Coverage of the novel coronavirus is supported by the Mick Hitchcock, Ph.D., Project for Visualizing Science, a science reporting project from the Reynolds School of Journalism.
Public health officials are using contact tracing to track and isolate people infected with COVID-19 or those who might have been exposed. This is a routine public health surveillance tool that can be effective for infectious disease control, but the workforce needs to ramp up in order to respond to the coronavirus. In this report, KUNR's Anh Gray and Lucia Starbuck team up to explore the challenges with contact tracing and how the Nevada National Guard will be stepping in to fill some gaps.
Rio Lacanlale is accustomed to penning stories about other people as a criminal justice reporter for the Las Vegas Review-Journal, but last week, she published her personal essay about her recovery from COVID-19. She received confirmation of her positive test results around the middle of April.
“Something I wish that I had done is the second that I started to feel sick, I wish I had written down everything that I could remember that I had done,” Lacanlale said, “and where I'd gone and who I had spoken to.”
The Southern Nevada Health District followed up with her in a call that lasted about 10 minutes, in a process known as contact tracing. Public health officials do this to try and halt the transmission of disease by identifying who else might have been exposed. Lacanlale says weeks had passed between the onset of her symptoms and the time she got the call, so she couldn’t recall as many details as she would have liked of everyone she came in contact with.
Lacanlale says it’s most likely she became infected through her boyfriend, who is a first-year psychiatry resident at a Las Vegas hospital. As a precaution, he sought a test when she showed symptoms.
“What was alarming was my boyfriend, he was asymptomatic, so we had no cause for concern,” Lacanlale explained. “He didn't show any symptoms at all, and had I not shown symptoms, we might not have ever known, really, that he came in contact with the virus.”
After getting their results, both remained at home for about two weeks. In the aftermath, Lacanlale and her boyfriend are surprised that he didn’t receive a follow-up call from the health district, despite testing positive.
“They had asked for his contact information during our phone call, so I had mentioned that he was asymptomatic, but had tested positive as well and works in a hospital,” Lacanlale said. “So, they took down his contact information, but he never heard from them.”
Health officials nationwide and in Nevada have been advising government officials about the need to scale up contact tracing, along with more testing, as a strategy that could help states ease out of shelter-in-place orders. But with a pandemic and a lack of resources, some cases could be falling through the cracks.
The contact tracing workforce in Nevada is insufficient during the pandemic, according to the National Association of County and City Health Officials. The group recommends about 30 professionals for every 100,000 people, and based on the size of the state, that would mean more than a total of 900 are needed. The state had less than 80 professionals at the start of the pandemic.
In addition to Lacanlale, KUNR received information from two more Nevadans who tested positive for COVID-19. Those individuals say Southern Nevada Health District officials didn’t reach people they’ve been in close contact with while they were sick. In an email response, the health district said it could not comment on individual cases.
“The whole idea of contact tracing is interrupting that chain of transmission,” said Brian Labus, an epidemiologist and an assistant professor at the University of Nevada, Las Vegas School of Public Health. “You start out with the sick person and you try to identify all of their contacts, and then you call the contacts and find out if any of them are sick. And if they’re not, we try to get them to self-quarantine, so that if that they do become sick, they won’t spread the disease to other people.”
Labus also serves on a five-member medical task force advising Governor Steve Sisolak. He says that contact tracing is a public health surveillance tool that has been commonly used to control the spread of infectious disease outbreaks like tuberculosis, STDs, and bacterial meningitis, but the practice is not without challenges.
“Well, people don't always return your phone calls. You don't always have the right contact information for somebody,” Labus said. “You know, if somebody's sick, they don't necessarily want to even answer the phone, and then, even if you can talk to them, trying to identify all the contacts could be a challenge.”
In Lacanlale’s case, she has been working from home for several weeks leading up to the onset of her symptoms. Aside from a few grocery store runs, she had minimal contact with others.
Labus says even pinpointing locations a person has visited doesn’t make the job of a contact tracer any easier.
“Trying to identify all the contacts could be a challenge,” Labus explained. “So, for example, if I went to the grocery store, I could say that I was at that particular location, but I couldn't tell you who else was there.”
But those aren’t the only challenges. Dr. Trudy Larson is a pediatric infectious disease specialist and another member of the governor’s medical task force. She’s also the dean of the University of Nevada, Reno School of Community Health Sciences.
She says isolating sick people from healthy people is critical to mitigating disease. Contact tracers advise infected patients to self-isolate, asking them to restrict personal behavior for the public good.
As states like Nevada eye a gradual reopening, regulating an individual’s behavior for the good of public health is tough, but a Nevada revised statute allows health authorities to quarantine infected people. Larson acknowledges some may be weary of government overreach, especially as people are becoming frustrated with more-than-usual restrictions in their lives, and there have been protests statewide. Maintaining public health is a complicated struggle to balance personal rights and population health.
“For all those protesters, I would love to say, 'Okay guys, you'll want to roll out the economy. Here's the steps to do it. And here's what you must do. Here's your responsibility,' " Larson said. "Because this is a personal responsibility issue and until you understand that this is a virus--this is not the government--that nobody wants to tell people that they can't have their freedom.”
For contract tracing to work effectively during this pandemic, more help is needed.
“What we need to have is an ongoing and permanent group of contact tracers for the foreseeable future,” Larson explained. “And, so, as we roll out the economy that they're there to be able to make sure that we can nip any outbreak immediately before it goes anywhere and keep those numbers down so we can continue to roll out.”
In an email to KUNR, a spokesperson for the Nevada Department of Health and Human services explained that the state is working to hire additional staff and recruit volunteers to help with contact tracing but did not specify how many.
Currently, the contact tracing workforce is insufficient in Washoe County and statewide, and the Nevada National Guard is stepping in to fill some of the current gaps.
The Washoe County Health Department has roughly 25 case investigators, with about 15 members of that staff from the Nevada National Guard. Their role is to contact people who have tested positive for COVID-19 and then interview them to determine their symptoms, if they have had any contact with a confirmed positive case and who they might have had contact with after getting infected.
Patricia Carney serves with the Nevada National Guard. Before the pandemic, she provided social work and behavioral health services. She’s also on track to graduate from the University of Nevada, Reno, with a master's degree in social work. She says her background allows her to connect with people in vulnerable situations.
“You have to be very compassionate. You have to be able to build that rapport with people. It's not just, ‘Hey, you have COVID-19 and give me all your information.' It's, ‘Hey, letting you know that you have COVID-19. How are you doing?’ Because they are people first; they're not just a number,” Carney said
Carney says these calls last from 20 to 40 minutes. She’s also bilingual and able to reach Spanish speakers.
“[It's] just really empowering to them to be able to speak to somebody in their own language and feel that compassion come across versus having their children talk for them, and they almost feel like that child again. I just really have connected with this community,” Carney said.
At the beginning of this week, there were more than 240 active cases in Washoe County among the Hispanic population, and that’s more than double the cases among white people, which is a little over 100. Washoe County health officials say identifying race is optional, so the data is incomplete.
Aside from language barriers, there are other challenges with case management. Imagine trying to explain a virus that health care experts are still actively trying to figure out. According to Heather Kerwin, the Epidemiology Program Manager for the Washoe County Health District, training people to help with investigating cases of COVID-19 is a long process.
“There's the need for a basic understanding of biology and virology with this to be able to speak proficiently to cases when they have questions," Kerwin explained, "as well as their contacts who may have just all sorts of burning questions when [they] pick up the phone and let them know they've either tested positive or have been exposed to someone who's positive.”
And that data they’re collecting is essential for public health officials to have to figure out how to slow the spread of disease.
“We're making sure that people are able to provide accurate and reliable up-to-date information,” Kerwin said.
According to Kerwin, each positive COVID-19 case generates three to 17 possible contacts. Close contacts are defined as someone who spent 10 minutes or more, within a six-foot radius of someone who is infected.
There’s even more to consider. Contact tracers also try to identify anyone who spent time with a COVID-19 patient 48 hours before the person started showing symptoms, and that window could have included any contact as much as seven days or more after.
Contact tracers first look to household contacts and then the workplace. Kerwin says pinpointing contacts outside of the household can be really difficult. Take for example, someone who may have traveled to a conference.
“For something like a respiratory disease, it's much more difficult because you may not know the name of a person you were standing in a huddle with for 20 minutes or 30 minutes, or that you sat around a meeting table with, and we're talking about something that's passed through air, even through just speaking and communication. You don't have to be actively coughing or sneezing, necessarily, to pass this,” Kerwin said.
Washoe County Chairman Bob Lucey said as officials start easing restrictions, there’s the responsibility to protect public health with increased measures like contact tracing. This would include asking people who have been exposed to self-isolate, which health officials say that also means people who aren’t showing symptoms.
“Quarantine and safety procedures have been the best course of action to really controlling this. As we move into that new normal, and as we continue to work on reopening our businesses, and reigniting our health care, and reigniting the way we do business, it's going to be important that those that are sick stay home,” Lucey said.
Even thougn the Nevada National Guard is helping with contact tracing right now, Washoe County Health District Officer Kevin Dick said it's a temporary fix, and the county needs to figure out a long-term solution.
“We've been fortunate with the National Guard integrating with our staff that they've been able to help us with increasing our staff that's working on that contact tracing function ... The guard will be standing down in the future. We're working on our plans for filling those positions and having everybody in place moving forward," Dick said.
Governor Steve Sisolak said all counties in Nevada must meet necessary requirements to begin reopening. Public health officials say contact tracing will need to ramp up before a move to reopen should happen, but it’s more than just that. Sisolak wants to see sufficient personal protective equipment, adequate hospital capacity, a steady decline in positive COVID-19 cases and increased testing.