The most effective containment strategy involves testing enough people to identify new cases, tracing all of their potential contacts, and isolating the people who may have been exposed before they can spread the virus to anybody else. But today, six months into the pandemic, America is still struggling to stand up these basic features of an effective public health response.
In the states where infections have exploded in the last month, officials say that their outbreaks are too big to have any hope of tracing all of the potential contacts of people testing positive for Covid-19. Even if and when the case numbers come down, they say they are dealing with antiquated technology and staffing shortages that will make it difficult to track new infections and prevent new outbreaks from flaring up. Public health workers in areas with lower Covid-19 spread told me they are only now reaching a point where they feel confident in their abilities to conduct adequate contact tracing, and they worry they could quickly become overwhelmed if spread accelerates again.
The federal government’s attitude toward contact tracing has been, at best, indifference and, at worst, active resistance. The Trump White House has reportedly tried to block any new funding for testing and contact tracing in the latest Covid-19 relief legislation, though that was overruled by Congress.
And making matters worse, public health officials told me test results have been taking a week or longer to come back from the lab, severely limiting their usefulness in heading off new outbreaks.
“If you can’t test and get a test back quickly, you can’t contact trace in a period of time that makes sense. You can’t count these cases in terms of what’s going on in real time,” David Harvey, executive director of the National Coalition of STD Directors, whose members run contact tracing programs, told me. “This is why we are failing.”
The United States is not going to be able to safely reopen schools and businesses without adequate test-trace-isolate programs in place. But deep into the crisis, the country appears to still be far behind its economic peers in establishing these capabilities.
Test: It’s taking too long to get Covid-19 test results back from the lab
America’s coronavirus testing continues to fall short relative to the size of our outbreak.
Nationwide, 8.3 percent of the tests being conducted are coming back positive. Experts have said the positive test rate should be 5 percent or less in order for public health authorities to feel confident they are tracking most infections. Otherwise, there is a risk that the virus will continue to spread undetected and new clusters flare up.
Most European countries, by comparison, are seeing fewer than 3 percent of their tests come back positive. Going by the number of tests conducted for every confirmed case, another metric of testing saturation relative to the size of the outbreak, the US also trails most of our economic peers in Europe.
The situation is especially dire in the state experiencing the worst coronavirus outbreaks right now. In Florida, for example, the positive test rate is 19 percent, essentially unchanged over the last two weeks. In Texas, 12 percent of tests are coming back positive from the lab; that’s down slightly from two weeks ago but still well above what experts say is necessary to effectively track the virus’s spread. Other hot-spot states like Alabama, Arizona, Georgia, and South Carolina also have positive test rates well above 10 percent.
“Even if we successfully trace every known contact, based on our percent positivity test, we’re missing a lot,” Caitlin Wolfe, a public health doctoral student who has done contact tracing work in Florida, told me. “If we’re not testing enough, we’re not going to be tracing enough.”
And the number of tests being conducted isn’t the only problem. Labs also need to be able to turn around the test results in a timely manner, but they have struggled to do that consistently. Quest Diagnostics, one of the major commercial lab companies, said in a statement that “persistent high demand has strained our testing capacity and extended delays for test results.” They are currently turning around results in seven days for most patients. It’s less, about two days, for hospitalized patients and other people considered a priority. LabCorp, another major lab, said they’re getting results back in two to three days.
Public health agencies in Florida and Texas reported waiting as long as 10 days for results to come back. The long delays in the hardest-hit states reflect America’s failure to establish a national testing strategy. Wolfe told me that while contact tracing workers there are waiting a week or more for test results, she knew a public health worker in Connecticut, where the outbreak is currently much more contained, whose department is using tests that provide results in as little as 15 minutes. Local officials in Washington state, also seeing a slight ebb in Covid-19 spread, also reported better turnaround times than the states currently more in need.
“It’s a huge problem getting the results,” Phil Huang, Dallas County health and human services director, told me. “That 8- to 10-day turnaround time is not helpful.”
Huang said his department has been asking the federal government to provide them with the chemical supplies necessary to run tests in the county labs and potentially get results much quicker, rather than relying on Quest and LabCorp.
But so far, the requests have gone unanswered. “We have been asking for that for weeks at least,” he said.
Trace: Outbreaks have gotten too big for comprehensive contact tracing
On top of those testing problems, the coronavirus is currently too widespread in Florida and Texas for public health agencies to realistically expect they’ll be able to trace every possible Covid-19 contact. Instead, they are concentrating for now on potential clusters, like in nursing homes or food processing plants, while waiting for the overall numbers to come down to a low enough level that they can hope to achieve comprehensive contact tracing.
But it will be a challenge to maintain these capabilities given the sheer number of infections, the lack of political leadership that has bred distrust toward the work of contact tracing, and the risk that there won’t be adequate funding for the staffing and supplies that are necessary to do the work effectively.
“The plan was: Get it down to numbers that you can manage. Then when a case pops up, you can jump on it and snuff it out,” Huang said. “But right now, we’re at case numbers that are at record levels.”
Huang’s department had developed a contact tracing plan that anticipated the daily number of new cases would top out at about 200 cases. Instead, they saw 18 consecutive days of 1,000 cases or more.
This is a nationwide problem: According to an NPR survey conducted last month, most states had not hired enough contact tracing workers to meet their expected need. Johns Hopkins researchers estimated the US needs, at a minimum, 100,000 people to do contact tracing work. As of last month, according to NPR, the actual number of hires was less than 40,000. Other important positions for contact tracing, like disease intervention specialists and medical epidemiologists, are also underfilled, Harvey said.
Local health departments have been trying to set up programs that automate some of the contact tracing work. In Dallas, for example, patients who test positive for Covid-19 are sent an online survey to fill out, in which they identify people they may have exposed and provide their contact information. Those people are then sent an automated message urging them to self-quarantine and get tested. About 40 percent of people fill out the survey, Huang said, and that kind of participation reduces the caseload for contact tracing workers.
That is a positive development, an example of how local authorities have been able to improve their capabilities since the pandemic started. But they still routinely run into structural problems that slow them down: for example, Huang said his department still relies on faxes from doctors’ offices to be notified of new Covid-19 cases.
Other challenges are of a more social nature, with contact tracing workers finding some people are distrustful when an agent of the government calls them and asks for personal information. Digital contact tracing apps, which would use a smartphone’s Bluetooth tech to anonymously track a person’s potential contacts, have been scuttled in the US because of the deep public skepticism about their privacy protections.
“I’ve spoken to people who say, ‘How did you find my information? Why is the state calling me? Why does the government want to talk to me?’” Wolfe said. “The level of mistrust in governments is quite high. There are people who are like, ‘I’m not going to give the government my information.’”
Some of the experts I spoke with blamed in the Trump administration’s hostility toward public health work for some of that resistance. The White House reportedly wanted to block any new funding for testing and contact tracing in the new Covid-19 relief legislation, but Senate Republicans objected and inserted $16 billion for those programs into their version of the bill.
“Without a robust national plan, national leadership around testing and contact tracing, we’ve seen resistance to contact tracing by some communities and some jurisdictions,” Harvey said. “If we had national leadership, we could break down some of those barriers.”
“It is mind-boggling that there is a debate about whether there needs to be more money,” he continued. “It’s a no-brainer. We need these funds.”
Isolate: Health agencies are setting up programs to help people quarantine
The last step in the pandemic response playbook is isolating. Once a person has tested positive and their contacts have been identified, those people need to be notified of their potential exposure and asked to quarantine themselves to avoid infecting other people. Research suggests that the three-pronged strategy is the most effective way to suppress Covid-19.
According to a study published in The Lancet last month, written by researchers from the London School of Hygiene and Tropical Medicine: “Strategies that combined isolation of symptomatic cases with tracing and quarantine of their contacts reduced [Covid-19 spread] more than mass testing or self-isolation alone.”
Other countries ramped up their isolation protocols months ago. As Scientific American reported, South Korea renovated existing public and private facilities so that people who needed to quarantine because of Covid-19 exposure could move in. They receive regular check-ups from public health workers and amenities, like food deliveries, that help make it easier for them to stay isolated.
US jurisdictions have finally started to set up the same kind of programs. In Dallas, Huang said the county has been working to identify alternative housing for people to quarantine in. Matt Golden, a King County, Washington, public health official, told me that his department is working with Safeway to provide groceries for people who are quarantining; they receive a code from the government and use it to order a delivery online.
“The best system is one that gives the people receiving the food the most options and involves the least touch by our staff,” he said. King County health workers also send text messages to people who have been asked to isolate, urging them to stay in quarantine.
The US has undeniably improved its test-trace-isolate capabilities since the spring. When and if case numbers come down to a manageable level, local officials I talked to sounded confident they would be able to trace the potential Covid-19 contacts in their area. But it will require sustained investment and there will continue to be challenges as long as test results are delayed and Americans remain dubious about contact tracing.
This strategy is how other countries have managed to reopen more of their economies without the debilitating spike in cases the United States experienced. Our ability to contain the coronavirus is contingent on building out these programs. That will be difficult to do in the middle of the crisis, but it’s the only choice we have.
“We are absolutely flying the plane as we build it,” Wolfe said. “Maybe we’ve now built the windshield so we can see what’s coming. But we are not fully encased.”
This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.
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