Unknown phone number? Don’t hang up. It might be an NC COVID-19 contact tracer
If a Wake County librarian reaches out unexpectedly in the days and weeks to come, it’s probably going to be about something far more important than an overdue book. It could mean you’ve potentially been exposed to COVID-19.
The effort is called contact tracing, and Wake County has pressed librarians into emergency service in what has become the latest front in the fight against the spread of COVID-19.
Contact tracing is one of the oldest tools in the epidemiologist’s kit for keeping contagious diseases from spreading. Cases of mumps and measles are routinely and quietly traced, but the scale of the effort required by COVID-19 is unprecedented, especially as the economy reopens.
The disease can spread quickly in any setting where people are close together — a cookout, a protest, a stock-car race, or in a restaurant or salon as the economy reopens.
And each positive case will require a contact tracer to retrace the patient’s steps and track down as many people as possible who they might have come into contact with. In some cases, that’s a simple list of names. In others, it might require a mass-media broadcast.
“Contact tracing only works if people pick up the phone, return the text and get back to that person,” North Carolina state epidemiologist Zack Moore said in an interview with The News & Observer.
The characteristics of Covid-19 make contact tracing an especially vital tool. The coronavirus that causes the disease is often spread well before patients develop Covid-19 symptoms. By alerting people to their exposures and asking them to quarantine, contact tracers hope to slow or halt that asymptomatic spread.
It’s going to require thousands of contact tracers in North Carolina alone, the cooperation of citizens and, in some cases, even your local librarian. Wake County has trained 110 of them as contact tracers to reinforce its existing staff, public health director Chris Kippes said in an interview with the N&O.
DHHS officials acknowledge they still don’t know how many contact tracers need to be hired statewide. It depends on the number of people who test positive, Dr. Mandy Cohen, the department’s secretary, said at a press conference last week.
“We’re doing training right now and we want to assess once we’ve trained up this cohort (and) we’ve hired the new (tracers)... Are we doing all of the contacts that we need within 24 hours of seeing the positive?” Cohen said. “If we’re not, we need to scale up. I don’t have a precise number, but that’s the work we’re trying to do.”
THE PROCESS
Everything starts with the positive test.
Once that happens, local health department officials ask the patient for a list of everyone with whom they have been in prolonged contact — meaning within 6 feet for more than 10 minutes. They ask the patient for whatever phone numbers, emails or addresses they might have and start reaching out.
“The goal is to try to get them on the phone the first day we know about them,” Victoria Mobley, a DHHS epidemiologist, said in an interview with the N&O.
DHHS estimates each case will have about five exposures, Mobley said, but some will have one and others will have as many as 30.
Mobley said a call from a contact tracer will likely include information about your exposure and what that means, as well directions on symptoms to look out for. The contact tracer will likely ask whether you are symptomatic while giving directions on how to get tested and what it means to quarantine. Tracers will direct a symptomatic person to seek testing right away, while someone who is asymptomatic will be told to seek a test about six days after their exposure.
U.S. Centers for Disease Control and Prevention guidelines indicate those who have had close contact with a Covid-19 patient should stay at home for two weeks, watch for symptoms and check their temperature at least twice a day.
“Some of our work that we’ve been doing in Wake County has involved providing ways to isolate homeless individuals who don’t really have a place to isolate,” Kippes said. “We can help meet that need by taking them to a location and providing the ability to isolate, and then obviously if they’re isolating, be able to take care of their food needs etc. while they’re under that isolation.”
Based on experience with other diseases and conversations with colleagues in Massachusetts, which is about three weeks ahead of North Carolina in the pandemic, officials here say they know they’re not going to get to every person who may have been exposed to COVID-19.
“That’s why it’s important for people to understand it’s a collaborative effort between the people who have been exposed to somebody with COVID-19 and the people trying to do the contact tracing,” Moore said.
THE MATH
The uncertainty surrounding how many contact tracers the state needs and how many it has now exists in part because contact tracing is conducted by individual counties. In the state’s last survey of county health departments, there were about 1,500 people working as contact tracers, Mobley said.
So far, the state has contracted with outside agencies to hire and train contact tracers who can be assigned where needed. Through a partnership with Community Care of North Carolina and the North Carolina Area Health Education Centers, DHHS has added 152 contact tracers to assist local departments out of a goal of 250.
DHHS data indicates 69 of the 152 hires through the collaborative are bilingual, and 44 are African American and 19 are Latino. As of June 7, 41 percent of North Carolina positive tests for which ethnicity data was available were from Hispanic individuals, dramatically outpacing the state’s Hispanic population. And the 28 percent of positive tests from African American individuals were higher than that group’s population in North Carolina.
“There’s been a disproportionate impact of COVID-19,” Moore said. “As we’ve been hiring people on, there’s been a very focused effort on making sure we pay attention to the diversity of the workforce and trying to match that to the population we’re seeing most affected by COVID-19.”
Last week, DHHS requested proposals from vendors to “meet the scale needed to respond to COVID-19” by building on the tracing work of local health departments, looking specifically for minority-owned businesses. The request cited the virus’ disparate impact and said applicants needed to demonstrate the ability to support testing and tracing among historically marginalized populations.
The goal is to find people who are connected with the community and match the demographics of the people they’re trying to contact, in hopes that anyone potentially affected will be more likely to respond.
“They may not necessarily be the ones calling the contact, but there’s a lot involved in contact tracing,” Mobley said. “Including case investigation and doing all the data entry so we know how well we’re doing reaching populations we’re really worried about and making sure we contact and get the resources to them that they need.”
THE DATA
Moore said the state recently distributed a new application to county health departments to better monitor and track contact tracing efforts that will provide more accurate and useful data. But the information already gathered has helped guide prevention and mitigation while offering valuable epidemiological data.
The goal of contact tracing isn’t necessarily to learn more about COVID-19, but there are still lessons to be learned from the information gathered during the process. Tracking which transmission settings tend to generate the most contacts, for example, could help guide targeted interventions. Or there may be basic medical data to be gleaned, since so little is known about COVID-19 compared to other infectious diseases.
“If you test positive and you didn’t have any symptoms, we’re still going to do contact tracing,” Moore said. “But it will be really helpful for us to understand how many of those contacts end up developing symptoms compared to contacts with somebody who had symptoms. There are things like that which can help us better understand where to intervene and how to intervene in transmissions.”
One of the biggest challenges while wrangling the data is matching the contract tracing workforce to the demographics of those exposed to COVID-19. As is the case with contact tracing in general, the demographics can be a bit of a moving target, with some counties — especially those with meat-packing plants — having extremely high numbers of COVID-positive Spanish-speakers.
“That is being driven probably by two factors,” Mark Benton, the state’s assistant secretary of health and human services for public health, said in a video interview. “One is looking at statewide demographics. What does our broader population look like? But also who is the virus affecting most right now?”
THE NEXT STEPS
More outbreaks are expected as the state reopens and people come into more contact with each other, especially indoors. Many, if not most, protesters have worn masks this week, but there’s still a risk of transmissions at large outdoor gatherings when people are close together. Few racing fans, for example, have worn masks at Altamahaw’s Ace Speedway.
The state has already dealt with the implications of one event like that: The Millenium Tour concert at PNC Arena on March 13, just as North Carolina was starting to shut down. A positive case from a concert-goer forced the Wake County health department to turn to social and traditional media to spread the word that others needed to be tested. That’s not the preferred way to do this. But sometimes it’s all that can be done.
“We don’t like to use that mass notification,” Kippes said. “We like to be a little more precise in our contact tracing. Sometimes you’re not dealt that hand.”
This story was originally published June 7, 2020 at 3:07 PM with the headline "Unknown phone number? Don’t hang up. It might be an NC COVID-19 contact tracer."
