Health departments around the U.S. that are using contact tracers to contain coronavirus outbreaks are scrambling to bolster their ranks amid a surge of cases and resistance to cooperation from those infected or exposed.
With too few trained contact tracers to handle soaring caseloads, one hard-hit Arizona county is relying on National Guard members to pitch in. In Louisiana, people who have tested positive typically wait more than two days to respond to health officials — giving the disease crucial time to spread. Many tracers are finding it hard to break through suspicion and apathy to convince people that compliance is crucial.
Contact tracing — tracking people who test positive and anyone they've come in contact with — was challenging even when stay-at-home orders were in place. Tracers say it's exponentially more difficult now that many restaurants, bars and gyms are full, and people are gathering with family and friends.
"People are probably letting their guard down a little ... they think there is no longer a threat," said Grand Traverse County, Michigan, Health Officer Wendy Hirschenberger, who was alerted by health officials in another part of the state that infected tourists had visited vineyards and bars in her area.
Her health department was then able to urge local residents who had visited those businesses to self-quarantine.
Hirschenberger was lucky she received that information — only made possible because the tourists had cooperated with contact tracers. But that's often not the case.
Dr. Anthony Fauci, the nation's top infectious disease expert, said Friday that contact tracing simply isn't working in the U.S.
Some who test positive don't cooperate because they don't feel sick. Others refuse testing even after being exposed. Some never call back contact tracers. And still others simply object to sharing any information.
Another new challenge: More young people are getting infected, and they're less likely to feel sick or believe that they're a danger to others.
While older adults were more likely to be diagnosed with the virus early in the pandemic, figures from the Centers for Disease Control and Prevention show that the picture flipped almost as soon as states began reopening. Now, people 18 to 49 years old are most likely to be diagnosed.
On Monday, the United States reported 38,800 newly confirmed infections, with the total surpassing 2.5 million, according to a tally by Johns Hopkins University. For a few days now, daily reported cases in the U.S. have broken the record set in April. That partially reflects increased testing.
Some states were caught off guard by the surge and are trying to quickly bolster the number of contact tracers.
"Right now we have an insufficient capacity to do the job we need to," Arkansas Gov. Asa Hutchinson said recently, announcing he wanted to use federal coronavirus relief funds to increase the number of contact tracers to 900.
Arkansas already has 200 doing the job, but infections have risen more than 230% and hospitalizations nearly 170% since Memorial Day. Businesses that had closed because of the virus were allowed to reopen in early May, and the state further eased its restrictions this month.
In addition to needing more staff to handle rising case numbers, contact-tracing teams also must build trust with people who might be uneasy or scared, said Dr. Umair Shah, executive director for Harris County Public Health in Houston, where an outbreak threatens to overwhelm hospitals.
That's difficult to do if infected people don't return calls.
In Louisiana, only 59% of those who have tested positive since mid-May have responded to phone calls from contact tracers, according to the latest data from the state health department. Just one-third answered within the crucial first 24 hours after the test results. Tracers there get an answered phone call, on average, more than two days after receiving information about the positive test.
Perry N. Halkitis, dean of the Rutgers School of Public Health, said COVID-19 spreads so fast that contact tracers need to get in touch with 75% of the potentially exposed people within 24 hours of their exposure to successfully combat the spread.
"Is it as good as we would like? Well, obviously not," said Dr. Jimmy Guidry, Louisiana's state health officer. "It's better than not having it."
Contact tracers around Utah's capital of Salt Lake City have seen caseloads double and cooperation wane since the economy reopened, said health investigator Mackenzie Bray. One person who wasn't answering calls told Bray they didn't want to waste her time because they and their contacts weren't high-risk — a dangerous assessment because the person might not know the health history of their contacts, Bray said.
Getting people to act on tracers' advice also is a challenge. In the Seattle area, only 21% of infected people say they went into isolation on the day they developed symptoms. People, on average, are going three days from time they develop symptoms until they test, said Dr. Matt Golden, a University of Washington doctor who is leading case investigations for King County Public Health Department.
Since people are infectious for two days before symptoms, that means many are spreading the virus for five days, he said.
In hard-hit Maricopa County, Arizona, officials hired 82 people to bolster contact tracing, allowing them to reach 600 people a day, said Marcy Flanagan, executive director of the Maricopa County Department of Public Health.
But the daily average of confirmed infections has soared, to 1,800 a day from 200 in May, county figures show. That means the county must leave the rest of the cases to be handled by colleges, health agencies and the Arizona National Guard, Flanagan said.
All of them must triage: Each infected person is asked in an automated text to fill out a survey to assess their risk level, and tracers only contact by phone those who appear to be high risk or work in settings that could trigger a dangerous outbreak, such as an assisted living facility.
Contact tracing is key to avoiding worst-case outcomes, said Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention and current president and CEO of Resolve to Save Lives, a nonprofit that works to prevent epidemics. But the explosion of U.S. case has made it nearly impossible for even the most well-staffed health departments to keep up, he said.
Contact tracing is "a tried and true public health function," Frieden said. "If the health department calls, pick up the phone."