LINCOLN, Neb. (AP) - To bring the coronavirus under heel, particularly as the measures that effectively closed Nebraska are lifted, public health agencies across the state will use a tried and true tool used for decades to help control infectious disease outbreaks.
Contact tracing, a kind of connect-the-dots for tracking how a disease spreads in a community, has been deployed to manage everything from outbreaks of sexually transmitted diseases to a recent flare up of the measles in New York.
The goal is to identify positive cases in the population, ask those individuals to isolate at home or elsewhere, and to identify any one else they may have come into contact with since becoming infected, according to the Lincoln Journal Star.
That’s not necessarily easy, said Dr. Crystal Watson of the Bloomberg School of Public Health at Johns Hopkins University, particularly when efforts to perform more tests are showing the virus continues to spread quickly throughout a population.
Nationally, estimates for the number of contact tracers needed in the ongoing response range between 100,000 to as many as 300,000, costing billions of dollars to deploy.
But it’s a tool states will want to have in place before this fall, Watson said, when infectious disease experts anticipate a resurgence of coronavirus cases across the country.
“This capacity is really needed to break those chains of transmission,” Watson said at a recent SciLine briefing on contact tracing for reporters. “But more importantly, at a population level, it’s to manage this epidemic on an ongoing, low level in different places around the country.”
Contact tracing efforts are already in place in several communities across the state, including Lincoln, which has seen its total cases rise by 148% this week alone.
On Friday, the Lincoln-Lancaster County Health Department deployed 16 contact tracers by phone to begin connecting the dots between newly confirmed cases in the county, and any residents they might have exposed to the virus.
Some of the tracers have worked in the health department’s clinic before the pandemic and were reassigned to the virus-stopping mission, while school nurses from Lincoln Public Schools have also offered to help with the effort as needed.
Tim Timmons, the health department’s communicable disease coordinator, said the caseload of the pandemic has required more public health nurses to trace contacts, but said the work itself differs little from other contact tracing done outside of the global pandemic.
The investigations can be painstaking, and a time-consuming process, however.
Done by phone, interviews with those who are infected can take anywhere from 30 minutes to two hours, and cases requiring an interpreter often take twice as long, said Bernice Afuh, who’s managing contact tracers for the department.
Other times, the movements of an individual - people can be contagious for several days before they begin to show symptoms - of the index case set the parameters for how many potentially exposed people need to be called.
“If they have been here, there and everywhere, there’s going to be a lot more contacts to track down, so to speak,” Afuh said.
Nebraska will raise an army of 1,000 contact tracers for local public health districts in the coming weeks and months, Gov. Pete Ricketts announced in April, as it also seeks to expand coronavirus testing capacity and provide accommodations for individuals who need to self-quarantine.
The state recently contracted with three Utah companies to expand testing capacity by some 540,000 tests this year, and has secured the use of University of Nebraska residence halls and hotels to help individuals quarantine as needed.
To begin in the third prong of its pandemic plan, more than 200 employees from the Department of Health and Human Services were temporarily reassigned to contact tracing duty, taking part in a three-hour online seminar before being deployed remotely to hot spots such as Hall and Dawson counties.
Dannette Smith, CEO of the Nebraska Department of Health and Human Services, said a total of 325 employees who work in the divisions of Public Health, Child and Family Services, and Development Disabilities - all areas where they have experience in Health Insurance Portability and Accountability Act (HIPAA) compliance - will be working as contact tracers by the end of this week.
“Contact tracing is absolutely important to make sure that we are taking a proactive stance on how we are monitoring and supporting people who have the potential to have COVID-19,” Smith said at a news conference.
Tracers will call individuals with lab-confirmed coronavirus infections to ask basic demographic questions, when they experienced an onset of symptoms, if they’ve seen a doctor or been hospitalized, and who they may have come into close contact with recently.
That information will be entered into the Nebraska Electronic Disease Surveillance System, a database shared with the Centers for Disease Control and Prevention, said Leah Bucco-White, a spokeswoman for the department.
Contact tracers can enter data into the system, but cannot access information stored there, Bucco-White added.
The first team of new contact tracers started placing phone calls in coordination with the hard-hit Central District Health Department last week, said Teresa Anderson, the department’s health director.
At first, the department’s in-house team of contact tracers was able to keep up with the caseload, Anderson said, but once the growth in new cases began to double every few days in mid-April, making Grand Island a national hot spot and account for roughly a quarter of all cases in the state, that work fell behind.
“As we have more tests available, that has increased our need for personnel to assist us with contact tracing,” Anderson said.
The DHHS team has been working under the direction of Anderson’s staff to broaden their capacity, making contact with those who are tested to remind them to hunker down until results come back, to notify those who test negative they can go about their daily lives, and to run positive cases through a battery of questions to learn who else may be in danger for contracting the disease.
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Contact tracing is also an important piece to ensuring those who are in quarantine stay there for the recommended 14 days, Anderson said, and follow up with positive cases as they recover.
“It allows us to keep working with them, asking if they have everything they need to stay in quarantine, if their family has what they need and to connect them with community resources,” she said. “It’s just a bigger safety net.”
Peeling off DHHS employees from their normal duties to contact tracing duties is a short-term solution to a long-term problem, however.
“We’re getting really scrappy really fast by pulling these resources from other divisions in DHHS so we can very quickly ramp up,” said Jason Jackson, director of the Department of Administrative Services.
Nebraska wants to have a team in place capable of quickly scaling up if case numbers spike and additional investigations are needed, or to tamp down its workforce if new cases slow over the next 1-2 years, a flexibility to respond to the outbreak’s ebbs and flows.
Call centers - which have capabilities to connect with people in multiple languages, training on HIPAA compliance, and the technological infrastructure to reach people - have reached out to the state about helping assist with contact tracing in the intermediate term.
“They are seeking a way to keep their workers engaged and employed, and altruistically, to help with this broader pandemic fight,” he said.
For the long haul ahead, Jackson said the state wants to strike a balance between keeping some of its contact tracing efforts inside DHHS’ Division of Public Health, where the state’s epidemiologists and infectious disease experts could consult as needed, Jackson said, and using a third-party vendor.
The state could begin looking for a company to serve those long-term needs by end of year. Jackson said it’s unclear how much a contract could cost at this point.
Watson said as the United States begins to reopen after weeks of shelter-in-place orders and limits to public life, other countries, including South Korea and Singapore, should serve as a model.
Both countries managed surges of coronavirus using an effective contact tracing effort in conjunction with expanded testing and isolation of positive cases.
“These are the tools we need to develop,” she said. “We need to put resources towards this, and we need to prioritize this at a national level because this is how we get back to work and do it safely.”
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