Aug. 31, 2021 -- As the pandemic raged last year, Ilish Pérez, a contact tracer and case interviewer for the Los Angeles County Department of Public Health, would often reach out to more than 100 people a day. She would talk to people about their positive COVID test result and tell others that they had been exposed to COVID.
"Our shifts were generally 8 hours," says Pérez, an experienced health educator who worked in HIV and other sexually transmitted diseases before being transferred to the COVID-19 effort. But "sometimes we would do overtime. At the end of the day, I was exhausted not only physically, but mentally as well. All the emotions you go through with each different call can be quite exhausting. And during the peak, there was no downtime between calls to reset your mind."
Once the vaccines became available, and new cases slowed, her call list grew shorter. Just a few months ago, she sometimes had as few as 10 contacts a day to reach.
But now, with the Delta variant triggering a dramatic uptick in cases, Pérez and other public health workers and officials nationwide involved in contact tracing have geared back up.
While contact tracing -- the process of identifying people potentially exposed to someone infected and advising them to quarantine and test -- has taken a back seat in recent months to pandemic control plans, experts say it's time to ramp it up again.
It's also time, some say, to do contact tracing smarter. That means merging it with testing and vaccination efforts.
The public perception of contact tracing may need to change, too.
"Contact tracing is so much more than getting ahold of someone and telling them to quarantine," says True Beck, a COVID-19 response manager for the Los Angeles County Department of Public Health. Ideally, she says, it begins with a call from a compassionate person who is able to personalize the advice.
"Anyone can Google 'What to do if I am COVID-positive,'" Beck says. An effective contact tracer will go much beyond that. For instance, she says, "Our contact tracers will ask, 'Do you live in a one-bedroom apartment?'" If so, they give advice about how to isolate or, if needed, help people find a hotel. They also connect people to services. And now, of course, contact tracers should help people get vaccinated, she says.
Contact Tracing, Done Right
Many other countries have the U.S. beat at contact tracing of infectious diseases, says K.J. Seung, MD, a senior health and policy adviser for Partners in Health, a global nonprofit health organization involved with COVID-19 efforts.
That's partly because those countries have more practice, he says, as they frequently trace tuberculosis and Ebola, for instance. Even so, the contact tracing protocol common in the U.S. is outdated, he says.
"It's clear we are going to have contact tracing going forward," he says. "But we have to do it smarter than we were doing it before," says Seung, also an assistant professor of global health and social medicine at Harvard Medical School.
One way is to stop "siloing" testing, tracing, and vaccination as three separate measures and instead integrate them, as Seung and Natalie Dean, PhD, an assistant professor of biostatistics and bioinformatics at Emory University in Atlanta, wrote recently in Stat News.
While the call from a contact tracer covers a lot of ground, such as if and when people should get tested or quarantine, it is also a perfect opportunity to suggest getting vaccinated right away, Seung and Dean contend. "Linking testing and tracing to vaccination might seem obvious," the two write, "but the reality is that it is not happening nationally."
In an interview with WebMD, Seung says public health officials should consider another approach to contact tracing recognized by the CDC. It's known as source investigation, and it involves looking back at patient movements 14 days before symptoms started and identifying interactions with people, places, and events that might have been the source of the infection.
"Instead of trying to figure out who [the infected person] may have infected in the last 48 hours," he says, the question is "Where do you think you got infected? Camp? Day care? A bar?"
Benjamin J. Ryan, PhD, an environmental health specialist and clinical associate professor of environmental health science at Baylor University in Waco, TX, knows contact tracing is important. But, he says, it can be a particular challenge to identify everyone who may have been exposed.
One solution, he suggests, is to use Bluetooth devices and advanced data analytics. Participants would wear the device as a condition of entry to an event or facility. It would identify others who come within 6 feet of another person for a cumulative 15 minutes of contact. The device would deactivate once people left the venue. Then, if participants later tested positive, the venue could give public health officials a limited list of close contacts, rather than the list of the thousands who attended.
Understanding Culture, Language Differences
"Contact tracing is fundamentally an exercise in trust building," says Emily Henke, executive director of the Oregon Public Health Institute (OPHI). She’s also director of the local office of Tracing Health, a partnership between OPHI and the Public Health Institute that focuses on advancing health equity.
It's difficult to build that trust if the contact tracer doesn't understand the language or the culture of the person they are calling.
The Tracing Health approach, Henke says, is to match its 293 contact tracers, culturally and linguistically, with the people they call.
"We are also looking at this as an investment in economic recovery of communities of color," she says, with 72% of its workforce Black, Indigenous, or people of color. Its team members speak 52 languages.
"When you speak the same language as someone else and you share their culture, you are better able to meet their needs," says Vadim Gaynaliy, a Tracing Health contact tracer fluent in Russian and English.
Without the need for an interpreter, he gains the trust of the people he calls more easily, he says.
Efforts to Ramp Up Contact Tracing
Approaches to contact tracing vary among states. Some states have their own employees doing it, others contract it out, and some states partner with other organizations.
With the surge of the Delta variant, many states are increasing efforts.
In Arkansas, where the 7-day average cases rose from 173 at the end of May to more than 2,000 by the end of August, contact tracing is also on the rise.
"When case volume was lower, staffing was also modified to match the lower workload,” says Danyelle McNeill, a spokesperson for the state Department of Health. “Now that the case volume has escalated, the vendors [that the state contracts with] are adding staff to meet the growing caseload."
With funding an issue for many public health efforts, partnering with universities can be one solution, says Ryan, the environmental health specialist. "Tap into universities and have universities do the contact tracing in partnership with the county," he says.
How Much Can Contact Tracing Help?
"Any amount of contact tracing can help to interrupt the chains of transmission," says Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security in Baltimore.
No expert would argue with that, but the lack of funding is an ongoing obstacle, he says. "Public health infrastructure is something that has been under-resourced and undervalued for decades,” he says, so it is a surprise many are having a hard time now.
Adalja bemoans the lack of cooperation early on, when many phone calls from contact tracers went unanswered.
"This was likely the result of politics and conspiracy theories about privacy issues being injected into the response from the very start," he says.
Even though the Delta variant is more than twice as contagious as previous variants, according to the CDC, contact tracing can help reduce transmission, Ryan says.
Research on prior variants found that good contact tracing could lead to a reduction in the virus's "reproductive number," or the number of secondary infections that occur, by 3 to 4 times, Ryan says. So he would expect the same reduction for Delta, but of course the overall transmission reduction would not be as great.
"Remember we are not going for [a goal of] zero COVID. We are trying to suppress the level among the unvaccinated."
Enough Exhaustion to Go Around
Contact tracers aren't the only ones who are exhausted, Henke says. Many of the people her contact tracers call are, too.
"They are exhausted and over it," she says. "That definitely affects the mood they bring into these phone calls."
Even so, Henke says, "What makes a good contact tracer is someone who can be there for that person and move the conversation forward, to help them understand there are supports out there to help them."
Pérez, the L.A. County contact tracer, notices some progress, compared to last year.
"I feel people are more willing to help,” she says
That’s a welcome relief from her experience last year, when family members sometimes urged COVID-positive patients to hang up and stop giving her requested information. She also senses less stigma.
"They are more comfortable telling their contacts themselves,” she says.