Contact tracing has largely failed in the US

In Arizona’s most populated region, the coronavirus is so ubiquitous that contact tracers have been unable to reach a fraction of those infected.

In Austin, Texas, the story is much the same. Just as it is in North Carolina, where the state’s health secretary recently told state lawmakers that its tracking program was hiring outside workers to keep up with a steady rise in cases, as a number of other states have done.

Cities in Florida, another state where Covid-19 cases are surging, have largely given up on tracking cases. Things are equally dismal in California. And in New York City’s tracing program, workers complained of crippling communication and training problems.

Contact tracing, a cornerstone of the public health arsenal to tamp down the coronavirus across the world, has largely failed in the United States; the virus’ pervasiveness and major lags in testing have rendered the system almost pointless. In some regions, large swaths of the population have refused to participate or cannot even be located, further hampering health care workers.

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“We are not doing it to the level or extent that it should be done,” said Steve Adler, the mayor of Austin, echoing the view of many state and city leaders. “There are three main reasons. One is the sheer number of people, the second is the delay in getting test results back, the third is the wide community spread of the disease.”

The goal of contact tracing for Covid-19 is to reach people who have spent more than 15 minutes within 6 feet of an infected person and ask them to quarantine at home voluntarily for two weeks even if they test negative, monitoring themselves for symptoms during that time. But few places have reported systemic success. And from the very beginning of the U.S. epidemic, states and cities have struggled to detect the prevalence of the virus because of spotty and sometimes rationed diagnostic testing and long delays in getting results.

“I think it’s easy to say contact tracing is broken,” said Carolyn Cannuscio, an expert on the method and an associate professor of family medicine and community health at the University of Pennsylvania. “It is broken because so many parts of our prevention system are broken.”

Tracking those exposed is so far behind the virus raging in most places that many public health officials believe the money and personnel involved would be better spent on other resources, like increasing test sites, helping schools prepare for reopening and educating the public about mask wearing. Some public health experts now believe that, at the very least, testing and contact tracing need to be scaled back in places with major outbreaks. In some places, they say the effort may never succeed.

“Contact tracing is the wrong tool for the wrong job at the wrong time,” said Dr. David Lakey, the former state health commissioner of Texas who helped oversee the Ebola response in Dallas in 2014.

“Back when you had 10 cases here in Texas, it might have been useful,” said Lakey, who is now the chief medical officer for the University of Texas System. “But if you don’t have rapid testing, it is going to be very difficult in a disease with 40% of people asymptomatic. It is hard to see the benefit of it right now.”

Dr. Thomas Frieden, a former director of the CDC who is a strong advocate for robust contact tracing programs, largely agreed that it is impossible to do meaningful or substantial contact tracing with huge numbers of cases. He noted that when testing results lag as much as they have, it becomes almost impossible to keep up with the high volume of infected individuals and those who have been in contact with them.

“At some point when your cases are very high, you have to dial back your testing and contact tracing,” said Frieden, who runs Resolve to Save Lives, a nonprofit health advocacy initiative. “We may be in that situation in some parts of the country today.”

Others argue that contact tracing efforts around the country are still nascent and that many workers fanning out in particular zones are still too inexperienced to call it quits. These experts contend that tracking remains an important mechanism that can help as flare-ups continue over the next year and beyond.

Crystal Watson, a risk-assessment specialist at the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, said she had hoped more contact tracers would be trained and in place before states started reopening. For now, she expects it to be feasible only in Massachusetts, New York, North Dakota and the District of Columbia. Massachusetts, where the nonprofit group Partners in Health leads the efforts, has done particularly well.

Contact tracing has been used as a tool for hundreds of years to contain diseases like tuberculosis, yellow fever and Ebola. A rudimentary form was even used to track the route of a syphilis outbreak in the 16th century. Countries like South Korea, Ireland and Australia used the method to successfully control the spread of the coronavirus, too.

The CDC has sent about $11 billion in relief funds to states and local jurisdictions for expanding coronavirus testing and contact tracing. A survey of state health departments by National Public Radio in June found they had roughly 37,000 contact tracers in place, with an additional 31,000 in reserve for when they would be needed. The workforce — a mix of government employees, volunteers and contract workers hired by outside companies or nonprofit organizations — still falls short of the 100,000 people that the CDC has recommended.

The contact tracers, whose training varies considerably in length and content depending on what state they are in, have struggled to keep up with the rising number of cases.

“The challenge is that we are not dealing with ones and twos,” said Fran Phillips, a deputy secretary for public health for Maryland, a state that has largely kept the virus in check but still faces over 900 new cases daily. For every new case, there are several if not dozens of people to contact, especially in large cities, which further strains the system.

Contact tracing generally works best, public health experts say, when a disease is easily detected from its onset. That is often impossible with the coronavirus because a large percentage of those infected have no symptoms.

“When you have a situation in which there are so many people who are asymptomatic,” Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, said at a recent Milken Institute event. “That makes that that much more difficult, which is the reason you wanted to get it from the beginning and nip it in the bud. Once you get what they call the logarithmic increase, then it becomes very difficult to do contact tracing. It’s not going well.”

Perhaps most harmful to the effort have been the persistent delays in getting the results of diagnostic tests. Often by the time an individual tests positive, it’s too late for the health care workers tracking that person to do anything.

“It’s a race against time,” Phillips said. “And if we have lost days and days of infectious period because we didn’t get a lab result back, that really diminishes our ability to do contact tracing.” In Maryland, like many states, some labs are taking as long as nine days to turn around results. “We are getting some assurances from national manufacturers this lag is short term,” she said. “I am not confident.”

In contrast, when sports teams and the staff of the White House test people constantly, with fast turnarounds, contact tracing is instant and effective.

Even as health care workers leap over these hurdles, they are also finding that it can be difficult not just to reach people who were potentially exposed to the virus but to get them to cooperate. Sometimes there is no good phone number, and in the cellphone era, unrecognized numbers are often ignored; 25% of those called in Maryland don’t pick up. Others, suspicious of contact tracers or fueled by misinformation about them, decline to cooperate, a stark contrast with places like Germany where compliance with contact tracers is viewed as a civic duty.

In Florida’s Miami-Dade County, contact tracers employed by the state have reached only 18% of those infected over the last two weeks, according to Mayor Dan Gelber of Miami Beach; many of the others were never even called. Gelber wrote a letter to Gov. Ron DeSantis on Monday decrying the state of the program.

“You think it’s a natural situation where people will say, ‘Oh of course, I’ll cooperate,’” Fauci said. “But there’s such pushback on authority, on government, on all kinds of things like that. It makes it very complicated.”

In Seattle, tracers found 80% of the people they reached were not in quarantine, even if they had symptoms. And there is little appetite in the United States for intrusive technology, such as electronic bracelets or obligatory phone GPS signals, that has worked well for contact tracing in parts of Asia. Although Americans are free to cross state lines, no national tracing program exists.

“We need federal leadership for standards and privacy safeguards, and I don’t see that happening,” said Dr. Luciana Borio, a former director of medical and biodefense preparedness at the National Security Council.

Many epidemiologists believe fixing the program in the United States to combat and contain the coronavirus outbreaks is essential.

We have to start by supporting people in getting tested, which means making it easy enough for those exposed to someone or has symptoms to just show up and not worry about a doctor’s order,” Cannuscio said. “People in the Covid era have a hard time telling you what day it is.”

Dr. Joia Mukherjee, the chief medical officer at Partners in Health, the group in charge of the Massachusetts effort, outlined the principles her group insisted on: Tracers must come from the hardest-hit communities and be able to speak Spanish, Haitian Creole or whatever language the communities do.

Every tracer must be paid, not a volunteer. And Massachusetts had to put in enough money to let the tracers “support” anyone expected to self-quarantine.

“We ask: Do you need food? Infant formula? Diapers? Cab fare? Unemployment insurance? And we help them get it,” Mukherjee said. “That way people feel it’s care, not surveillance.”

Dr. Marcus Plescia, the chief medical officer at the Association of State and Territorial Health Officials, said that despite the failures so far, it was too soon to surrender. States need more time to build up a tracing workforce and the infrastructure to do it well, he said, and Americans need to grow more comfortable with the concept, similar to becoming accustomed to wearing masks.

Dr. William Foege, a former director of the CDC, said recently that effective tracers should be “psychiatrists, detectives and problem solvers all at once,” and that will also take time for many who are new to the job.

But in the meantime, Plescia said, even finding a fraction of cases through contact tracing will help slow the virus’ spread.

“We don’t have to strive for perfection on this,” Plescia said. “It’s a heavy lift and it’s going to take some time. We need to hang in there and keep at it.”