Distrust, Underfunding Hinders COVID-19 Contact Tracing

Crook County, Oregon, located in a rural area about 150 miles southeast of Portland, has successfully traced the vast majority of contacts connected to its positive COVID-19 cases.

Karen Yeargain, LPN, of the county health department, considers her community one of the lucky ones.

"We have a low number of cases, but the amount of work is still huge," Yeargain told MedPage Today, adding that public health officials have not needed to ramp up these efforts on a national scale like this before. Currently, Crook County has a total of 13 cases in a population of about 24,000.

Contact tracing, which has long been used to curb other infectious disease outbreaks like sexually transmitted infections and tuberculosis, involves a workforce that confidentially calls COVID-19-positive individuals to identify potential exposures and connect them to resources. While it is traditionally performed in-house by public health staff, the vast number of COVID-19 cases has overwhelmed public health capacity and forced counties and states to find more creative ways to perform contact tracing.

Although the practice has been successful in some areas, contact tracing efforts in other states have been crippled by a lack of testing, funding, and national guidance. With a growing distrust in public health that is leading some Americans to opt out of contact tracing efforts altogether, Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, has said the U.S. contact tracing paradigm in the context of COVID-19 is just "not working."

Understaffed, Underfunded

As of the last week of June, between 27,000-28,000 people were working as contact tracers across the U.S., according to the CDC. Yet public health officials have estimated that something like 100,000-300,000 are needed, with at least 30 contact tracers for every 100,000 people.

Alabama reassigned staff from its health department to work with public health officials, while Massachusetts is collaborating with a nonprofit health organization, Partners in Health, to hire contact tracers. Oklahoma and North Dakota hired recent public health graduate students to perform contact tracing for academic credit, and Kansas is using a technology platform to track anonymized cell phone location data.

Contact tracing needs to be performed with some flexibility because of varying needs across states, but at the same time, discrepancies across states could be hampering the overall response, said Trish Riley, MS, executive director of the National Academy for State Health Policy (NASHP), which tracks contact tracing plans by state.

"The disease knows no state lines and people know no state lines, so this testing protocol should be consistent across the country," Riley told MedPage Today.

In April, the Coronavirus Aid, Relief, and Economic Security (CARES) Act earmarked $631 million for local health departments' surveillance efforts, including contact tracing. But the cost of hiring 100,000 contact tracers, on the low side of the demand, would cost around $3.6 billion, according to the Association of State and Territorial Health Officials (ASTHO) and the Johns Hopkins Center for Health Security.

Many states allocated funds from the CARES Act to go towards hiring and training contact tracers, according to NASHP data.

Others resorted to funds outside of federal funding to compensate for costs. Hawaii, for example, entered into a $2.5 million contract with the University of Hawaii using state funds. New Jersey and New York are relying on funding from donors like Bloomberg Philanthropies, which invested $10 million into contact tracing.

But not all of those dollars may be well spent. In Utah, the state spent $2.75 million on a contact tracing app, with $300,000 a month allocated for maintenance fees. Yet just under 2% of state residents downloaded the app, according to Business Insider. Spanish speakers and members of the Navajo Nation have also spoken out against it, saying those dollars could have been better spent to serve their immediate needs.

Public Distrust

Low engagement with contact tracing is symptomatic of a growing distrust in government agencies and the politicization of public health issues. That may be one reason why contact tracing, which has been relatively successful in Germany and Taiwan, is not shaping up to be as effective in the U.S.

A snapshot of data from public hospitals in New York, the state with the most contact tracers in the U.S. (50 per 100,000), shows just 50% of contacts were successfully traced in the first 3 weeks of June. The remainder did not have an accurate phone number, could not be reached, or refused to complete the interview.

Public health officials have estimated that 75% of contacts need to be elicited, located, and tested within 24 hours before implementing reopening measures.

But other states are struggling even more to reach people. In Louisiana, 13% of contacts were traced as of July 1, which has since fallen to about 11%, according to COVID Act Now, a database of statewide testing and contact tracing rates. State legislators, as well as their constituents, have publicly expressed skepticism of the practice, citing privacy concerns.

Although contact tracing is entirely voluntary, the concern is that contact tracing apps will track users' location data involuntarily.

"A lot of people are very reluctant to embrace the idea of contact tracing," said Louisiana state Rep. Raymond Crews (R) at a May hearing. "We don't know the extent of it."

Challenges with technology and manpower are shackling contact tracing efforts, but a larger issue is deep-seated in American culture, identity, and individualism, said Keith Humphreys of Stanford University.

"A huge portion of Americans ... don't have that much trust in the government, don't trust public health officials, and are mostly not going to do it," Humphreys told MedPage Today. "Culture eats strategy for breakfast."

Maximizing Effectiveness

Will Humble, MPH, former director of the Arizona state health department, said testing and contact tracing go hand in hand, and likened the role of adequate testing in the COVID-19 response to "the base of a pyramid."

In some states, however, there are still not enough testing supplies to meet the demand, leading to shortages and long lines.

"All roads lead to testing," Humble told MedPage Today. "Contact tracing doesn't work without robust testing."

Contact tracing is most effective in communities when they are in the early or later stages of an outbreak, as opposed to peaks, Humble said. Overall, public health officials should focus on implementing strategies with the largest return on investment, he said, noting things like mask wearing or social distancing are highly effective strategies as well, and don't require the same dollars and manpower as contact tracing.

"The return on investment is a lot higher when you're early on in the epidemic or as things flatten out, but it's always valuable and worthwhile," Humble said.

One way to beef up the contact tracing response would be to align reopening incentives with surveillance, such that businesses could only reopen after an adequate number of contact tracers are hired in the community, Humble said.

"That would mobilize stakeholders in that county to push the board of supervisors that is the governing body for county governors," Humble said. "Businesses would [say] ... 'Where are the resources to get contact tracing capacity up in our county?'"

The growing pool of unemployed Americans could also be tapped into as a potential workforce for contact tracing, according to an ASTHO report released in April. It suggests hiring laymen who work alongside epidemiologists, public health officials, and professional disease investigator specialists to maximize tracing capacity.

"The public health and health care system must also prepare to contain future outbreaks and associated health care surges," it states. "Time is of the essence."

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