Contact tracing an effective tool in fight against virus

Robert Cox

After four months of dealing with the COVID-19 pandemic, the Perry County Health Department has contact tracing down to a science.
They’ve spent hours and hours of overtime reaching that point, sometimes with the department’s entire staff lending a hand and working seven days a week as they struggled to keep up with new cases while trying to continue serving the community.
Like many small health departments across the state, they’ve been doing all on their own.
During a news briefing Monday, Gov. Mike Parson said the state’s Department of Health and Senior Services has 37 contact tracers who have supported local agencies since the beginning of the pandemic and that they are training 150 more “to support local agencies’ response to COVID-19 surges in their communities.”
“Let me be clear,” Parson said. “State government can help, but contact tracing depends upon the work of our local public health agencies. They know their communities. They have the trust of their neighbors.”
Parson pointed out that Missouri counties and municipalities have been given shares of the $521 million dollars the state received as part of the federal Coronavirus Aid, Relief, and Economic Security Act, much of which had yet to be dispersed. Perry County’s share was $2,245,035.

“So far, not enough of the money has gotten to the people who are doing frontline public health response,” Parson said. “We have surveyed local health departments across the state. Out of 81 responses, only 17 — about 20 percent — indicated they have received CARES Act funding support from the counties. We have to do better.”
According to state guidelines, entities that qualify for a portion of the allotted funds must submit an application to receive it.
In Perry County, where the health department has been in the midst of a second peak — with numbers rising from 110 confirmed cases on June 22 to 183 by July 13 — the application process got pushed to the back burner. On July 8, the health department was monitoring 81 concurrent active cases, the highest total since the first case was reported on March 22.

Over the past two weeks, the county has seen a significant drop in new cases and the number of active cases has dropped to single digits, finally giving director Sylvia Forester time to return to more administrative duties.
“Fortunately — knock on wood — it’s been pretty quiet,” Forester said Tuesday. “We continue to work with the schools and hearing their plans and finishing up the application to receive some CARES Act money.”
Some of that money, Forester said, will be used to account for items and resources the department needed for its COVID-19 response that wasn’t included in its regular budget, as well as covering overtime pay and improving the phone system.
“Our current phone system only has 3 lines, and we oftentimes have to wait until there is a free line available to make calls to individuals and businesses for COVID-19,” Forester said. “Also, there have been a multitude of times when people cannot reach us because all of our phone lines are busy.”

Labor intensive

According to Liz House, the health department’s assistant director and epidemiologist, contact tracing is nothing new when dealing with infectious diseases.
It is labor-intensive, requiring health officials to interview people who test positive, track down anyone they may have had contact with and ask them to self-quarantine.
“The initial process for each new positive from the initial interview, to contacting close contacts, contacts businesses, etc., can take up to three hours depending on the number of close contacts, businesses involved, length of time the individual has been symptomatic, and so forth,” said House. “When the health department receives confirmation of a positive case of COVID-19, that individual is called to inform them of the results and to conduct our initial interview. The time frame assessed to identify close contacts starts either two days before symptom onset or two days prior to when the individual was tested, if they are not experiencing symptoms.”
Those deemed as close contacts of the infected individual are then advised to self-isolate for at least 14 days, the incubation period for the virus.
“Currently, we do not recommend a close contact to seek testing right away. Instead, we ask if they become symptomatic that they reach out to a provider and seek testing.” House said.
When the state and county stay-at-home orders were lifted in early May, the job got that much harder. As people returned to work, stores, bars and restaurants, they came into contact with many more people, increasing the number of contacts from single digits per case to potentially many more.
“When community transmission was at its worst in Perry County, the health department had identified over 200 close contacts who were asked to isolate for a 14-day period,” Forester said. “Our workload for response mirrors our new and active cases. If you see high numbers of new cases and high active case counts, you can guarantee we are putting extra hours in the evenings and weekends.”
The extra hours and long weeks are necessary. In an effort to contain the spread of the virus, contact tracing must be done quickly.
“Our goal is to complete tracing on new cases with-in 24 hours of receiving a positive result,” Forester said. “Sometimes we have to come in on the weekends to accomplish non-COVID work that still has to be done, but wasn’t able to be done during the regular work week because of COVID.”
And it’s only gotten harder.
“Since the state reopened, contact tracing has become much more difficult and time consuming,” Forester said. “Some of the problems we have faced recently are people not self-isolating while awaiting the results of a doctor-ordered test. Also, people have become less forthcoming with information to help us identify all of their close contacts. Unfortunately, as well, when calling close contacts to inform them of their potential risk, some citizens refuse to listen to staff, become rude, and end up hanging up before all education or recommendations can be given.”

Extra hands

In Perry County, the health department has only 12 full-time and two part-time employees, a staff that includes three nurses. During the height of the recent spike — which House described as a “second wave” — everyone lent a hand.
“All three of our full-time public health nurses participate in contact tracing,” Forester said. “Other staff, such as our emergency preparedness coordinator, assistant director, and myself, support other efforts that are involved with the process, including notifying close contacts and businesses where the positive may have visited while they were infectious. The nurses also call all of our active cases at least 3 times a week to follow up with them, monitor their symptoms, and support them through quarantine.”
With most of the staff focused on contact tracing and related response efforts, many of the health department’s other programs have suffered.
“Our other programs have had to take a back seat many times,” Forester said. “We used to take walk-ins — we now require an appointment to see a nurse. Also, there were several new projects that we had just started, or were hoping to start, that addressed other issues in the community such as opioid misuse, prenatal tobacco use, and chronic disease management, that we cannot currently address and work on due to COVID-19 response.”
The workload got so big, in fact, that the health department had to seek additional assistance, hiring a part-time public health nurse to help with other responsibilities, such as immunizations and the reporting and monitoring of other communicable diseases.
“Back-to-school and the fall are very busy for the health department during any other year outside of COVID-19,” Forester said. “Our newest staff member will help offset some of that additional work. She has worked in public health before, has a background in communicable disease work, and will be able to help in a variety of efforts, including our COVID-19 response. We are very lucky to have her.”

An effective tool

Despite all the difficulties the department has faced over the past four months, Forester said her department’s efforts have not gone to waste.
“So far, this has been an effective strategy,” Forester said. “With effective contact tracing and isolation, along with reduced community opportunity for further transmission, we have been able to slow the spread we have been seeing in this second peak.”
She also pointed to her decision to issue an alert last month strongly discouraging county residents to avoid large social gatherings as a contributing factor.
“Fewer opportunities for community transmission through large social gatherings has helped Perry County to reduce the increase in positive cases,” Forester said. “What we have seen in the last two weeks is a great example of the effectiveness of public health’s guidelines and recommendations, and how as a community we can use it to reduce any further burden of the virus on our community. Perry County has seen four COVID-related deaths so far this summer. With all of us working together, we can prevent further loss of life.”


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