After an 82-year-old woman died of COVID-19 in South Georgia, the state’s epidemiologist wanted to warn anyone she might have infected. He tracked her trail to a Sunday worship service attended in March by some 60 people in Waycross.
Ordinarily, under the method of epidemiological detective work known as contact tracing, every person in the woman’s close orbit while she was contagious would be identified and told to take steps to avoid infecting others.
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But ordinary methods wouldn’t do, given the possibility the highly contagious coronavirus was spread by people without symptoms and the risk of quickly overrunning local hospitals. So the Department of Public Health took the extreme step of posting a public announcement in early April: “If you or someone you know have recently attended New Mount Pleasant Baptist Church in Waycross, Georgia, you may have been exposed to COVID-19.”
Over the past two months the novel coronavirus has reached so far into the state, health experts question whether Georgia can make a sizable enough investment to track it patient to patient. The state is now expanding its contact tracing program as part of Gov. Brian Kemp's plan to restart public life. Health officials hope the investment, paired with the increased availability of test kits, can tamp down on community spread as more people venture outside their homes.
But the challenges associated with the coronavirus are immense, and many longstanding tracing protocols must be altered or abandoned, experts warn. The Waycross church case revealed limitations in the ability of contact tracing — a process normally conducted outside public view — to keep pace with the disease.
“In typical contact tracing, you could be on the street, going to someone’s house, knocking on the door, leaving a note and finding them at a basketball court or a hair salon,” said Brian Castrucci, CEO of the Maryland-based de Beaumont Foundation, which assists local and state public health agencies. “This is going to be different.”
Public Health Commissioner Kathleen Toomey said the department plans to engage as many as 1,000 people for the task, which the Atlanta-based Centers for Disease Control and Prevention says should be ramped up immediately. But some experts say the state will need to train thousands, not hundreds, of tracers quickly to catch up with a virus that continues to sicken upwards of 700 people a day.
Georgia recently signed a five-year contract with the technology services company MTX Group for a new online platform to aid its efforts.
“This is more than an epidemiologic activity, this is a logistical deployment,” Toomey said Thursday.
Officials will also need to build the support of a public that’s often leery of government and unlikely to accept more invasive forms of surveillance that have been deployed with some success in Southeast Asia.
» Coronavirus in Georgia: stats in real time
The large-scale effort won’t be successful without a robust diagnostic testing system alongside it, experts say. Georgia ranked 30th nationally in testing per capita as of Tuesday, according to an AJC analysis of national testing figures, an improvement from 33rd last week and rankings as low as 45th a few weeks ago.
“While contact tracing may be the tentpole of public health and infectious disease response, testing is the cornerstone,” said Castrucci, a former public health official.
The limits of tracing
In the Waycross case, the church’s pastor, Jackie L. Hooper Sr., said the woman who died had been a visitor at two services. More than a half dozen people from his congregation later fell sick with coronavirus, he said. Some were hospitalized, and a 62-year-old church member died April 8.
“It was very, very devastating for us,” Hooper said, “because she was a dedicated usher, and we couldn’t have a service for her like we wanted. We had to have a graveside.”
The state’s Waycross-based epidemiologist wouldn’t talk about the case in detail in an interview with the AJC last month. The public service announcement was one of four that the Southeast Health District put out about Baptist churches in Ware, Pierce and Coffee counties that held services in late March.
“Contact tracing was difficult to impossible,” Trevor Thomas, the health district’s infectious disease coordinator, said, “and so prudent steps, historically in these cases, is to do larger notifications to a larger group that attended that event.”
Two months ago, a worst-case scenario unfolded in Albany, where a sick guest turned a funeral into a super-spreader event, the catalyst for an outbreak that's killed hundreds of people in southwest Georgia. In a March 26 interview, the district health director said the virus had spread so far, his office was no longer trying to trace its origins, but rather stop it from tearing through hospitals and nursing homes.
“At this point, it’s not a wise way to spend our resources, looking back about what happened,” Southwest Health District Director Charles Ruis.
For decades, Georgia has used contact tracing to limit transmission of infectious diseases such as tuberculosis, measles and HIV. It had about 250 tracers on staff before the pandemic arrived.
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» MORE: Coronavirus cases, deaths projected to rise as Georgia reopens
For the coronavirus, the CDC currently recommends that tracers contact anyone who was within six feet of an infected person for at least 15 minutes starting from 48 hours before illness onset. Those people are isolated, and if they test positive the process repeats for their contacts.
Not only can the work be tedious, but it requires personal sensitivity on an extremely tight timeline. Tracers need to quickly build trust with contacts so that they’re willing to share personal health information and isolate for two weeks to halt the virus’ spread.
Building trust can be challenging, particularly with people leery of public authorities and vulnerable populations more likely to have preexisting conditions.
“They may not have access to health care … or they may not have basic things like transportation to get to a testing site,” said Grace Bagwell Adams, an associate professor of health policy at the University of Georgia.
Traditionally, contact tracers would have time to track down people and offer resources to help them get tested and isolate, including food, transportation, shelter and even money to compensate for lost wages. Most work for the coronavirus will be completed over the phone or via the new online platform given social distancing guidelines and the need for speed.
In some respects, contact tracing veterans say outreach for the coronavirus could be easier than for HIV or AIDS, since tracers don’t need to pry into a person’s sexual history or drug use. On the other hand, the coronavirus spreads more easily, and people who are contagious may show no symptoms.
Some experts question whether going back two days, as the CDC recommends, is enough. Colin Smith, an assistant professor at Georgia State University’s School of Public Health, said ideally tracing should go back a week.
“But it may be a question of manageability,” Smith said. “Do you know what you had for breakfast six days ago?”
The state apparently stuck to that formula even when it faced the makings of a disaster in Vidalia. In March, the first person there known to have contracted coronavirus was longtime mayor Ronnie Dixon.
Three days before he checked into a hospital, the mayor had dropped by city hall, checked his mail and chatted with the city clerk, saying he wasn’t feeling well. Thirteen days earlier, he had presided over a city council meeting, attended by 14 other city officials and about 40 spectators including police officers, firefighters and other city workers.
Dixon, 77, died April 1. No one at city hall was ever contacted by state epidemiologists, and the only person placed in quarantine was the mayor’s widow, city and county officials told the AJC.
“We were all concerned that it could have been contracted by the staff, and obviously anybody that had come into contact with him,” City Manager Nick Overstreet said. “So far, we have been fortunate and had no employee with COVID-19.”
DPH has kept the details of its expanded contact tracing program tightly held, but Toomey said the department plans to hire at least 600 additional staff in the weeks ahead and engage upwards of 200 students. DPH recently posted job listings for $15 an hour full- and part-time positions — Toomey said 1,000 people have applied — and has reached out to the state's medical and public health schools to recruit student interns.
A surge of interest at the University of Georgia’s College of Public Health helped inspire an upcoming summer course about contact tracing for the coronavirus, according to Adams, the associate professor. A student-led contact tracing webinar at the Medical College of Georgia at Augusta University drew about 180 participants last week.
“This is kind of our way of helping the medical community, our mentors, our fellow physicians in the way that we can,” said Catherine Waldron, a graduating Mercer University medical student who helped lead the webinar. Waldron signed on as a volunteer contact tracer at the state’s Coastal Health District in Savannah in March after her hospital rotations were canceled.
The District has two teams of tracers. The first, made up of epidemiologists, is responsible for contacting and interviewing every person who tests positive for COVID-19.
Students like Waldron and Rebecca DeCarlo, a fourth-year medical student at the Medical College of Georgia, are part of the second, which calls the close contacts.
That team puts information about a person’s symptoms into a database known as SendSS, or the State Electronic Notifiable Disease Surveillance System. If symptoms develop, DeCarlo and her team can update the portal, alert a person’s doctor, have people seek a test and isolate themselves and other members of their household.
“If we can reach them immediately as soon as they have symptoms, we can keep them quarantined and stop the spread,” DeCarlo said.
The state public health districts, including in Savannah and metro Atlanta, began testing MTX's new monitoring application last week. It interfaces with SendSS and Google Cloud and allows people under contact tracing to log their daily symptoms on their smartphone.
The state signed the $546,000-per-year contract with MTX in early April. The company, headquartered in Texas and New York, has made similar monitoring and tracing platforms for more than a dozen other states over the last two months.
“Everybody wants to know how fast a solution can move so they have a reopening plan in place,” said CEO Das Nobel.
Some privacy advocates have raised concerns about the rules governing the health data being collected by contact tracing software, particularly a separate app being jointly developed by Apple and Google that will use Bluetooth to alert people whose cell phones come into close contact with those of infected people.
MTX’s platform does not use Bluetooth. Nor does the company have access to Georgians’ personal health data, said Nobel.
DPH declined to discuss details of the pilot program or whether current tracers have enough bandwidth to focus on all cases or only high-risk ones such first responders and people in senior centers.
Some experts say that contact tracing will not be a panacea and that the state should have started such efforts earlier.
“It’s stunning to me this is just in the early stages of rolling out when we started opening businesses a week-and-a-half ago,” said Dr. Harry J. Heiman, a professor at GSU’s School of Public Health.
Others say any effort will be helpful.
“You have to start somewhere,” said Nannette C. Turner, professor and chair of the Department of Public Health in Mercer’s College of Health Professions.