Through the ebbs and flows of the coronavirus pandemic, the phone calls have kept coming.
A small army of so-called contact tracers has worked to stem transmissions by dialing Marylanders infected with COVID-19 to ask that they isolate themselves and consider who else they may have exposed so they, too, could be rung up.
More than a million calls later, the massive effort was supposed to end next month with the closing of the state’s main call center, which is run by NORC at the University of Chicago, an independent research organization.
Instead, the more contagious delta variant is fueling a new wave of infections and state health officials are scrambling to rehire tracers let go during COVID downtimes and find new ones to investigate cases — which could rise further with students returning to school.
“We anticipated the potential surge this fall and worked with NORC to add contact tracers,” said Marcia Pearlowitz, contact tracing unit chief for the Maryland Department of Health.
“But adding contact tracers isn’t easy,” she said. “They require training.”
The situation has frustrated public health officials, who said last year that tracing would be needed until vaccines were widely available. But many people chose not to get the shots, and others were infected with the delta variant after they were vaccinated. A quarter of the calls now go to those with such breakthrough infections.
The state had let the call center’s tracers drop to about 200, close to a third of its peak employment. It now seeks to add at least an additional 100 tracers, Pearlowitz said. Another 500 to 600 tracers work for local health departments.
The cost of continuing the tracing programs, and what has been spent so far, isn’t clear. The state allocated $35 million for the NORC contract before extending it beyond next month and an additional $4 million for tracking technology, all from federal sources.
Complicating hiring, many people who staffed call centers were school nurses or others who volunteered when schools or businesses were closed but now have returned to their previous jobs. Still, Pearlowitz said, it’s a boon to schools to have experienced tracers among their staffs to help control spread.
The scramble for tracers speaks to the disinvestment in public health resources in non-pandemic times, said Dr. Georges Benjamin, executive director of the American Public Health Association and a former Maryland health secretary.
He has advocated for using federal dollars to build and maintain a ready workforce for a range of public health needs, including contact tracing, a longtime bread-and-butter task in local departments for all manner of infectious disease control.
Benjamin also called for a tougher stance on vaccinations to control the pandemic, since most of the severe COVID-19 cases are among the unvaccinated.
“I’m for mandates because we’ve already tried all the carrots,” Benjamin said.
Benjamin spoke Thursday, just hours before Democratic President Joe Biden issued a plan that will require large private employers to vaccinate or regularly test employees. It also includes mandates for federal employees, the military and anyone who works in a health care facility that accepts Medicare or Medicaid dollars. The orders are expected to affect tens of millions of people.
Some Maryland businesses and universities, and all hospitals and nursing homes, already have required shots or regular testing for those exempted.
Close to 82% of Marylanders have gotten at least one shot, but the delta variant of the virus continues to find targets. After easing this spring, cases began rising again in July and exceeded 1,000 new daily cases in the state in August.
With each positive test logged into the state’s electronic records system by state, private, hospital and other labs, the goal is to call within a day or so. Pearlowitz said she believes the state and local tracers are capturing most reported cases. She did say, however, that it’s unknown how many people now take over-the-counter home tests and do not report the positive results to their doctor or health department, as the packages direct them to.
The key is to be as quick as possible, said Emily Gurley, an infectious disease epidemiologist in Hopkins’ Bloomberg School of Public Health and the lead instructor of a free online contact tracing course developed by the university.
The course has been used by 1.2 million aspiring tracers in every state and is still enrolling. Another course just became available to help health departments evaluate the effects of their program on transmission.
Gurley said the need for contact tracers “is dynamic, and changes with infection rates and how society opens up. Ultimately, contact tracing is one tool in the tool kit.”
A report by Hopkins researchers at the pandemic’s start last year called for a network of 100,000 tracers nationwide.
Hopkins’ latest review in May found that many states reduced staff or no longer have workers dedicated to tracing. Maryland had 1,200 tracers at the time and ranked 10th with 20 tracers per 100,000 residents, which meant there was sufficient staff to prevent callers from being “overwhelmed” by cases.
In Maryland so far, Pearlowitz said they’ve reached about 79% of positive cases reported to the state system. The others never answered after tracers made multiple attempts.
When those infected provide details of their whereabouts — many don’t, even when they answer the phone — they most often tell tracers they attended family gatherings, other large events and religious services. Fewer say they attended other events such as weddings, funerals and concerts.
Some local health departments rely on the state call center to make initial calls, then take over when people cannot be reached or there is a large outbreak. Others, such as Baltimore City, have their own tracers and rely on the state mainly during surges.
Anna Schauer, director of case investigation and contact tracing for the Baltimore City Health Department, said the office has a “motivated” crew of 100 that makes the calls.
“We rely on the buy-in from the community, answering the phone and talking about who they might have exposed and ultimately agreeing to answer other questions about their behavior, as well,” she said.
Schauer said the staff has been able to respond to the increase in cases due to delta and is gearing up for students who have returned to school.
This is, perhaps, the local health departments and local school systems’ major focus right now, officials said. Children 12 and younger are not yet eligible for vaccination.
In Baltimore City’s school system, the contact tracing is more involved than in the counties because the city conducts regular asymptomatic testing of groups of students and that turns up more cases.
Samples are initially pooled for testing. When a batch comes back with a positive result, the school knows that one of 20 people in that pool has COVID-19. Every student and teacher must then be tested individually to see who is positive.
Jeremy Grant-Skinner, the city schools’ human capital officer, said when a positive test identifies a staff member or student, school officials report it to a contact tracing team in the school system’s central office, along with any information that might help identify those who had close contact with the infected person. Such material could include a school seating chart, or video from a cafeteria. The 18-person team does contact tracing for 70 hours a week.
In Anne Arundel, Baltimore, Harford and Howard counties, school nurses working with school staff are doing the majority of contact tracing when there are cases in schools. When contact tracing becomes complicated or there is an outbreak in the schools, officials generally bring in help from local health departments.
“We have been really lucky. We have a nurse in every building,” said Mary Nasuta, supervisor of health services for Harford County Public Schools. “This isn’t new to the nursing staff. Each school has principals, nurses, pulled together to make sure we can do the investigative work.”
Sometimes that investigative work can take time, creativity and energy. In Anne Arundel County, teams of contact tracers often end up working odd hours so that students’ lives aren’t put on hold by a quarantine.
Bob Mosier, a spokesman for the county schools, said last spring they met at 6:45 a.m. on a Saturday to determine whether it would be safe for a team to play a game later that morning. A team was once pulled off a field minutes after players would have started practice because a case was discovered, he said.
“The behind-the-scenes stuff of all of this can be all-consuming,” Mosier said. “It is what you have to do to try to keep kids safe.”
Baltimore Sun reporter Liz Bowie contributed to this article.