- State of COVID-19 Contact Tracing in the U.S
- Contact Tracing in States
- About United States of Care
- States prepare to ramp up contact tracing efforts
- How does contact tracing work?
- Will contact tracing be the key to easing stay-at-home orders?
- How tech companies, public health officials want to fill the gaps
State of COVID-19 Contact Tracing in the U.S
States will continue to grapple with scaling contact tracing programs for the duration of the COVID pandemic with their existing resources.
It is critically important that Congress appropriate additional funding for contact tracing in states and state legislatures continue to prioritize public health investments as they return in the coming months.
As we learn to live with this deadly virus until a vaccine or curative treatment is discovered, contact tracing is an important tool which can help states keep their residents safe.
USofCare Key Takeaways and Next Steps
- Congress should increase investment for contact tracing and self-isolation in the next federal COVID-19 relief package. While states are launching creative approaches to meet this important need, federal funding will be necessary to scale and sustain this critical work.
- States should continue to implement contact tracing tracing programs as part of a comprehensive approach to stopping the spread of the disease.
- United States of Care will monitor the progress of states and identify best practices that can lead to scalable and sustainable contact tracing solutions and programs.
- United States of Care will leverage collective knowledge by connecting states and cross-sector leaders with models and resources to support the rapid development of contact tracing programs.
- United States of Care will support the safety of all Americans by applying shared values and a people-centered lens to new approaches and solutions.
Contact Tracing in States
COVID-19 continues to spread rapidly through the United States and states need a frontline force to fight the spread.
Critical components of this effort must include increased testing and contact tracing which will require funding levels states can’t currently afford.
Contact tracing is a data-driven and effective public health strategy to slow and ideally stop the spread of communicable diseases – including COVID-19.
Through contact tracing, public health officials inform individuals if they may have been exposed to the virus and encourage them to isolate during the 14-day incubation period. Public health experts have substantial experience in this method but few have ever had to ramp up a contact tracing program as quickly or to staff up to the levels this pandemic requires.
States under both Republican and Democratic leadership are ramping up contact tracing because it is a critical component to beginning to reopen schools and businesses while limiting the spread of Coronavirus.
Technology can aid in contact tracing efforts, but contact tracing requires significant human capital in order to maintain daily communication with individuals who may have been infected.
In addition, technology-based contact tracing tools should be vetted carefully to ensure they maintain appropriate privacy protections for individuals.
United States of Care has called on Congress to significantly increase its investment in contact tracing in the next federal COVID-19 relief package. In addition, former Acting CMS Administrator and USofCare Board Chair Andy Slavitt joined with former Trump Administration FDA Commissioner Dr.
Scott Gottlieb to lead a letter of bipartisan public health experts calling on Congress to invest $46.5 billion for contact tracing and self-isolation. Congressional leaders are currently developing the next round of federal COVID-19 response and contact tracing is ly to be a critical component of the next effort.
USofCare has also recommended state policy makers continue to make investments in contact tracing as legislatures return in the coming weeks to complete their work.
Nearly all states are conducting contact tracing for COVID-19 in some capacity. However, their approaches are dictated not only by the spread of the disease in their state, but also resources available to conduct contact tracing. States are approaching contact tracing in a variety of ways:
- Hiring or Reassigning State and Local Government Employees
- Contracting with Outside Vendors
- Deploying the National Guard
- Recruiting Volunteers
- Utilizing Technology
United States of Care is monitoring state action on contact tracing and also connecting leaders with models and resources to support their contact programs. The document below highlights ways states are ramping up contact tracing programs to keep their residents safe.
Hiring or Reassigning State and Local Government Employees
- In Washington, officials are scaling up their contact tracing program to be deployed by the second week of May with the goal of a 1,500 person workforce including 500 from the National Guard. Governor Inslee announced a COVID-19 risk assessment dashboard with five metrics to gauge when and how to best lift restrictions around his Stay Home, Stay Healthy order. The state’s ability to conduct contact investigations is one of those metrics.
- Utah is assembling state employee volunteers into eight- to 10-person contact tracing teams with a supervisor who can provide on-the-job training. 1,200 state employees have signed up to help with this effort.
- Alabama has reassigned staff from within its Health Department to increase its capacity to conduct contact tracing.
- California plans to build a coalition of at least 10,000 state-employees to do contact tracing and build on the robust tracing already taking place in 22 counties. The Newsom administration partnered with the University of California, Los Angeles and the University of California, San Francisco to provide 20 hours of online and in-person training to the employees selected to be re-deployed.
- Tennessee re-trained 230 state employees idled by the pandemic as health investigators and announced plans to hire an unspecified number of additional workers in the coming days.
- Missouri state health officials announced plans to work with colleges and universities to recruit new contact tracers.
Contracting with Outside Vendors
- In early April, Massachusetts officials announced their launch of a large-scale contact tracing program called the Community Tracking Collaborative. They are working with a nonprofit health organization, Partners in Health, and budgeting $44 million to hire 1,000 people to investigate and record instances of potential COVID-19 transmission across the state. The collaborative has hired over 1,600 contact tracers from a pool of 30,000 applications. Several states have mentioned following Massachusetts’ lead including New York and Illinois.
- Ohio has also partnered with Partners in Health and will increase the number of contact tracers from a few hundred to possibly nearly 2,000.
- Indiana Governor Eric Holcomb announced the state is partnering with Maximus to centralize contact tracing and investigations for Hoosiers testing positive for COVID-19.
- Maryland signed a contract with NORC-University of Chicago to quadruple its contact tracing capabilities, enough to track as many as 1,000 new cases per day.
Deploying the National Guard
- Some states, including Washington, Rhode Island, West Virginia, and Iowa, are using emergency infrastructure and activating the National Guard for contact tracing work.
- North Dakota launched a pilot project “Operation Drive-In” to expand COVID-19 testing and improve contact tracing, which also utilized the National Guard for support.
- Oklahoma, North Dakota, and Sedgwick County, Kansas have been using medical and public health graduate students to conduct contact tracing in exchange for academic credit.
- Kansas’ state health department is bringing on 400 volunteers plus 20 medical students to help assist the state’s contact tracing work.
- Michigan’s Department of Health and Human Services announced the launch of a large-scale effort expanding contact tracing capacity through a public-private partnership, with more than 2,200 trained volunteers to aid local staff and 130 state agency staff in contact tracing. Michigan is recruiting volunteers with a background in public health, health care fields, or community organizing.
- Arizona launched the Arizona Testing blitz. Its health department is augmenting its contact tracing workforce by: training state employees; working with university partners to utilize faculty, staff, and students from different concentrations (including public health, medicine, nursing, and social work); partnering with the CDC Foundation; and onboarding new employees to staff up to 40 teams of public health investigators that can be deployed statewide to augment local health departments’ efforts.
- San Francisco is working with the state’s Department of Public Health, University of California San Francisco, and DIMAGI, to digitize a workflow to support contact tracing and monitoring of people who are potentially infected with COVID-19.
- Rhode Island is partnering with SalesForce to create a secure database allowing the state’s Department of Health and the National Guard to conduct contact tracing
- Several states including Colorado, North Dakota, South Dakota, and Utah, are using voluntary cell phone tracking as a step toward reopening their economies.
- In Colorado, people feeling sick can fill out an online form and provide cell phone information allowing the state to record their GPS data. In addition, the Colorado Department of Health and Environment is releasing survey data from the Colorado Symptom Tracker to target outbreaks and help direct contact tracing.
- North Dakota and South Dakota are using Care 19, an app allowing phone users to record their own movements.
- Utah recently announced the beta launch of Healthy Together, a strictly opt-in app to augment current contact tracing efforts.
- Kansas is using a recently launched platform analyzing anonymized cell phone data to track the location of state residents.
- Vermont Governor Phil Scott announced efforts to increase Vermont’s existing contact tracing program to 14 days prior to symptoms. The state currently has 53 trained contact tracers and is implementing a plan to train additional tracers as needed. Contact tracing staff will engage with cases and their contacts using SARA Alert technology, a text-based monitoring system, enabling the state to handle 300-900 cases and their contacts per week under this new strategy.
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About United States of Care
United States of Care is working to ensure that every single American has access to quality, affordable health care regardless of health status, social need, or income.
As a team of experts, with experience in health care policy, crisis management, and emergency response, we are leading the charge to ensure that a comprehensive set of effective policy solutions to address the ongoing COVID-19 pandemic are being considered at all levels of government leveraging the expertise of our Staff, Founder’s Council, Voices of Real Life, and other partners. You can find additional COVID response resources on our website at https://unitedstatesofcare.org/covid-19/#resources.
States across the country are laying the groundwork to launch massive contact tracing efforts to identify people who may have contracted the new coronavirus. Some public health experts say the efforts are crucial to relaxing social distancing measures intended to curb America's Covid-19 epidemic. But how does it work?
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States prepare to ramp up contact tracing efforts
Public health officials say widespread testing for the new coronavirus and contact tracing for those who test positive are crucial to safely reopening nonessential businesses and easing social distancing measures intended to slow the virus' spread.
Now, as many states are eager to ease loosen those restrictions—and, in some cases, already are—some are working to implement contact tracing efforts.
For instance, an NPR survey of 41 states and the District of Columbia found respondents reported a total of about 7,324 contact tracers and plan to increase that number to more than 35,500.
In addition, about half of the states surveyed said they are considering using smartphone data or online apps to assist with contact tracing.
CDC Director Robert Redfield said the agency has deployed 500 staff to assist with contact tracing, and the agency plans to provide $45 million to support another 650 contact tracing positions.
Researchers estimate the United States will need between 100,000 and 300,000 contact tracers to adequately track the new coronavirus' potential spread and identify Americans who might have been exposed to the virus.
However, NPR's survey indicates that only one state, North Dakota, currently has enough workers per capita to perform adequate contact tracing, and only Michigan, Nebraska, and Washington, D.C.
, have plans in place to reach the needed amount of workers.
According to the survey, the average rate of contact tracers among the states was 12 per 100,000 people, which is a third of what experts project states will need to combat the country's coronavirus epidemic—and some states indicated they didn't have a plan to hire more contact tracers, NPR's “Shots” reports.
Former CDC Director Tom Frieden, said, “There are some states that are really thinking about this and scaling it up,” and “there are others that are just beginning to think about it.”
How does contact tracing work?
For contact tracing to work, a team of public health workers must quickly follow up with people newly diagnosed with the novel coronavirus to identify any individuals who may have come in contact with the patient while they were infectious.
According to “Shots,” the goal is to have people who were exposed to the virus to isolate themselves, in hopes of preventing the virus from spreading any further. Contact tracing also can help public health officials identify outbreaks and their causes early, the Milwaukee Journal Sentinel reports.
Because people infected with the new coronavirus sometimes show mild or no symptoms of Covid-19, the disease caused by the virus, containing the virus is particularly difficult, according to Joel Hersh, former director of the bureau of epidemiology at the Pennsylvania Department of Health. That makes contact tracing especially necessary to curbing the new coronavirus' spread.
So what would contact tracing for the new coronavirus look ?
1. Identifying the index case
First, contact tracers would have to identify and contact the “index case,” or a person who was recently diagnosed with Covid-19, within 24 hours of the diagnosis.
Due to the nature of Covid-19, the best way to identify the index case is through testing for the new coronavirus, according to Bruce Lee, a professor of health policy and management at the City University of New York.
Then, contact tracers would have to determine how long the index case was infectious by figuring out how much time passed since the index case was initially infected with the virus.
To do so, public health workers have to calculate the virus' incubation period, which can be between two and 14 days for the new coronavirus.
From there, workers determine the length of time a patient was infectious by summing the number of days the patient was asymptomatic but ly infected and the number of days they patient showed symptoms of infection.
2. Identify, reach out, and isolate contacts
Next, contact tracers interview the index case about their whereabouts during their infectious period to find out how many people the index case had “effective” contact with during that time.
Lee explained that effective contact includes only the types of contact through which the pathogen possibly could be transmitted.
For the new coronavirus, effective contact can include physical contact a hug or handshake, as well as standing within six feet of an infected person for 15 minutes or more, ABC News reports.
During this stage, the individual must try to recall the names of those with whom they may have had effective contact. Contact tracers then work to locate those contacts, inform them that they were exposed to the new coronavirus, and recommend they self-isolate for 14 days to prevent them from exposing others.
If the contacts self-isolate, “[t]he viruses then have nowhere to go,” said John Swartzberg, a clinical professor emeritus in the infectious diseases and vaccinology division at the University of California Berkeley School of Public Health.
3. Contact follow-up
The final step is for contact tracers to maintain a connection with people who may have been exposed to the virus. Tracers follow up with the contacts to see if they are developing symptoms of Covid-19, and instruct them to contact a physician as needed.
If a contact ends up testing positive for the new coronavirus and reveals that they have made their own effective contacts, tracers begin the process all over again, with that patient now serving as the index case.
Will contact tracing be the key to easing stay-at-home orders?
However, contact tracing has its shortcomings.
First, contact tracing requires a lot of time and a huge workforce, STAT News reporter Sharon Begley told Vox.
“On average, to identify a person's contacts … takes something 12 hours of asking, 'Where were you? What were you doing,'” she said. “So it's very time-consuming. … The estimates are that the United States would need at least 100,000 tracers, possibly as many as 300,000.”
Contact tracing efforts also would require billions of dollars in funding, according to a report by the Johns Hopkins Center for Health Security. The report estimated that contact tracers typically would be paid about $17 an hour, meaning the cost of paying about 100,000 contact tracers for a year would be more than $3.5 billion.
Carolyn Cannuscio, an associate professor of family medicine and community health at Penn University's Perelman School of Medicine, said volunteers could help lower those costs, but organizations could need government or philanthropic assistance to fund the efforts.
And even if the country has an adequate contact tracing workforce, proper contact tracing relies on human memory and cooperation—which can be flawed.
For instance, some people may forget some of their contacts or, in some cases, a person may not know their effective contacts' names.
How tech companies, public health officials want to fill the gaps
Some tech companies, such as Google and Apple, are developing tracking systems smartphone data and applications that potentially could “fill a hole in person-to-person contact tracing” by automatically identifying and notifying contacts who were near index patients—whether the contacts are familiar with the index patient or not, The Verge reports.
But it remains to be seen if users will opt in—and until that technology is released, areas without an adequate number of contact tracers might not have the robust efforts needs to effectively curb the new coronavirus' spread.
But in places where robust contact tracing is possible, health officials are finding that most patients are eager to contribute to the process. “People who are sick don't want others to suffer,” said Cannuscio, who is leading a contact tracing effort in Philadelphia. “I think there's probably some healing potential there.”
Jeff Engel, senior adviser for COVID-19 to the Council of State and Territorial Epidemiologists, added that even flawed executions of contact tracing will be key to relaxing social distancing measures. “Even the leaky quarantine is effective,” he said. “If you get 85% of contacts to self-quarantine for 14 days, you're going to do a lot in the community to decrease transmission.”
Frieden expressed a similar view. “Yes, [contact tracing is] really hard. It's not perfect,” and “[s]ome cases will be missed, some context will be missed,” he said.
However, Frieden added, “it can make a big difference, and it can help us get out sooner and safer” (Simmons-Duffin, “Shots,” NPR, 4/28; Luthern, Milwaukee Journal Sentinel, 4/25; Lee, Forbes, 4/17; Pletz/Hill, ABC News, 4/24; Avril, Philadelphia Inquirer, 4/24; Wetsman, The Verge, 4/10; Simmons-Duffin, “Shots,” NPR, 4/14; Markus, Vox, 4/24).