K.J. Seung is surprised to be hiring and training new workers in Boston.
His public health nonprofit, Partners in Health, specializes in helping the poorest people in developing nations — tracking down contacts of Ebola patients in Liberia and Sierra Leone; running child health and HIV clinics in Haiti; and operating tuberculosis control programs in Peru. But now it is advertising for 500 people to help do what’s known as contact tracing to try to control Covid-19 in Massachusetts.
It’s the first step in the next stage of fighting the pandemic. Boston-based Partners in Health has trained 12,000 community health workers in countries including Malawi, Mexico, and Rwanda and now it will help train a battalion of workers in Massachusetts to interview everyone diagnosed with Covid-19 and find other people who may have been infected by them. This old-fashioned, shoe-leather public health approach contained the SARS outbreak in 2003 and 2004, and public health experts agree it will be vital to eventual control of the new disease.
“We never thought we would be doing this kind of work here,” Seung, senior health and policy adviser for tuberculosis at Partners In Health, told STAT. “We never thought we would be in a once-in-100-year pandemic, either.”
Combined with more widespread testing, contact tracing is seen as an essential part of the strategy for keeping the coronavirus in check after the first wave recedes and the economy reopens. But the work is highly labor-intensive, and public health departments across the U.S. have been woefully underfunded for years.
“This is going to test the capacity of the existing public health system,” said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials. “I don’t know if we have enough staff in public health departments to do that.”
Hence the hiring spree kicking off in Massachusetts and a few other places.
Partners in Health is working with state officials in Massachusetts, who say they will eventually deploy nearly 1,000 people to do contact tracing.
In San Francisco this weekend, three dozen volunteer nurses, medical students, and librarians started training at the University of California, San Francisco — the first of an expected 100 people who will supplement the city’s 10-person contact-tracing workforce.
“We are providing the people to make phone calls, we are working on standard scripts, we are working on IT solutions, training, and we are fielding teams of contact tracers,” said George Rutherford, UCSF’s head of disease and global epidemiology.
This will be the only way to contain further spread of Covid-19 once the initial surge is past, and get into the suppression phase, argues Tom Frieden, a former director of the Centers for Disease Control and Prevention. “We need an army of 300,000 people,” he told STAT.
The current CDC director, Robert Redfield, said last week that a “substantial expansion of public health fieldworkers” will be needed to undertake aggressive contact tracing — “what I call ‘block and tackle.’”
Speaking to NPR on Thursday, he said it would be “premature” to say how CDC would expand contact tracing but that planning was “far along.”
But Frieden said he doubted the federal government would help much immediately. “Until the federal response is more coherent, each state is going to be on its own,” he said.
Normally, the CDC would be taking the lead, Plescia added. “Right now, they are pretty maxed out. It is the state and local governments who will have to train people and have a system that works.”
The $2 trillion stimulus package signed into law last month creates a $150 billion Coronavirus Relief Fund for states and local and tribal governments, plus gives $4.3 billion via the CDC to help in responding to the pandemic. The money is not earmarked for epidemiology but states could, in theory, use some of the money for hiring workers to do contact tracing.
It will require a much larger effort than the mass deployment that eventually conquered SARS.
Unlike SARS, Covid-19 has spread easily and quickly from person to person. It took SARS more than a year to infect 8,000 people, killing close to 800 of them. Since December, Covid-19 has been diagnosed in more than in the United States alone.
“We are going to have to handle it with an extreme amount of effort,” said Frieden, who is now president and CEO of the nonprofit Resolve to Save Lives. “I think of it as a four key actions: test, isolate the infected, contact trace, and then follow up the contacts. And each of those four things needs to be going really, really well and at a massive scale.”
Right now, countries, cities, and states are struggling just to treat the onslaught of Covid-19 patients. Most are relying on shelter-in-place, stay-at-home, and social isolation orders to prevent spread. The idea is to bend the curve of infection, spreading out new infections over a greater time so that hospitals and clinics can cope better.
But bending the curve doesn’t mean transmission will stop. Only a small percentage of the population anywhere will have been infected and presumably immune in the coming months, Frieden noted.
“We are not going to get herd immunity soon,” he said. “It will come back. Even in the worst hot spots, only 5% to 10% of people will have been infected.”
A usable vaccine is likely a year or longer from the market, and groups are only beginning to test potential treatments. “Until we develop a vaccine or viable treatment strategy, ongoing testing, isolation, monitoring, and contact tracing will be a necessary to contain the epidemic and prevent another spike,” Plescia said.
So Frieden and others are pressing for an “army” of public health workers armed with diagnostic tests to track down every case quickly.
“We are going to have to be able to test every patient with pneumonia in the country within minutes or hours,” Frieden said.
“The concept is once you get down to a manageable number of cases and scale up the public health system, then you will be able to pounce on any case or cluster to proactively identify cases, identify contacts, and follow up on those contacts. And when you get those things done, you can prevent the clusters from becoming outbreaks, prevent outbreaks from becoming epidemics, and prevent the epidemics from driving us into our homes again.”
This approach may have helped Hong Kong and South Korea get a quick handle on their epidemics, said David Holtgrave, dean of the School of Public Health at the University at Albany in New York.
“They didn’t do so much of physical distancing by shutting down whole cities and whole regions. They did more in the way of using testing data and contact tracing data to see who should be quarantining themselves or isolating themselves,” Holtgrave said.
David Harvey, executive director of the National Coalition of STD Directors, has seen a steady drop in the number of staff in state and local health agencies trained to track down contacts of patients with sexually transmitted diseases, even as STD rates have soared. These same workers would have been immediately available to work on coronavirus. Now states will have to hire a fresh corps. “We need to radically increase the numbers of these positions in order to help the country recover,” he said.
“Twenty years ago, this workforce had a high of 5,000 or 6,000 people,” Harvey told STAT. “Today it is only 1,600. The reality is that we at least need a work force of 30,000 people.”
Frieden puts the needed number at 10 times that.
Luckily, potential workers are right at hand, with so many jobs lost to Covid-19 over the past weeks. “There are a lot of people out there,” Frieden said. “There are college graduates, people working at social service agencies, social workers, child health workers, people doing Meals on Wheels.”
Technology can help, and numerous apps are being developed to speed up the process of tracking down contacts. But public health experts said such tools won’t eliminate the need for thousands of new workers.
Costs would be relatively low – maybe $720 million for 30,000 workers, said Harvey.
States are not even close to having enough workers, and most state health departments contacted by STAT said they had not begun to think that far ahead. Florida, a state with the one of the smallest epidemiology work forces, hired 100 people in one weekend last month, according to the Tampa Bay Times.
Plus, there are other barriers, Holtgrave noted. To diagnose cases, many more tests are needed. And any in-person contact will require personal protective equipment, also in short supply.
That’s why Partners in Health plans to start workers out on the back end, interviewing patients who have already been diagnosed to find their contacts.
“We are not knocking on doors,” Seung said. “People are working in their homes and they are making phone calls.”
One piece of good news – it’s not hard to find people who want to do the work. Seung says his office has received more than 5,000 applications for the 500 jobs.
“People are really grasping to do something,” he said.