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As Maryland officials work on a plan to ease restrictions that already have kept residents home for weeks, they are not only seeking to isolate those who test positive for the COVID-19 infection but bring on an army of workers to identify anyone who may have been exposed to the coronavirus.
The state now has about 200 to 250 so-called contact tracers on the job at local health departments, but that force will need to be multiplied, said Fran Phillips, deputy secretary of the Maryland Department of Health. The job isn’t easy; such workers must find everyone an infected person has been in contact with and seek to isolate them until they’re either confirmed infected or not.
“We’re going to be doing contact tracing. We’re going to be doing that until we have a vaccine," she said. "This is not a short-term project. This is going to be sustained work.”
Isolation, contact tracing and widespread testing will be crucial elements to reopening businesses and schools and allowing people to leave home eventually.
If people with COVID-19 and those potentially infected are quarantined, infections will slow and restrictions could be eased for everyone else, said Crystal Watson, a senior associate at the Johns Hopkins Center for Health Security.
She co-authored a new report that outlines the necessity of tracing for reopening society. Each person with COVID-19 infects an average of two or three people, according to the report.
The report for the first time estimated what will be needed nationwide: a workforce of 100,000 tracers at a one-year cost of about $3.6 billion.
“Before we make consequential decisions about reducing social distancing measures, we need to have them in place," Watson said.
“This is our best estimate of what we think is the need,” she added. “It’s a good place to start.”
The basic idea of testing, tracing and quarantining has been embraced by many public health officials and governors, including Maryland Gov. Larry Hogan.
State officials announced last week that the state is partnering with the University of Maryland School of Medicine on a testing initiative that could do up to 20,000 tests a day.
Phillips said there are now about 3,000 tests conducted a day in Maryland, but the number is increasing by about 5% a day.
“We need to triple that at least," she said. “We need to have testing readily available without charge to whoever needs it. It needs to be everywhere. It needs to be rapid.”
At the same time, she said the state must ramp up its workforce to be able to do contact tracing of those who test positive. To multiply the workers, she suggested unemployed Marylanders could be trained.
She could not estimate how long it would take to hire and train such a workforce or how big it would be eventually, but suggested federal funding could be used to support the workers.
Watson said hiring and training could take at least a month or two. Ideally, the workers would be coordinated at the federal level, but absent that, states would have to take the lead and coordinate within their borders and with one another.
Some coordination efforts are underway already. New York Gov. Andrew Cuomo announced a regional partnership Monday among Northeast governors on an eventual reopening. California and other Westerns states also said they were coordinating efforts.
“I think it’s a really good idea, the regional cooperation,” Hogan said Monday during a CNN interview with host Anderson Cooper.
None of the governors have said when they believe restrictions can be lifted. They said, however, the decisions would be theirs, contradicting statements by President Donald Trump that he has the “total” authority to order states to lift restrictions.
While Hogan said he would “love” to have the president’s cooperation, it was the governors who enacted restrictions such as closing schools and businesses and ordering people to stay home, and it will be governors who decide when to reverse those restrictions.
Members of the governor’s coronavirus task force have said several things need to happen before then. That includes a sustained period of declining COVID-19 cases and enough hospital capacity and protective gear for health workers in case of a second wave of cases. Such an easing of the state’s initial outbreak could be weeks if not a couple of months away.
The group also said there needs to be widespread testing, which includes testing for new cases as well as testing for antibodies among those who were previously infected and may now enjoy some immunity. And then there are those tracers.
Massachusetts is perhaps the state farthest along on tracing. Officials there have partnered with a nonprofit to hire 1,000 contact tracers.
While the overall number of tracers Maryland needs isn’t clear yet, local health departments have begun to add staff.
Baltimore County has moved 15 nurses and a supervisor from the school system to the health department, and some of them will trace those who have had contacts with confirmed cases.
Watson said Baltimore City has been working with Hopkins to scale up its tracing, though no one in the city health department was available to comment.
In Howard County, the health department has reassigned workers on the nursing and public health staffs to contact tracing to double its contact tracing workforce, said Dr. Jacqueline Douge, medical director in the Bureau of Health Services.
The county now has eight tracers and is adding nine more this week, a county health spokeswoman said.
So far, the department is keeping up with the demand the coronavirus poses, Douge said, but if large outbreaks occur or caseloads otherwise accelerate, more staff and resources to devote to contact tracing could be needed.
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“I think everybody would need more resources,” she said.
The workers need to be trained and will likely use technology to trace people’s whereabouts, potentially through people’s smartphones. That way health officials can warn people who were in a grocery store or elsewhere at the same time as someone who later tested positive and order them to quarantine for 14 days.
The tracing work can be intense, Douge said, sometimes requiring repeated calls to reach people who are in quarantine or may have been exposed to the virus. Some training is required to ensure that staff new to contact tracing are following the proper protocols to gauge exposure risks and ensure thorough investigation.
The Hopkins report said the testing-tracing-quarantining plan has worked in other countries in past pandemics, and in China during this one.
"This is what we’re seeing in countries that have been successful at controlling the virus,” Watson said. “It will really come down to that contact tracing ability and having people cooperate and stay home when they are sick and quarantined if they are exposed.”