St. Louis area public health officials are working to ramp up contact tracing, a key to reopening businesses safely and preventing another surge of COVID-19 cases.
Health departments, so far, have heavily relied on volunteers and switching staff members from their usual duties to perform the labor-intensive process of tracking and monitoring the contacts of infected people.
Now officials say they are hiring more staff, including 100 contact tracers in hard-hit St. Louis County. Other improvements include developing ways for tracers to work at home.
It’s hard to estimate how many will be enough, officials say. It depends on several factors: How much will testing increase? Will people limit the spread of the disease by staying six feet apart? Will they continue to work at home? How many will travel?
“Having so much that still remains unknown is a challenge in and of itself,” said Samantha VanNatta, an epidemiologist with the St. Charles County Department of Public Health. “We are operating the best we can with the knowledge that we have.”
While several states are hiring hundreds of contact tracers, according to a survey by NPR, it appears no such statewide plan is in the works in Missouri.
Gov. Mike Parson’s office and the Missouri Department of Health and Senior Services did not respond to requests for information.
But one nonprofit group working with local health departments says the state is surveying the departments to determine how many tracers they have and identify areas of greatest need. It is difficult to determine, however, because staff members are juggling contact tracing in addition to their regular jobs, says Larry Jones, executive director of the Missouri Center for Public Health Excellence.
Lynelle Phillips, vice president of the Missouri Public Health Association, said her advocacy organization has expressed concern to the governor’s office about the need for contact tracers.
“It’s important to not let the virus run amok. We know how it can get out of hand so quickly,” Phillips said. “We really feel like investing in public health, and things like contact tracing in particular, is critical to our success in combating an outbreak.”
1,800 contact tracers
The National Association of County and City Health Officials recently issued a position statement recommending health departments have 30 tracers per 100,000 people.
That equates to over 1,800 tracers in Missouri.
Jones likens the spread of infection to standing on the edge of a cliff. While front-line workers are helping those who have fallen off the cliff, contact tracers are building a fence at the top to prevent others from falling.
Contact tracing has long been used as an effective tool in public health, to stem the spread of things such as measles, tuberculosis and sexually transmitted diseases.
When someone tests positive for COVID-19, the disease caused by the coronavirus, a contact tracer asks a series of questions over the phone to determine who that person has had contact with, dating back to at least two days before showing symptoms.
Tracers will contact those at risk of infection, check their symptoms and encourage them to self-quarantine. Tracers also continue to monitor the individuals, answer questions and connect them to resources they need to successfully stay home.
Jones and Phillips say some staff has been working at the task 60 to 80 hours a week, especially in rural areas. Even police detectives are helping. Other routine health department duties, such as providing childhood immunizations and conducting facility inspections, are put on hold.
Urban health departments can pull volunteers from nursing and medical schools, but they face challenges living in denser areas.
“They have such a large population to take care of that they are just as understaffed as our rural health departments are,” Jones said.
St. Louis County has reported the most cases of COVID-19 in the state — about 3,800. Over the past week, an average of nearly 75 new cases were reported each day.
The county health department has relied heavily on nursing students from the University of Missouri-St. Louis, as well as medical and public health students from several other area universities, said Gena Traver, the department’s health promotions manager.
The students are required to complete clinical hours in order to graduate, and the contact tracing work has helped them meet their requirements as hospitals and clinics are limiting visitors.
While there are plans to expand the number of student volunteer tracers this summer — such as 40 UMSL students from its summer community health nursing courses — the health department wanted more consistency.
Two weeks ago, the county announced it would hire 100 contact tracers, funded by the $173.5 million relief funding from the federal Coronavirus Aid, Relief and Economic Security, or CARES, Act.
“We are really trying to be proactive with this,” Traver said. “Volunteers are amazing and continue to support us, but we also want to make sure we are adequately staffed to be able to respond to this.”
About 1,000 people have applied for the temporary jobs, which pay $15 an hour, she said.
Previously, tracers were required to work at the health department, which limited the number who could work safely together. Last week, they started working remotely with the help of a computer program that allows supervisors to guide them and immediately answer questions.
Dr. Carole Baskin, the county’s director of communicable disease control, said she hopes the new hires will allow other employees to be able to get back to their regular job duties such as disease education and pest control.
“This is not something that can be long term. We have to maintain all lines of services for the county,” Baskin said. “We don’t want mosquitoes everywhere.”
The 30-per-100,000 guideline would mean the county needs nearly 300 contact tracers, but Baskin said she expects the new hires to be enough.
“We are confident we are able to keep up based on data from the past two months,” she said.
The city of St. Louis has reported about 1,500 COVID-19 cases and has been seeing an average of 37 new cases a day.
The city’s health department typically has three full-time disease investigators whose jobs include contact tracing. As staff has been shuffled around, the city now has what is equal to 16 full-time contact tracers, said department programs supervisor Michele Welker.
Welker said they’ve also relied on small number of medical student volunteers.
The population guideline would mean the city needs 90 contact tracers, but Welker says “we feel pretty confident with our staff and the volunteers we currently have.”
The St. Charles County health department has relied on a volunteer team of about 50 school nurses, VanNatta said. Two staff nurses train and manage the volunteers, and this past week the county hired four more nurses and epidemiologists to help with managing and tracing.
Population guidelines recommend the county have 75 tracers.
Over the past two months in St. Charles County, VanNatta estimates the team has contacted more than 2,000 people, including all of the county’s approximately 675 cases. The county is averaging 10 new cases a day.
“It’s something we’ve focused on in the very beginning and put our resources toward,” she said. “We couldn’t have done it without volunteers.”
The public’s help
To streamline recruiting, health departments have created training videos and materials. New contact tracers also train with a supervisor until they feel comfortable working on their own. Depending on experience, training can take as little as a day or longer than a week.
Sheila Grigsby, assistant professor in the college of nursing at UMSL, said student volunteers have learned about the importance of public health.
“They feel like they are really able to help families and those that have been exposed through one-on-one conversations with them on how to keep them and their families safe,” Grigsby said.
Kristin Stewart-Perkins, an adjunct faculty member at UMSL who volunteered a month ago as a tracer, said many people she contacted wanted to do what they could to prevent the spread but were worried about how to pay bills or limit contact with others in their home.
“You are supposed to quarantine yourself to one room and one bathroom,” Stewart-Perkins said. “In some families, you can make this happen, and in others, you can’t.”
The Centers for Disease Control and Prevention recommends contact tracing include connections to support services such as housing, food and medicine. Some may need packages of thermometers, sanitizers and masks.
Health departments are asking the public to help by keeping a calendar of where they have been in case they are contacted, answer their phones and contact the health department if a loved one suddenly becomes sick and is hospitalized.
“Time is of the essence when trying to do contact tracing and protect people who have been potentially exposed,” Welker said.
The Missouri Center for Public Health Excellence created a form to print that helps people track their contacts as they go out, as well as supplying a list of answers to questions about contact tracing. The tools are available at oneforallmo.com.
Jones said, “We need to do as much as we can to help an overtaxed public health system be able to do its job.”