INDIANAPOLIS – Contact tracing is the foundation of the next phase in battling the novel coronavirus – and it requires a legion of individuals identifying everyone who might have been exposed to the deadly disease.
It's a more targeted form of stopping the spread rather than blanket restrictions on society as a whole.
Some states are hiring hundreds of people to perform contract tracing while Indiana so far has relied on a small paid staff along with volunteers, and hasn't finalized a plan for the future.
But Gov. Eric Holcomb says it “will be a key part of our plan so, that army, if we need to fund it we will.”
So what is contact tracing and why is it so important to opening up the economy?
Dr. Anthony Fauci, the nation's top infectious disease expert, said when states begin to pull back on mitigation – the stay-at-home orders and other restrictions – health officials must have a robust system to identify and halt small outbreaks quickly.
“The real proof of the pudding of the success of this reentry is how quickly and effectively you identify them, you get them out of circulation, you give them care where needed, and you do contact tracing so that you don't have a beginning of a peak,” he said. “If you don't have that, then you may have some difficulty.”
Contact tracing isn't new or particularly complicated, but it is labor intensive. The general idea is to interview anyone who is confirmed positive for COVID-19 and identify people they were in contact with recently who might have been exposed to the virus. Those people would then self-isolate for 14 days.
The Allen County Department of Health does contact tracing throughout the year for cases of measles, tuberculosis and HIV. It's just now on a much wider scale.
“We didn't have to re-create the wheel,” said Erika Pitcher, director of community health and case management services for the health department.
A physician with Indiana University's Fairbanks School of Public Health describes tracing as “essentially the disease detective part of an epidemiologist's job.”
Contact tracers take a detailed history of the person to both try to figure out where they got the disease and whom they might have passed it on to, said Dr. Brian Dixon, a faculty member in the school's Department of Epidemiology.
When the numbers get too large, he said counties often lack the manpower to trace and turn to more community-level monitoring. But when the rates start to drop they pick it up again.
“You do it towards the end of the outbreak so you can isolate new cases and not have to have mass orders to stay at home,” he said. “That is the pathway to trying to keep things open – to quickly isolate a person. If we fully reopen with no contact tracing or surveillance measures, the disease could spread again and rapidly overwhelm the system and we are back to having to shut everything back down again.”
Pitcher said public health officials can't identify every single person someone has walked by in a store or on a street. So they focus on high-risk contact – anyone the person was within 6 feet of for more than five minutes and without any personal protective equipment. Household members and fellow employees usually top the list and are told to quarantine for 14 days so they don't unknowingly pass the virus on.
Allen County has a “small-but-mighty crew” of five people doing contact tracing every day. Pitcher said even with more than 400 cases they are still doing the surveillance work on weekends and extra hours.
Dr. Deborah McMahan, Allen County's health commissioner, said people are focusing now on contact tracing but it has always been a core function of Public Health 101.
“We do it every day with 82 reportable diseases,” she said. “We'll have to respond to the situation as it arises. We will scale up if we need to. We will never lower our standards.”
Dixon said a very rough estimate of how many people are needed is one person for every 40 cases.
Massachusetts, for example, has begun hiring and training 1,000 contact tracers. The state has roughly the same population as Indiana.
The Journal Gazette asked for specific information from the state on contract tracing, including dollars spent and hiring plans. This was the response:
“(The Indiana State Department of Health) assists local health departments with contact tracing when requested and is currently working on adding resources to provide additional support for contact tracing across the state. That plan is still being finalized, so specifics are not available at this time.”
State Health Commissioner Dr. Kristina Box has said the state is using college students in public health as volunteers to conduct contact tracing, especially in Marion County where a third of the cases and deaths are happening.
“That's an incredibly important part of being able to open up so we can track down these cases as quickly as possible and isolate,” Box said.
She said Indiana will likely have to hire call center-type help.
Box said a key focus of contact tracing going forward is for those who have been exposed – but aren't showing symptoms – to isolate quickly.
She said the U.S. Centers for Disease Control and Prevention just came out with guidance on how it wants tracing to occur, and the state is reviewing that.
Box said there are different ways to do it – including adding technology applications and mapping.
“We're looking at all the options,” she said.
Apple and Google are set to launch a series of updates to their smartphone operating systems that will use Bluetooth signals to track potential coronavirus cases, according to national media outlet Vox. The companies recently confirmed the contact tracing technology will go away when the pandemic does – a measure meant to assuage some privacy concerns.
But Dixon said “there is no way to fully automate it. You need details of their social life and interactions. We aren't at a place where computers know everything about us.”
He said you can track movements of a person but not who they interact with – and he thinks people would be uncomfortable with the invasion of privacy.
“It's important to talk one-on-one with the individual,” Dixon said.