As thousands of Connecticut businesses opened their doors for the first time in months, local and state health officials devoted to contact tracing quietly made preparations last week for a surge of coronavirus cases.
Despite limited resources, many local health districts have been hustling to keep up with a steady trickle of new cases, reaching out to people who test positive and their close contacts. State leaders are depending on those efforts to curb the spread of the virus as people venture out of their homes.
But with large-scale venues like zoos, movie theaters and amusement parks reopening, health officials worry they’ll need more help. They are recruiting additional volunteers and training more staff to prepare for a possible influx of infections.
“We’re definitely concerned that the numbers will spike again,” said Mary Day, a nurse practitioner who is helping to coordinate tracing efforts for the Ledge Light Health District in southeastern Connecticut. “We can only be so effective, and that largely is dependent on people knowing who they’ve been in close contact with. If you’re in a public space, you’re not necessarily going to know who is next to you or have any way to get in touch with them.”
At the beginning when everything was locked down, it was a lot easier to identify those close contacts. Now, as we’re starting to emerge from that isolation, we’re seeing it be a bit more difficult. People’s interactions are becoming a lot more varied.”
Complicating an already-difficult process are new problems with the state’s tracing software. Contact tracers begin with a phone call, then allow residents to choose whether they want calls, texts or emails as a follow-up mode of communication. But text and email prompts are available only in English, hampering outreach to non-English speakers.
It’s one of the latest issues with state’s tracing program. Municipal health workers had reported other difficulties early on, including bugs in the system and a lack of training. They are pressing the state to come up with a swift solution to the language problem.
“The issue of the languages is critical – it’s an equity issue,” said Jennifer Kertanis, director of the Farmington Valley Health District. “If we are saying that the majority of our cases and the hardest hit communities are our large cities – where a significant portion of the residents speak Spanish or another language – we need to rapidly make the investment in a tool that can work for those populations.”
While the state works through its technology issues, it also is training 118 students to join the hundreds of workers and volunteers already embedded in the tracing effort. The students, who come from undergraduate and graduate health programs at Connecticut colleges, will assist in what is expected to be a more hectic pace of tracing.
“With bigger gatherings where people don’t know everybody, that makes contact tracing not only challenging, but sometimes impossible,” Dr. Lynn Sosa, deputy state epidemiologist, said. “The goal here is to focus on the person, making sure they’re staying home and asking them to provide the context that they know.”
Efforts speeding up
In May, as Connecticut headed toward its first stage of reopening – allowing some retail and tourist attractions to serve customers, primarily outdoors – state leaders said aggressive testing and tracing were critical to containing the spread of COVID-19.
Those strategies became even more important in the run-up to the second stage of reopening, which began last Wednesday and includes more indoor options, such as movie theaters, gyms and bowling alleys.
The state has fallen short of its testing goal – nearly 50,000 tests were completed over the last week, half the amount it had hoped to run on a weekly basis. Gov. Ned Lamont’s administration has since backed away from its ambitious benchmark of 100,000 tests per week, citing evolving guidance from federal agencies.
After a slow start on contact tracing, Connecticut has managed to successfully connect with 46% of new COVID-19 cases, said Josh Geballe, the state’s chief operating officer. Those do not include people in long-term care settings like nursing homes. State officials said nursing homes and other congregate facilities are responsible for their own contact tracing.
“Based on that kind of trend line, we’re optimistic that we’ll continue upwards,” he said.
Fifty-one of the 65 municipal and regional health departments have begun using the state’s new tracing software – double the number from just two weeks ago, Geballe said.
The local departments make up the bulk of the tracing workforce – each has some staff dedicated to the effort and many have recruited volunteers. Some have trained additional employees and volunteers ahead of the second reopening stage.
It’s a substantial undertaking for the departments, which have been battered by years of funding cuts.
The state promises $1.85 per capita in public health funding to every community of more than 50,000 people or to regional health districts with at least three communities. With funding cuts, the actual per-capita payment in the current fiscal year was $1.18, according to the Connecticut Association of Directors of Health.
Nationwide, it’s been a difficult decade for local public health agencies. A national group estimates the loss of 50,000 local positions, or nearly 25% of the workforce, since the Great Recession of 2008.
Local health officials interviewed by the CT Mirror said they are doing the best they can with limited resources. Several reported being able to keep up with the flow of cases, but they acknowledged that infections are growing at a much slower pace than earlier in the pandemic.
The agencies are prepared to ask the state for help if the latest stage of reopening spurs a flood of new cases.
“At the beginning when everything was locked down, it was a lot easier to identify those close contacts,” said Charles K. Brown Jr., director of the Central Connecticut Health District. “Now, as we’re starting to emerge from that isolation, we’re seeing it be a bit more difficult. People’s interactions are becoming a lot more varied.”
Preparing for a surge
Brown, whose district covers Berlin, Newington, Rocky Hill and Wethersfield, is training volunteers in anticipation of a surge. Thirty-five nurses who typically staff flu clinics in the area have agreed to help. They’ll be instructed on interview techniques and guided through the state’s new software.
Brown estimated that about half of his 11-member staff has been working on contact tracing. After a rocky start with the computer system, things are getting easier.
“We’d go into the system, even when it was in active production, and overnight they would be instituting changes to it,” Brown said. “It was similar to building an airplane while you were flying it.”
As the state reopens, Brown is leery about large groups of people congregating in businesses and public spaces. He’s already had to shut down a local day care center twice after people tested positive.
“With just one big room, everybody’s in there for a full day and there is no way to guarantee they haven’t been exposed,” he said. “We had to quarantine the entire day care, shut them down and then wait the two weeks to ensure more people didn’t contract it.”
Day, the nurse practitioner whose district includes New London, Waterford, Stonington, and six other southeastern communities, said she is training 10 additional volunteers to help. They will join the two workers and 16 volunteers who already are devoted to the effort. Four other staff members have also been trained in case of a surge.
With bigger gatherings where people don’t know everybody, that makes contact tracing not only challenging, but sometimes impossible.”
“We figured as things started to reopen, we would need to have more resources in order to reach out to close contacts,” she said. “And we figured people would probably have more close contacts.”
Agencies define close contact as being six feet or closer to someone for more than 10 minutes. Some departments use more than 15 minutes as a guideline.
People who test positive are expected to isolate themselves for 10 days. Those exposed to someone who tests positive must isolate for 14 days, since it can take longer for symptoms to present. The state also recommends that people who are exposed get tested.
Everyone who tests positive is entered into the state’s system, and their names and contact information are funneled to local health districts.
The tracers initiate contact with a phone call. They interview residents, fill out a questionnaire in the computer system and share guidelines, then arrange for follow-up communication. Residents can choose to receive calls, text messages or emails for the duration of their quarantine.
During the follow-up contact, tracers are checking on how a person is feeling, the progression of their symptoms, whether they are running a temperature and whether they need medical care. State officials say the information is kept private.
Residents’ participation and adherence to state guidelines is voluntary.
“With these larger gatherings, it’s really making sure people are practicing best behaviors – social distancing if possible, wearing a mask, hand washing,” Sosa, the deputy state epidemiologist, said. “Hopefully, they won’t be in a situation where they get sick and expose other people or where they’re exposed.”
Even as workers and volunteers get the swing of the new system, glaring problems remain.
Members of several local health districts have raised concerns about the language issue. If a resident elects to receive follow-up communication via text or email, it’s only available in English.
“You need different languages,” said Patrice Sulik, director of the North Central District Health Department, which serves Enfield, East Windsor and six other communities. “We were told something like, ‘Well, we wanted to see what language groups you needed.’ But Spanish didn’t occur to you? There’s pretty robust data about the languages people in Connecticut speak.”
Sulik said she doesn’t fault the state’s health department because the new system came along in the middle of a pandemic, when everyone was scrambling. Still, she hopes the problem is corrected soon.
“A priority in Connecticut is looking at everything through a health equity lens,” Sulik pointed out.
The language limitation also puts more of a burden on the local health departments. Follow-up phone calls require manpower; texts and emails are automated.
Local officials also mentioned that while conducting the initial survey with residents, only two symptoms for COVID-19 appear in the state’s system – cough and shortness of breath. The Centers for Disease Control and Prevention lists 11 symptoms associated with coronavirus.
Health workers said most tracers are savvy enough to ask about the full range of symptoms, even though they are not included in the system. But they worry new volunteers might overlook them.
State officials said they are working to resolve both issues.
They also are setting up a program so that “CT COVID Trace” appears on people’s caller IDs when a contact tracer reaches out. Residents sometimes avoid the calls because they don’t recognize the number.
“We know how prevalent and pervasive telemarketing has gotten,” said Av Harris, a spokesman for the state’s health department. “This will at least give people some indication of why they’re getting that phone call.”