalition of STD Directors, which represents the workforce, the organization is ready to do more in the current crisis, but needs more help from the CDC.
As it stands, the approach has been largely cobbled together state-by-state, with some, such as Massachusetts and Illinois, opting to outsource the jobs instead of hiring within their own health departments. Harvey believes we need a more unified approach to training and mentoring new tracers as they are deployed around the country, and that the federal government could be doing more to facilitate that work.
Mic spoke to Harvey to gain a better understanding of what resources his organization is lacking, how plans to massively scale up the contact tracing workforce are progressing, and what a typical day in the life of a tracer looks like.
Mic: There is a lot of talk about contact tracers at the moment, but I think there’s still a bit of confusion over how they operate. Can you walk me through a typical day in the life of a contact tracer?
David Harvey: A typical day for a contact tracer will be that they get a case report of somebody who has tested positive, or may be a presumptive positive, and they are then tasked with reaching out to that individual to inform them, give information, answer questions, navigate them through the healthcare system, and advise on isolating.
Then they move to a phase of discussions around people who they may have had sustained contact with. They discuss a plan about how to notify people to protect themselves and perhaps take steps to test and isolate themselves. A lot of this happened in person pre-COVID, but during COVID this is all happening through distancing. So through the telephone, and sometimes social media platforms.
How important is social and cultural awareness for tracers? New York City’s job description, for instance, lists a requirement that applicants have the "ability to understand the concepts of institutional and structural racism and bias and their impact on underserved and underrepresented communities."
One of the ways to think about this is much like the field of social work. One emphasis within the field of social work is on helping people to understand the principles of cultural humility and cultural competence: How can I develop a set of communication skills that allow me to bridge differences between race, gender, class, people of different origins? So there’s a very big emphasis placed on training people in terms of how they can bridge those divides and develop trust and understand where people are coming from.
We know COVID disproportionately impacts Latinos and African Americans, and so the contact tracers coming into this role either will be from those communities or, if not, there has to be a big emphasis on helping to educate people around cultural competence: What does it mean to understand where people are coming from in their lives and how can I best help this person navigate the system?
How would you say this effort with coronavirus is different, or more challenging, than tracing in previous outbreaks like Ebola or HIV?
Well, first of all, each infectious disease will have its own science. So Ebola, Zika, COVID, STDs, HIV, Tuberculosis … the basis for doing this work starts with training people on the basic science of these infectious diseases. So unlike STDs, COVID of course is a respiratory infection and it’s got the potential of exposure to a whole lot more people in a shorter amount of time. However the basic skillset is the same. With COVID there’s the potential of many more people who you have to be in touch with because of contacts a person may have had. So there’s a lot more people to interview, but our field has been doing this work for many decades.
This is definitely a massive undertaking, and we are worried about getting this done in a way that quickly matches what’s happening with reopening economies.
How exactly do contact tracers deliver the unwelcome news to people? What do they say to someone on the phone who may have been exposed and how do they convince them to stay at home?
So most people are very responsive to hearing this news. Most people do not want to engage in any situation where they’re going to potentially expose other people. So most of the cases that people are dealing with are people who are very receptive to understanding what’s going on, understanding the safeguards that need to be in place to isolate, and understanding how not to infect other people. So you’re starting from a place usually of very good will on the part of someone who’s receiving this information, and they are gonna want to know and have lots of questions about how to safeguard themselves and safeguard people who are close to them.
I saw you released a statement last month on the president’s plan to reopen the country, and I’m curious how you feel the federal government has done since then with recruiting contact tracers? Do you think they are doing enough to utilize the resources you have inside your organization?
[Laughs] We are waiting this week for the CDC to issue some national contact tracing standards and to beef up training nationally. That we know they are interested in supporting. What is happening, as we all know through the approach of the White House Coronavirus Task Force, is a decentralized approach, which is allowing local jurisdictions and states to make their own decisions about opening up their economies and making their own decisions about hiring contact tracers. And we’ve seen lots of developments in this arena.
We are looking forward to what we hope will be announcements this week on guidelines for hiring contact tracers and training them. Meanwhile we’re seeing states and cities move forward to hire their own contact tracers, and so those developments are definitely happening. There are training initiatives in the tri-state arena — New York, Connecticut, and New Jersey — there’s another massive initiative happening in California, and then meanwhile nationally we teamed up with ASTHO, the Alliance of State and Territorial Health Officials, and with our own money we developed an online introductory training for contact tracers that we unveiled last Tuesday night, and there’s already been 5,000 people who completed the training and gotten a certificate. So we’re excited that that happened, but we do need more resources, guidance, and help from the CDC.
Some people have expressed skepticism about contact tracing on the scale that it seems we’ll need for this. Is that something you’re worried about?
We are worried about it. I mean infusing 100,000 people into state, city, and county health departments is a massive undertaking. And training these people… you can’t just plop folks into the system. They have to be trained, they have to be supervised and mentored and guided. We know the science of COVID is changing, and that’s going to constantly impact the information that contact tracers need as they work with members of the public. So this is a massive undertaking.
This is an essential public health workforce that has been starved for 20 years.
Some people are calling for upwards of 300,000 people within the system. That is a lot of people to absorb into health departments that have been previously really starved for resources. In the states of Massachusetts and Illinois, they’re outsourcing the function to a nonprofit group. That is one model that we know some states are employing. We would rather see state health departments supported with additional funding and that these staff members be incorporated within the health department so that can be sustained into the future. But yeah, there’s a lot of different approaches happening right now, this is definitely a massive undertaking, and we are worried about getting this done in a way that quickly matches what’s happening with reopening economies.
In an ideal world, with everything we know now, when do you think was the ideal time to start contact tracing?
In a containment phase. So as the numbers come down or flatten out, that’s when it becomes very important to contain new outbreaks before they grow into much larger outbreaks. Contact tracing is an effective tool in a containment strategy, not a mitigation phase.
When do you think it will be time to wind things down?
I don’t have a magic number for you, but I can tell you that beefing up public health workers, disease intervention specialists, and contact tracers, while we may not need the number of contact tracers that are being called for right now to continue into the future, we do need to have a lot more disease intervention specialists to be sustained into the future. Because there are going to be other infectious disease outbreaks, there will be other food-borne illness outbreaks — this is an essential public health workforce that has been starved for 20 years. There’s more than enough work for these folks to do once the COVID pandemic is over.