“That is something that we’re working very hard to spin up, to get going in a large way,” the governor said this week. “I’m pushing hard on the team — they know it — for us to get that going because … that allows us to open up the economy even more.”
But state, Chicago and Cook County public health leaders concede they’re not yet ready to fully roll out a coronavirus contact tracing system. The big problems to solve? Finding enough workers and putting technology in place.
Dr. Ngozi Ezike, director of the Illinois Department of Public Health, cited estimates that there needs to be 30 contact tracers for every 100,000 people. That means more than 3,800 interviewers to handle the data, sleuthing and leg work necessary to trace contacts on the unprecedented scale needed during a pandemic caused by such a virulent disease.
The city can’t say how many people it has on the job, with officials noting there are people working on it from different divisions within the Chicago Department of Public Health and its health care allies.
The county, meanwhile, says it has 29 people devoted to the effort but will need at least 300 to cover more than 2 million residents spread over 700 square miles of suburban Cook.
And so state public health officials say the goal is for “some portion” of the program to be in place by late May, the current expiration date on Pritzker’s stay-at-home order.
“We don’t necessarily have to have all of it by then,” said Dr. Wayne Duffus, the acting state epidemiologist. The priority will be “critical areas,” including nursing homes, long-term care facilities, prisons and jails, he said.
Beyond that, the state is working on a standardized hiring process, an online training program and a computer app to help track cases and contacts, Duffus said. The bulk of public health system work in Illinois is done at the local level, so the state envisions its role as being “an operations manager" for contact tracing at the 97 county and regional health departments.
National experts agree that contact tracing is essential if states are to avoid another surge in COVID-19 cases and an overwhelming flood of patients into hospitals.
Tools are limited to slow the virus’s spread before the nation develops therapies and a vaccine, but social distancing remains effective, said Anita Cicero, deputy director of the Johns Hopkins Center for Health Security.
“But as communities and economies need to relax some of those social distancing restrictions, testing and tracing the cases is the tool that we have right now that will be effective," she added. “And if communities aren’t able to isolate the sick and quarantine those who are exposed, then rapid community spread is probably likely to increase again, which would bring us back to requiring the strict physical distancing measures.”
What is Contact Tracing?
Contact tracing in the U.S. dates back to at least the early 20th century, when it was used to limit the spread of communicable diseases such as smallpox and tuberculosis. Since then, it’s been employed to control other scourges, including sexually transmitted diseases, measles and Ebola.The practice has been credited with limiting the spread of COVID-19 in other countries that quickly turned to the approach. That includes South Korea and Singapore, where the government used digital surveillance and enforcement methods that likely would meet stiff resistance here from privacy and freedom advocates.
“So many diseases are highly communicable," said Dr. Jennifer Layden, chief medical officer for the Chicago Department of Public Health. "So contact investigations are part of the public health bread and butter.”
Here’s how it works: When a confirmed case of COVID-19 is reported to the state, a contact tracer tracks down the sick person, or their relatives when the person is too ill to talk or has died from the disease.
The interviewer tells them the patient should be isolated at home until they no longer are believed to be contagious. Sometimes, if the person doesn’t have the capability to isolate on their own, they refer them to social service agencies that can help find alternative housing and delivery of food, medicine or health care services.
The interviewer tries to determine who the patient had contact with up to two weeks prior to symptom onset. In some cases, a person may have no symptoms at all, making that calculation more difficult.
The tracers then track down those contacts and attempt to speak with them. They suggest precautions to avoid spreading the disease and ask them to quarantine at home for two weeks from the time of contact with the infected person, or if they are sick, until they have fully recovered.
Ideally, the tracers also would track down the contacts of everyone who is presumptively diagnosed with COVID-19, given that person could be spreading SARS-CoV-2 — the virus that causes the disease — before a test confirms they actually have it, experts said.
“At the very first hint of somebody being ill, they need to immediately be put into isolation, even while they are awaiting their test results,” said Dr. Rachel Rubin, the county public health department’s senior medical officer. “Even if they did a test that went off to a lab, they can’t even wait that two days to 10 days of getting that result, because in that intervening time when they are just beginning to get sick is when they are infecting everybody around them.”
Tracing work takes time, requires empathy and social skills, and can be emotionally taxing.
“We’re asking people to kind of recount stories that they have probably already told other physicians before, and sometimes we’re asking family members to recount how their loved ones died,” said Dr. Chen Wang, a preventive medicine fellow for the county health department who has been tracking down cases for a couple months.
"I’ve had cases where I called the phone number of that person who has passed away and I speak with their spouse. And their wife says, ‘This was my husband I had been with for 60 years, and the longest time we every spent apart were those days that he was in the hospital.’ And now the surviving spouse is back in their home alone.”
Despite the anxiety that can be involved, nearly everyone is cooperative with the efforts, Wang added.
“People recognize that we’re all in this together, and everyone has something that they can contribute,” she said.
Efforts Underway
Pritzker and Illinois officials have looked to Massachusetts’ partnership with global health nonprofit Partners In Health as a model. That northeastern state — with a little more than half the population of Illinois but more COVID-19 cases and deaths, is deploying 1,000 contact workers. Johns Hopkins experts say even that likely won’t be enough.Duffus, acting state epidemiologist, said one particular aspect of the Massachusetts program that he would like to implement in Illinois is the use of resource coordinators. Those workers are tasked with making sure people who test positive for COVID-19 have the food, medications and services they need to be able to self-isolate.
“A resource coordinator is going to be crucial to the success of this because we can ask people to do things, but if their needs are not met, it’s going to be very difficult for them,” he said.
Not all of the contact tracers would need a background in medicine or public health, Duffus said. They should be hired locally because they will have an easier time establishing trust with the people who they call, he added.
The state also is looking at the use of technology to help with case tracking, with the possibility of an online application that would let people enter their symptoms and contacts so that workers can follow those leads.
Illinois has been without a permanent state epidemiologist since Layden resigned at the end of February to become the city’s chief medical officer. Duffus, a senior medical adviser in the Division of Global HIV and TB at the Centers for Disease Control and Prevention, arrived April 5. At the time, the state had reported more than 11,000 known cases of COVID-19 and 274 deaths.
Ezike said that there was no downtime because Illinois’ public health department was covered by epidemiologists who have been CDC-trained and are longtime infectious disease experts.
Chicago has been doing some contact tracing since the initial outbreak. But it has had to pick and choose what to focus on because of limited resources.
“Certainly congregate settings where we’re seeing a high level of spread, and that would be long-term care facilities, public shelters, jails, those outbreaks that are reported to us … in a workplace are priorities,” Layden said.
“But we are really striving to get to a point — I mean where there’s review of the data and there’s investigation into every case — to the point where we are thoroughly investigating all the contacts is something we are striving to do,” she said.
The city is working to build partnerships with community health workers, students and others to expand the ranks of contact tracers, so when cases eventually decline they can work to prevent another flare-up, Layden added.
Like the state, Chicago is searching for ways that technology might make the job easier and more efficient. While rolling out the city’s “Covid Coach” app, Dr. Allison Arwady, the city’s public health commissioner, said they were looking at the possibility of using it to help track contacts and send warnings to contacts via text when someone contracts the virus.
Cook County has focused its 29 contact tracers on nursing homes and group homes, as well as hospitalized patients, said Rubin, the health department’s senior medical officer.
When the surge starts to decline, the program will need to expand, she added. Rubin also said testing is not yet as widespread, quick and accurate as necessary to detect cases early, when a patient may be most contagious. And there needs to be a more thorough system for reporting test results to the state because not all health care providers are doing that, she said.
“Once we reach a point where we can start doing more contact tracing, we really will need to ramp it up, because we want to stop that next surge ... from being as high and as steep,” Rubin said.
A ‘Near Miss’
A Johns Hopkins study concluded the nation needs about 100,000 contact tracers, with more than 3,800 in Illinois. But Crystal Watson, the report’s lead author, warned that “we also shouldn’t delay in conducting tracing until we have a perfect testing system.”In Chicago, Howard Brown Health has been doing contact tracing from the start.
It was a natural for the nonprofit organization that serves the LGBTQ community and other groups that face health care disparities. For many years, the organization has been contact tracing for sexually transmitted diseases, including AIDS, said Dr. John Schneider, an infectious disease specialist affiliated with the University of Chicago.
Since early March, Howard Brown Health has interviewed about 300 people with COVID-19 and reached out to as many as 1,200 of their contacts. Schneider makes many of those calls, and described one situation that he described as “a near miss" where intervention may have come too late.
He was talking to a woman who had COVID-19 and lived at home with her husband, son and daughter. Everyone but the daughter had become sick, so they sent her to live with relatives, including her grandparents. By the time she was tested — and found to be infected with the virus despite having no symptoms — the disease already had spread to others in her temporary home.
"If I could have gotten to her three days earlier ... then I could have said, ‘The daughter needs to stay home, keep her in a different room if asymptomatic, that’s fine, but no one should be going to the grandparents right now,’ ” Schneider said.
The case illustrates the need for doing contact tracing from the very moment of diagnosis, possibly at the lab where the person went for the test.
Like the governor and the experts, Schneider believes contact tracing will be crucial to prevent or limit future outbreaks after the number of cases in the current surge diminishes.
“We’re entering a phase where it’s really important, because then it starts to become more manageable, and then it has implications for keeping things open, keeping families healthy," he said.
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