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As Utah Gov. Gary Herbert says the state could move as early as this week to begin to “stabilize” its economy, a national team of health experts is warning that “massive” testing and tracking of infected people’s contacts will have to happen nationwide before the country can reopen.
“A contact tracing effort of this unprecedented scale ... has never before been envisioned or required,” a team of scientists and public health officials wrote in a new report from Johns Hopkins University. “And our current core public health capacity is woefully insufficient to undertake such a mammoth task.”
But Utah may be more prepared for the project than some other states, health officials here say. In recent weeks, local and state governments have been retraining scores of employees to work as contact tracers: workers who interview patients who are diagnosed, contact everyone they may have exposed, and then make daily calls to check the symptoms of everyone at risk.
About 300 state employees have been trained in these new positions, with another 600 available, said Lt. Gov. Spencer Cox, who leads the state’s Coronavirus Task Force. And twenty soldiers and linguists from the Utah National Guard’s 300th Military Intelligence Brigade have been assigned to assist the task force with contact tracing, the Guard announced Wednesday.
And that’s just supplemental staff; county governments also have redeployed workers for contact tracing. In Salt Lake County alone, nearly 100 employees have been added to a previous staff of about 30 infectious disease investigators, and they are calling hundreds of people each day as new cases roll in.
The state announced 130 new confirmed cases Wednesday — the highest daily number of new patients since April 9, which comes after five days running when the number of new cases was less than the day before. Utah had reported 49 new cases Tuesday.
There are now 2,542 cases statewide — and the origins of 85% of those infections have been traced, state epidemiologist Angela Dunn said.
The Utah Department of Health also announced Wednesday that another Utahn has died from COVID-19, bringing the state’s death toll to 20. He was a Salt Lake County man over age 60 with underlying health conditions, and he died at a hospital, Dunn said. Since the beginning of the epidemic, 221 Utahns have been hospitalized.
‘Tens of thousands’ of contacts
Some of Salt Lake County’s new investigators had been working in the travel clinic and STD prevention, or as inspectors for restaurants and cosmetology businesses that have largely suspended operations, said Nicholas Rupp, spokesman for the county health department.
"In this process, we're probably in the tens of thousands" of contacts made, estimated Tara Scribellito, a nursing supervisor in Salt Lake County's infectious disease unit.
With the state averaging fewer than 100 new cases per day for the past week, until Wednesday, Utah’s contact tracing staff is “enough to handle the current demand,” said Tom Hudachko, spokesman for the state health department.
But that’s with a sharp and perplexing decline in the number of people being tested in Utah, even as the state’s testing capacity has ramped up.
And, the Johns Hopkins team warns, the level of testing and tracking necessary to safely open the economy is likely beyond many Americans’ imagination. Testing would need to be “ubiquitous,” the report states, because “even one missed case can significantly undermine control efforts.”
"If one person spreads the virus to three others, that first positive case can turn into more than 59,000 cases in ten rounds of infections," the research team wrote.
To prevent unidentified cases from reinfecting large numbers of people when the economy reopens, the team estimated, there would need to be at least 100,000 contact tracers operating nationwide.
“If we can find nearly every case, and trace the contacts of each case," the researchers wrote, "it will be possible, in time, to relax the bluntest approaches: the extreme social distancing measures, such as stay at home orders, and realize the commensurate social and economic benefits.”
Per capita, that would mean about 1,000 contact tracers in Utah — a number the state already hopes to exceed.
“We are working to identify up to 1,200 total volunteers who can be temporarily reassigned from their current positions within state government,” Hudachko said.
‘Let’s go back’
For each case that comes in, Scribellito said, the tracer interviews the patient about all of their activities starting two days before their symptoms began.
"We sit down with a calendar and go day by day: 'Let's go back two days. From the moment you woke up, who were you in contact with? Please relive your day.' Did they work while they were sick? Who's in their household? Were they in a medical facility while sick? Based on that information, we start reaching out to all of these different people."
In the Salt Lake County Health Department, Scribellito said, each case typically produces five to ten contacts that require daily follow-up. Anyone in close contact with the patient — within six feet for 15 minutes or more — is asked to quarantine for 14 days: to not leave home, even to run errands, even if they feel fine. Those people are called each day during that time for symptom reports, and if they feel sick, they’re told to isolate within their homes, Scribellito said.
"Technically, it's voluntary quarantine or isolation, but [health departments] do have fairly broad authority if there's a need to place a noncompliant individual in forced isolation or quarantine," Cox said. "The good news is that people have been really great about it."
Contact tracers have to use their best judgment to determine whether a contact is truly "at risk," Scribellito said.
A meal-delivery driver who drops off a bag, knocks and leaves without any face-to-face contact probably will not be contacted, she said. If a patient went to a grocery store, grabbed a jug of milk and went back home, the contact tracer may alert the store but not call for the staff to quarantine. A regular who visits the store every day and interacts with employees? That could be a different story, Scribellito said.
"These cases are all so individualized," she said.
‘There isn’t a real perfect answer’
Although Utah and other states have deemed widespread testing and contact tracing to be essential steps before resuming “normal” life — even with masks, regular temperature checks or limited admission to gathering places — none have identified a specific threshold where it’s safe to relax the rules.
Does a certain percentage of the population need to be tested with a certain frequency, and with a certain limit of positive results? Does that low positive rate need to be sustained for a given number of days or weeks?
Or does a certain length of time need to pass without any new cases where contact tracers cannot identify the origin — or what Dunn calls “community spread” cases?
“Those are the discussions we’re having every day with our health care experts, our testing experts,” Cox said. “The problem is that there isn’t a real perfect answer for what that is. There certainly are more variations on that, and degrees. In a perfect world, we would test every person every few days and we would have an unlimited supply of contact tracers. We know that’s just not possible.”
The vast majority of confirmed Utah patients know how they were infected, Dunn said on Wednesday. Health officials determined that 70% of Utah’s cases were spread between known patients; 11% were travel-related; and 4% spread between health care workers and patients, such as those infected at long-term care facilities.
Only 15% are the result of community spread, Dunn said.
“The fact that we know where 85% of our cases were exposed to COVID-19 is a sign that the public health infrastructure is working," she said. “Our contact tracing, our active monitoring, our case investigation is doing the job we want them to do.”
That also suggests Utahns are social distancing as instructed, Dunn said.
"They’re staying home, they’ve having limited number of contacts — so that when public health reaches out to them, they know exactly who they’ve been in contact with and we can take the appropriate action," she said.
But the number of community-spread cases hasn’t dropped, as travel-related cases have, she acknowledged. And if one confirmed patient cannot be tracked to another, it means the person who exposed them has not been tested.
‘A disconnect’ over testing
Utah is among the top ten states for its per-capita rate of coronavirus testing, according to data from CovidTracking.com. As of Wednesday, 47,614 patients had been tested in Utah, with about 5.3% testing positive.
But the number of patients being tested has dropped precipitously, right as the state has escalated its testing capacity and relaxed guidelines for who can be tested.
For the past week and a half, Utah has reported on average about 1,600 tests per day, though the state has the capacity to process about 4,500 tests per day. And the state expects to be able to conduct 6,000 tests per day by the end of this week, Cox said.
“For several days [we’ve been] working actively with all testing sites to ensure they are applying the updated more broad guidance,” Dunn said. That includes an expanded list of symptoms that qualify a person for testing: fever, cough, shortness of breath, muscle pain, chills or loss of sense of smell or taste.
Health officials are also trying “to better understand the demand,” Dunn said — and they suspect some patients are deterred by earlier limits on testing that excluded many symptomatic patients.
"There's a disconnect from the beginning, when we had a low capacity to test, and so it's going to take awhile [for the new guidelines] to take hold," Dunn said.
Several patients have told The Salt Lake Tribune that they tried to get a test only to have their health care providers deny them — something Cox said his office also noticed. This week, the state task force requested accounts from patients who were denied tests despite being symptomatic, and state officials began reaching out directly to their providers, Cox said.
About 15 have been contacted so far, he said, and clinicians have said they simply weren’t aware tests had been made more available.
“This is so frustrating, and one thing that I’m learning ... is that sometimes it takes a while for these messages to percolate all the way to the front desk or individual providers,” Cox said.
“It took time for some of the bigger systems to incorporate [the new guidelines] into their protocols. Or hotline scripts were not updated as they should have been," he said. "Sometimes there were gaps in making sure information was flowing ... and they have been operating on the same parameters they were set up on three weeks ago.”
— Tribune reporter Jessica Miller contributed to this story.
