Jan Donnelly, a school nurse, might have just the right combination of skills to oversee a growing effort to contact people in Anne Arundel County who may be infected with the coronavirus.
With a background in infectious disease control and case management, Donnelly and dozens of other school health workers have transitioned from lice, measles and gastrointestinal illnesses to the virus almost overnight.
“There are definitely some similarities,” Donnelly said. “We’re used to communicating with parents by phone continuously."
Donnelly joins nearly 100 people who have begun working the phones as part of the Anne Arundel County health department’s contact tracing operation, seeking to reach those infected with the coronavirus — and those they may have exposed — and get them to self-quarantine.
They are part of a statewide force of about 1,400 people considered key to fully reopening Maryland as the first wave of infections appears to ebb and more places open their doors.
Officials are bracing for potential new cases from that reopening and from the large protests against police violence happening now.
The state’s contact tracing effort launched in earnest in the past week with the opening of a virtual call center that’s begun calling people who have tested positive, and then people they have may infected.
Health officials hope if residents hear the ring and see “MD COVID” on the caller ID they will answer.
“It is our primary way of controlling spread, knowing who has tested positive, who may have been exposed, and getting them not to expose anyone else,” said Victoria K. Fretwell, the Maryland Health Department official heading the effort. “We hope people will be collaborative, cooperative and take the call when we make it and take steps that will help protect their families and their communities.”
After emerging in Maryland in early March, the virus spread unabated for weeks, infecting tens of thousands of people here and leaving more than 2,500 dead. Now that distancing measures effectively slowed the pandemic’s growth and testing is more widespread, officials are turning to contact tracing to further curb cases.
In every part of the country it would have been ideal if there was better contact tracing in place from the beginning."
Crystal Watson, senior associate at the Johns Hopkins Center for Health Security
Share quote & link
Tracers will call those with positive test results within 24 hours and create lists of people with whom they had prolonged contact starting two days before they showed symptoms. Then the tracers will call those people to warn them they may have been exposed.
People will likely be asked to monitor for symptoms, get tested and stay home for two weeks. They should be offered support services such as food delivery and even another place to stay away from vulnerable relatives.
It’s a labor-intensive effort and takes community will to work, experts say.
Tracing has been a local health department tool for decades, with callers looking for potential cases of HIV, sexually transmitted diseases and other infections.
Public health officials say years of budget cuts left departments in Maryland and around the country ill-equipped with staffing or funding to handle so many calls now. Tracing efforts also were hampered early on because there was so little testing available to identify who was infected.
The slow response has been widely cited by experts for much of the spread.
“Think of them as precision tools — they only work if there are limited number of cases,” said Dr. Leana Wen, a former Baltimore health commissioner and a George Washington University professor.
“These measures were not in place at the start of the outbreak, and the numbers grew too large and too quickly, and that’s why the blunt instrument of social distancing had to be applied instead. The hope is that the number of infections is low enough and we can get enough testing and tracing going that we can switch to the precision tools again.”
Anne Arundel’s 100-person team has managed to stay on top of each county case, said Jennifer Schneider, deputy director of the county’s disease prevention and management bureau. She attributes the county’s success to those school health workers, though the bureau could lose them in the fall if schools reopen.
“From Day One we have attempted to touch, or have touched, every case in our county,” Schneider said. “We have shared our protocol and process with others, and become a resource and model for other counties.”
The department has hired Spanish speakers, conducted site visits and sent letters to people who did not answer the phone.
Maryland will spend about $35 million on tracing at its new call center, run by NORC, formerly called the National Opinion Research Center, a nonprofit research institution at the University of Chicago. The state gave the outfit an emergency six-month contract ending in October to eventually provide about 580 contact tracers. It could be extended.
The technology that will be used to log and track cases cost another $4 million, and local health departments will spend more on their own tracers.
More than half of local jurisdictions will rely primarily on the state call center, including most counties around Baltimore. County officials will take over when residents need special attention or don’t respond after three tries. At least 10 jurisdictions, including Anne Arundel and Baltimore City, will run their own programs and use the center if they become overwhelmed.
Such a community-based program could have an advantage because workers are speaking to their neighbors, said Dr. Josh Sharfstein, a vice dean at the Hopkins Bloomberg School of Public Health and a former state health secretary.
“The success of these programs depends a lot on who is hired, how well the training is done and how well they connect with people,” he said. “They can’t come across as bureaucratic. It has to be a genuine, we-are-in-this-together thing. There is a risk when calls come from outside the neighborhood, from a remote call center.”
Others fear no matter where the calls come from, there may not be enough of them.
More Marylanders began venturing outside their homes after Gov. Larry Hogan started lifting restrictions in May. Crowds emerged first for large Memorial Day gatherings and now for protests over the death of George Floyd in Minneapolis police custody. That confluence of events will likely lead to more coronavirus cases, said Sen. Clarence Lam, a Democrat from Baltimore and Howard counties and a physician.
“I’m concerned the contact tracers will get overwhelmed very easily, very quickly,” Lam said.
“There is no easy way to ramp up testing and contact tracing," he added. "It’s not like flipping a switch. They have to be hired and take a course and learn to do the work. They probably are undercounting the contact tracers needed given recent events. Time will tell if there are an adequate number.”
The state-coordinated program has hired 1,395 tracers, according to the health department. That works out to about 23 per 100,000 people in Maryland, below the 30 recommended by the National Association of County and City Health Officials.
Fretwell said the state had such an overwhelming response to its ad for tracers, who are paid $16 to $18 an hour, that it could add workers. NORC is maintaining a waiting list. Health training is not required, she said.
Nationally, the health officials association recommended a total of 100,000 tracers, the same number recommended in a report co-authored by Crystal Watson, a senior associate in the Johns Hopkins Center for Health Security. The report said the one-year cost would be about $3.6 billion
With no national framework, states have been hiring tracers. But Watson said hiring, training and paying them are not the only challenges. That will be getting people to answer the calls and understand the importance of self-quarantining.
“It’s a lot to ask of people,” Watson said. “It’s why messaging is so important. If we fail to do it, the alternative to some people staying home for two weeks is everyone staying home for months.”
The Hopkins report, released in April, found a person with COVID-19 infects an average of two or three people. Watson said tracing could “break the chain.”
The idea isn’t to stop all cases, but enough to stem the pandemic. Many governors, including Hogan, eventually embraced tracing. Hogan identified it as one of four keys to lifting stay-at-home orders. Others are widespread testing, sufficient protective gear for health workers and hospital bed capacity.
Like Maryland, most states have allowed some businesses to reopen and other activities. Hogan lifted the stay-at-home order without all of the pillars in place, though he gave discretion to localities such as Baltimore City, which has kept more restrictions in place.
Watson said the state’s testing is still below ideal levels as measured by positivity rate. Many health officials say a positivity rate below 5% indicates adequate testing, but half the states do not meet the threshold, including Maryland, which dipped below 10% for the first time in recent days.
About 11,000 people are tested a day at state and private labs in Maryland, state health officials said. The state continues to build lab capacity, obtain tools such as swabs to collect samples, and expand public testing locations in an effort to reach a goal of 20,000 daily tests.
Researchers and experts have flagged ethics and privacy as concerns as a state launches widespread tracing. They have provided road maps to ensure the data is safe and tracers don’t share health information, which could erode community confidence.
Some plans, such as one led by the Hopkins Berman Institute of Bioethics, say tracing efforts should be tailored to communities and capable of evolving if there is new information. Technology should be secure but easy to manage and monitor for effectiveness. All programs should be transparent and subject to oversight.
Breaking News Alerts Newsletter
As it happens
Get updates on the coronavirus pandemic and other news as it happens with our free breaking news email alerts.
Watkins said she was encouraged by the start of Maryland’s program, as well as a public awareness campaign to alert people about the calls and their importance. There will be educational videos, public service announcements, social media posts and other materials.
When people get a call, they will be asked about symptoms and their whereabouts and interactions, but tracers will not ask for personal information or for financial information or payments.
Information on those testing positive will come from an existing state electronic health information system. All the cases handled by state and local health departments will be entered in a new data management platform for coordination. That will help officials see where outbreaks are occurring or if a second wave has begun.
Health department officials said the program will be able to track 1,000 cases and up to 10,000 contacts daily.
“In every part of the country it would have been ideal if there was better contact tracing in place from the beginning,” Watson said. “Had that been in place early on, we may have been able to prevent the virus from being so widespread. That’s not to say it’s too late now.”