If the busy streets outside Umair Shah’s window are any indication, Houston is done staying home.
Shah runs public health for Harris County, Texas, which includes Houston and 33 other cities and towns. It’s the third-largest county in the U.S., with more land than Rhode Island and roughly the population of Ireland. The area has been stirring back to life since the state loosened restrictions that locked down schools, businesses and many other aspects of daily life for six weeks.
“It feels just like we’re back to where we were,” Shah said.
As people return to restaurants, stores and offices, Shah recognized they could unwittingly bring the virus with them. He made plans to hire and train hundreds of workers, increasing a staff that usually numbers between 700 and 800 people by 50%. The workers will investigate new cases; notify people who might have been exposed; and ask them to quarantine to avoid making others sick.
Contact tracing is a critical tactic to slow and eventually stop the spread of an infectious disease. It has been used for decades to track outbreaks of everything from tuberculosis to Ebola, and other countries have adopted it to try to slow the transmission of Covid-19. In Wuhan, China, where the coronavirus began to spread late last year, at least 9,000 contact tracers tracked down tens of thousands of people who might have been exposed to an infected person each day, according to a World Health Organization report in February.
Across the U.S., local officials like Shah are preparing for new waves of Covid-19 as lockdowns ease. They hope by documenting the virus’s path, they can limit new outbreaks before they strain the health-care system. But contact tracing is a high-stakes logistical challenge that, like manufacturing diagnostic tests and securing protective equipment, gets harder as cases rise. Shah is worried that even his ambitious plans won’t be enough.
“It feels like we’ve gotten better than we were but not as good as where we need to be,” Shah said. “None of us will know if it’s going to be enough until we see what’s happening with case transmission in our community.” The county had more than 10,000 confirmed cases as of May 21, with scores of new cases per day.
Health experts have urged the U.S. government to swiftly recruit 100,000 or more contact tracers, a monumental expansion of the public-health workforce. State and local health departments together employed about 225,000 full-time positions before Covid-19, according to recent estimates from public health professional groups, numbers diminished in past years by funding cuts.
Recent stimulus legislation has poured new funding into the gap. An emergency fund for states enacted April 24 includes $11 billion that can be used for testing, contact tracing, and other disease surveillance. A proposal passed by House Democrats, the HEROES Act, would add an additional $75 billion for testing and contact tracing.
Even if the provision passes—Senate Republicans oppose the House package, saying earlier stimulus bills were enough—there is concern that the fast-moving virus will outpace efforts to contain it. Failure could mean more illness and death.
“The general consensus among public health experts is that we’re not ready,” said David Harvey, executive director of the National Coalition of STD Directors, a professional group for disease investigation specialists. “State economies are reopening, but they’re also scrambling hour by hour, day by day, to get these public health systems in place.”
The federal money would help add more people like Oscar Baez to the nation’s virus response. Baez, 33, was recently posted in Jerusalem as a foreign service officer in the State Department. As Covid-19 spread, he returned home to Boston, where he learned that Massachusetts Governor Charlie Baker planned to recruit a contact-tracing corps with the help of Partners In Health. The decades-old nonprofit is best-known for delivering health care to people in Haiti and other impoverished places.
Baez, who was born in the Dominican Republic, worked with Partners In Health there after the 2010 earthquake in Haiti. Now he’s among 1,700 people the group has hired in Massachusetts that make about 10,000 calls a day, augmenting workers from the state’s 351 local health agencies.
Teams across the state make calls seven days a week, from 8 a.m. to 8 p.m., to follow the steps of Covid-19 patients. The work is divided among case investigators, who interview people confirmed to have the virus, contact tracers who alert those they may have exposed, and care resource coordinators who assist people in quarantine. Many, like Baez, are trained in multiple roles.
Most patients have already been notified of their diagnosis by medical providers, but occasionally investigators have to break the news on the phone. They retrace the patient’s steps in the days before they began to show symptoms to compile a list of other people who might have caught the virus. A sample script asks patients about encounters at work, their household, social gatherings, medical appointments, shopping and travel. The initial calls can take half an hour.
Tracers call the contacts to alert them to possible exposure and ask them to self-quarantine for 14 days. They don’t identify the person who tested positive. The tracers follow-up daily through the quarantine and resource coordinators like Baez try to make sure that people have what they need while staying inside. From a small studio apartment near his childhood home, Baez spends the day on the phone, mostly speaking in Spanish or Portuguese, sharing information and connecting people with help.
“It’s effectively life or death for some,” Baez said. “If they have to stay home for two weeks when they don’t have food on the table the next day.”
Some people need volunteers to pick up medication at the pharmacy. A nurse Baez spoke to was returning to work after Covid-19; she had lost her mother to the disease and needed childcare for her infant. An undocumented man who was getting sick wondered how he could see a doctor. Baez has encountered violent homes and people struggling with substance use.
“You can’t meet all their needs, but you know what the stakes are,” Baez said.
In Harris County, Shah said the mitigation efforts that slowed the virus give public health officials a chance to get ahead of it. “How do we actually make this a more robust effort that really allows us to not just identify, not just to trace, but honestly, to hopefully isolate and contain?” he said.
Ana Zangeneh supervises disease surveillance and epidemiology for Harris County Public Health. She helped recruit and train 300 contact tracers in recent weeks. The training, which combines online courses and in-person sessions, is staggered to avoid having too many people in the same room.
“With this reopening, there’s going to be naturally an increase in cases,” Zangeneh said. “We’re just prepared to handle the surge that we’ll be faced with.”
Texas has recorded more than 50,000 cases statewide, and more than 1,400 deaths.
The shutdowns that slowed the virus incurred a devastating economic cost. Zangeneh’s staff is trying to persuade strangers on the other end of the line that their cooperation will help preserve those hard-won gains.
“If we can identify as many infected people as possible, including their contacts, and ask them to remain at home, and make sure that they really understand the purpose and the reason for that message, if we can do this all really relatively quickly,” Zangeneh said, “we’ll be able to control the outbreak.”
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