The Washington PostDemocracy Dies in Darkness

The Health 202: U.S. isn't ready for the contact tracing it needs to stem the coronavirus

with Paulina Firozi

The United States is finally doing a better job of identifying Americans who are infected with the novel coronavirus.

But its capacity to contact and warn the web of people they potentially exposed to the virus is sorely lacking.

Contact tracing in which those who had contact with infected people are notified and asked to self-isolate is a key tool in keeping the highly infectious virus at bay as states reopen and Americans start visiting restaurants, shopping at retailers and going to their offices again.

Yet states and localities largely haven’t assembled the teams necessary to carry this out on a scale that public health experts say is necessary. Many are short on funds to scale up their contact tracing capacities, and those that have invested heavily are still finding it hard to reach the people they need to warn.

“Right now, we haven't been able to trace [spread of the virus] back to the source because we don't have all that track and trace work in place,” Scott Gottlieb, former commissioner of the Food and Drug Administration, said yesterday on CBS’s “Face the Nation. “And so that's a challenge for public health officials.

Contact tracing is especially crucial as infections keep rising in many states. 

Infections are increasing in at least 21 states across the South and West, as states allow businesses and individuals to gradually resume some semblance of normal life after shutdowns. While some governors have delayed reopening measures in response, it’s unclear whether there is wide political will to do so and President Trump has said there won’t be a return to shutdowns even in the case of a second wave.

“Alabama, Oregon and South Carolina are among the states with the biggest increases,” my colleagues reported over the weekend. “Alabama saw a 92 percent increase in its seven-day average, while Oregon’s seven-day average was up 83.8 percent and South Carolina’s was up 60.3 percent.”

And in New York, which is reopening after the highest death toll from the virus in the country, Gov. Andrew Cuomo (D) threatened Sunday to shut down Manhattan and the Hamptons if local governments don't observe social distancing guidelines. “We’re not going to go back to that dark place because local governments didn’t do their job," he said, according to the New York Post.

Contact tracing failed to stem the first wave of coronavirus infections, which spiked in the United States back in March. Congress has since provided $631 million to state and local health departments for surveillance, including contact tracing, in coronavirus relief legislation. 

But that’s far short of the $3.6 billion needed for the effort, according to an estimate by the Association of State and Territorial Health Officials and the Johns Hopkins Center for Health Security. With infections now spread across the country, contact tracing is an even more extensive undertaking requiring 100,000 or more trained tracers to get in touch with strangers and persuade even some without symptoms to stay at home, The Post’s Frances Stead Sellers and Ben Guarino report.

“Health departments in many of the worst-affected communities are way behind in hiring and training those people,” they add. “The effort may also be hobbled by the long-standing distrust among minorities of public health officials, as well as worries about promising new technologies that pit privacy against the public good.

States aren’t waiting to reopen until they have sufficient contact tracing.

In Arizona, where cases are rising, the governor reopened businesses before local health departments had hired and trained its new contact tracers.

“We flattened the curve. Then, by the time we ended, the contact tracers weren’t up and running yet,” Will Humble, former director of the state’s health department, told Frances and Ben.

Humble said health departments in the state’s hard-hit urban counties have been repurposing staff and making new hires using federal dollars and support from an Arizona-based nonprofit group, the Crisis Response Network. But he said leaders could have tied each region’s reopening to its hiring of adequate contact tracers.

“We didn’t do that here,” he said. “Now we have to ramp up a contact-tracing workforce that isn’t going to get to everything, probably.”

Texas and South Carolina are also working to ramp up contact tracing but haven’t met their goals yet.

Both states are also seeing surges in cases. Texas has hired about 3,000 of the 4,000 contact tracers Gov. Greg Abbott (R) said he planned to have in place, Frances and Ben report. 

Michael Sweat, director of the Center for Global Health at the Medical University of South Carolina, said the state’s health department is putting a lot of effort into training and deploying contact tracers but said that “they are still getting their footing.”

States that have invested heavily in contact tracers are still running up against problems.

Contact tracers in Louisiana’s dramatically ramped-up program successfully reached fewer than half of the people with exposure to the virus they called between May 15 and June 2, the state’s health department reported last week.

Many people the tracers called simply didn’t answer their phones, raising questions about how effective contact tracing can be when it hinges on mass cooperation from the public.

Massachusetts has deployed a 1,000-person contact tracing task force. But the state is still seeing such rapid growth in cases more than 1,000 new cases daily that reaching everyone necessary to make a real difference could be a challenge even for that large team.

There’s wide variety in efforts across the country to scale up contact tracing. A few examples from Frances and Ben:

  • The University of California at San Francisco has been tapped by the state to create a Pandemic Workforce Training Academy that will train as many as 3,000 people for the state’s 58 county health departments, many of them focusing on low-income communities where requests to quarantine can be financially devastating.
  • In Fairfax County, Va., the county health department has subcontracted to a private company, GattiHR, to create a 400-strong, largely remote contact-tracing team, looking for people with “empathy, attention to detail, resilience [and] investigative skills,” and finding successful applicants among those furloughed from the hospitality industry.
  • In Rhode Island, Gov. Gina Raimondo (D) unveiled a voluntary app health officials hope will prove more reliable than people’s memories in re-creating their recent contacts — one of numerous cellphone tracking innovations, including the Apple-Google exposure notification system, that have prompted privacy concerns from civil libertarians.
  • In Florida, the Coalition of Immokalee Workers has been working urgently with Doctors Without Borders to win the confidence of migrant workers, where 37 percent of those tested at pop-up clinics were positive. Their goal is to slow the virus’s spread before farmworkers leave for summer jobs in Georgia, South Carolina and beyond.

Ahh, oof and ouch

AHH: Tulsa's top health official says he wishes President Trump’s scheduled Saturday rally there would be postponed.

“I think it’s an honor for Tulsa to have a sitting president want to come and visit our community, but not during a pandemic,” Bruce Dart, director of the Tulsa city and county health department, told the Tulsa World. “I’m concerned about our ability to protect anyone who attends a large, indoor event, and I’m also concerned about our ability to ensure the president stays safe as well.”

“Coronavirus infections are rising sharply in Tulsa and have spiked across Oklahoma, which is in its final phase of reopening. Last week, the state recorded a seven-day average of 145 new cases, its highest since early April, and Tulsa officials on Saturday reported 82 new infections,” Derek Hawkins writes for The Post’s live blog. “ … The Trump campaign has not said whether it will require attendees to wear masks or practice social distancing.” 

President Trump on June 10 said he would soon begin holding his first campaign rallies in over three months. (Video: The Washington Post)

Health experts are weighing in about the potential risks of such an event. 

Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said in an interview with Chris Wallace on “Fox News Sunday” that chanting and shouting could aerosolize the virus and fuel its spread. 

“Would I want my loved ones in a setting like that? Absolutely not,” Osterholm said. “And it wouldn’t matter about politics; I wouldn’t want them there.” 

Ashish Jha, director of Harvard’s Global Health Institute, told the Associated Press the event is “an extraordinarily dangerous move for the people participating and the people who may know them and love them and see them afterward.”

The president’s top economic adviser, Larry Kudlow, on CNN encouraged people to be cautious as they venture out into public, insisting that people “must observe safety guidelines. Okay, must. Social distancing must be observed. Face-covering in key places must be observed.” 

But he was less forceful when asked about whether supporters should wear coverings at Trump’s rally. “Well, okay, probably so,” he said when asked whether he thought that applied to the president's upcoming rally. 

OOF: The longest-hospitalized covid-19 patient amassed a $1 million bill.

Michael Flor, a 70-year-old Medicare recipient, won’t have to pay most of the bill. But Seattle Times columnist Danny Westneat writes that it's an example of the nation's convoluted and costly health-care system. 

“The total tab for his bout with the coronavirus: $1.1 million. $1,122,501.04, to be exact. All in one bill that’s more like a book because it runs to 181 pages,” he writes. “…The bill is technically an explanation of charges, and because Flor has insurance including Medicare, he won’t have to pay the vast majority of it. In fact because he had COVID-19, and not a different disease, he might not have to pay anything.” 

The bill includes 3,000 itemized charges, about 50 for each of his 62 days in the hospital. Lawmakers have allotted more than $100 billion to help hospitals and insurers cover coronavirus costs, which means Flor may not have to pay even is Medicare Advantage policy’s out-of-pocket costs, which could have cost him $6,000. 

“It’s like we’re doing an experiment for what universal health coverage might be like, but confining it to only this one illness,” Danny writes. “… Flor said he’s hyper-aware that somebody is paying his million-dollar bill —  taxpayers, other insurance customers and so on.” 

OUCH: More than a third of Philadelphia's 476 retail pharmacies were looted during the protests over police violence.

“Robbers stole thousands of dollars worth of prescription drugs, including what the agency characterizes as a substantial amount of narcotics, which police now fear will soon make their way to the city’s illegal drug market,” public radio's WHYY News reports.

The Philadelphia Police Department and the Drug Enforcement Agency could not confirm if the attacks were strategically planned or spontaneous. Most of those pharmacies are slowly reopening, but large amounts of drugs, particularly insulin, were stolen.

“Industry experts warn that for independent pharmacies, already struggling to compete with large chains and dealing with the costs of safety gear required by the coronavirus pandemic, losses incurred by looting could force them to close in the weeks or months ahead,” WHYY reports.

“Those stores that were on the edge, this may be the culmination that closes them up,” said Mel Brodsky, executive director of the Philadelphia Association of Retail Druggists.

In the states

States across the Sun Belt and in the West are reporting some of their highest coronavirus case numbers yet. 

“Hospitals in Arizona have been urged to activate emergency plans to cope with a flood of coronavirus patients. On Saturday, Florida saw its largest single-day count of cases since the pandemic began. Oregon has failed to contain the spread of the virus in many places, leading the governor on Thursday to pause what had been a gradual reopening,” the New York Times’s Julie Bosman and Mitch Smith report. “And in Texas, cases are rising swiftly around the largest cities, including Houston, San Antonio and Dallas.” 

The country overall is experiencing steady case numbers, with about 21,100 new cases every day. Much of the nation is seemingly open or gradually reopening. 

But on a state level, it's a different picture. As of Saturday, the daily case count was surging in 22 states, “shifting course from what had been downward trajectories in many of those places,” Julie and Mitch write. “The spikes in cases bring leaders in these states to a new crossroads: Accept the continued rise in infections as an expected cost of reopening economies or consider slowing the lifting of restrictions aimed at stopping the spread or even imposing a new set of limits.” 

A mid-March flight from New York’s John F. Kennedy Airport to Los Angeles included a passenger infected with the coronavirus. 

The passenger, a retired Manhattan surgeon, was rushed to the hospital the next day and the coronavirus spread quickly among those he came into contact with soon after he left the airport, the Los Angeles Times’s Harrier Ryan and Kiera Feldman report. But no one warned the public or his fellow passengers.

“L.A. was still in an early stage of the COVID-19 pandemic when the surgeon’s flight touched down, with fewer than 250 confirmed cases. Local health officials regularly assured the public then that the county was investigating each case and engaging in aggressive contact tracing to control the spread of the virus,” they write. “Despite these pledges, no one in public health informed any of the passengers and crew who had flown cross country with the surgeon that they were at risk. The airline only recently learned of the case from The Times.” 

There were two such flights to LAX in which public health officials didn’t warn other passengers or crew when a passenger later tested positive for the virus. 

“Without instructions to self-quarantine or seek testing, more than 200 people on these flights returned to their families and communities ignorant of their exposure, potentially seeding new outbreaks,” they add. 

A Florida restaurant closed its doors again after six patrons from the past week tested positive. 

The restaurant, Kiwi’s Pub & Grill in central Florida, had been open for less than six weeks, Meryl Kornfield reports for the live blog. 

“Owner Rick Culmer wrote on Facebook that health officials told him the area has been ‘hammered with new infections,’ ” she writes. 

Numerous restaurants are having to shutter after new cases in their own businesses or in the area. 

Meryl adds: “Three bars in downtown St. Petersburg shared they would shut back down temporarily out of ‘an abundance of caution’ after staff members tested positive. Park & Rec DTSP and Avenue Eat + Drink said one employee had the virus, although it was unclear whether it was the same worker at both bars, which share an owner. The Galley said ‘a few’ staff members were infected.” 

The number of daily coronavirus hospitalizations in Maryland has been rising, although the overall trend in currently hospitalized patients has been declining. 

There were 134 hospitalizations in Maryland on Friday and 130 reported on Saturday, following six days of daily hospitalizations below 100, Rebecca Tan reports. “The number of patients currently hospitalized, however, continued to decline from 836 on Friday to 799 on Saturday,” she adds. 

The entire D.C., Maryland and Virginia region reported 1,405 coronavirus infections Saturday, higher than the seven-day-average of 1,248. 

“It is still unclear whether the steps taking toward reopening or the mass protests against the killing of George Floyd last week have contributed to a resurgence of infections in the region,” Rebecca adds. 

The administration will propose a rule allowing single-sex homeless shelters to consider someone's biological sex in making accommodation decisions.

Single-sex homeless shelters could choose to accommodate only people whose biological sex matches that of those they serve, under a rule to be proposed by the Department of Housing and Urban Development in the coming weeks, we reported over the weekend.

The proposed rule would scrap the Obama administration’s 2016 guidance requiring such shelters to accept transgender people but retains its 2012 rule barring federal housing discrimination on the basis of sexual orientation or gender identity. The agency had been working on the regulation since spring 2019.

Under HUD’s proposed new rule, operators of single-sex shelters may consider someone’s biological sex — instead of how they self-identify — in making placement and accommodation decisions. It's the latest effort by the Trump administration to rewrite federal rules on how government programs provide for transgender people. The Department of Health and Human Services finalized a rule Friday that also emphasizes biological sex over how a person identifies.

Coronavirus latest

Here are a few more stories to catch up on after the weekend: 

The latest research: 
  • A wave of new research, including a review funded by the World Health Organization and published in the journal Lancet, found “data from 172 observational studies indicate wearing face masks reduces the risk of coronavirus infection,” Ben Guarino, Chelsea Janes and Ariana Eunjung Cha report.
The economic fallout: 
  • Economist Mark Zandi of Moody’s Analytics said without another $1 trillion in federal rescue efforts, the U.S. economy could relapse into a double-dip recession later this year, David J. Lynch writes.
  • The pandemic has the potential to widen racial disparities, including for homeownership, columnist Michelle Singletary writes.
More from the states: 
  • The Florida Department of Health fired its coronavirus data scientist after she objected to and sometimes declined to comply with requests she believed were unethical, Marisa Iati reports. Now, she has created he own dashboard for the state’s coronavirus statistics.

Sugar rush

On Memorial Day, Colette Hawley rented a cherry picker so she could entertain residents through the windows of Chicago Methodist Senior Services. (Video: Susan Besson)