When cases of COVID-19 started cropping up among recent graduates of The Lovett School in late May, public health officials began the tedious work of tracing the infections’ origin.
It didn’t take long for them to encounter challenges.
First, some parents didn’t pick up the calls from state workers trying to determine who those infected had come in contact with. Then, when health authorities asked for Lovett’s help in getting parents to cooperate, officials there initially dragged their feet, said Dr. Lynn Paxton, district director for the Fulton Board of Health. And health officials learned a private physician with ties to the prestigious Buckhead school was leading a do-it-yourself approach to investigating the outbreak, Paxton said, and not keeping the board of health in the loop.
“We lost a lot of time with this runaround,” Paxton said recently.
It wasn’t exactly what public health officials envisioned during all the years when they were planning for the inevitable pandemic, though a Lovett spokeswoman strongly denied any lack of cooperation.
Two months after Georgia began rapidly expanding the state's ability to track potential infections, it's clear that contact tracing is no panacea.
Generally speaking, the public can be cajoled into helping state workers identify cases and contact those potentially exposed to the virus so they can be quarantined, according to local epidemiologists interviewed by The Atlanta Journal-Constitution.
But some uncooperative patients and incomplete contact information continue to stymie progress.
And, with the number of COVID-19 cases soaring in Georgia, it may become increasingly difficult to keep up with the work, even when the public is cooperative.
“When there’s this degree of community spread going on, there’s no way to execute a containment strategy,” said Dr. Harry J. Heiman, clinical associate professor at the Georgia State University School of Public Health.
Losing ground
As Georgia began its economic reopening this spring, contact tracing was held up as one of the most important tools for the state to manage the pandemic.
Public health agencies have a mandate to investigate diseases, and the public has a legal obligation to comply.
But it’s difficult to determine how successful the government has been at contact tracing. The Georgia Department of Public Health (DPH) doesn’t regularly release statistics like it does with testing.
This much is apparent: The Lovett parents aren’t the only ones tracers have had trouble reaching. Dr. Kathleen Toomey, the state’s commissioner of public health, recently suggested that outreach efforts are being met with skepticism and, in some cases, all-out hostility. Earlier this month, she pleaded with the public to pick up the phone if contacted by the health department.
Recent state data indicate tracers are losing ground as cases spike. Between June 23 and July 8, the state interviewed 37% of the people who were diagnosed with COVID-19, according to an AJC analysis of DPH data. But, between May 15 and June 22, tracers touched base with 60% of newly infected people. (See box.)
Read more: Coronavirus may spread too fast for Georgia tracers to catch up
Since mid-May, tracers have identified more than 76,000 close contacts of infected people, according to DPH.
DPH declined to make Toomey available for an interview or answer many of the AJC’s questions for this story. But in a written statement to the AJC, Toomey said she’s “very happy with where we are, how far we’ve come and how we’ve been able to ramp up the system so quickly and efficiently with total coordination across the state.”
“However, as the cases of COVID-19 increase daily by the thousands, it becomes harder and harder to keep up with contact tracing,” she said. “Our work is further hampered by the fact that it’s taking longer to get test results from commercial labs that are recently backed up due to the volume of testing. By the time we get test results, many contacts are already outside of the risk period.”
Answering the call
This spring, Toomey promised a military-like effort to implement contact tracing, a form of disease detective work long used to tamp down infections such as measles and HIV. Coronavirus tracers contact a person who tests positive, ask for information about their close contacts and then urge those contacts to quarantine for 14 days, report their symptoms and get tested.
Toomey aimed to quadruple the number of disease trackers the state employed, to upward of 1,000. DPH launched a campaign to educate the public about tracing, hoping the information would encourage people to cooperate.
Read more:Georgia expands contact tracing program
Georgia had hired some 1,225 tracers as of July 1, DPH said, using federal money to employ more than initially promised.
But public cooperation proved to be a bigger challenge than expected, Toomey said.
“We haven’t had as much support as we’d hoped from all the communities,” she told reporters at the beginning of the month.
Credit: ASSOCIATED PRESS
Credit: ASSOCIATED PRESS
Many ignore calls from numbers they don't know. Scammers posing as contact tracers to steal personal information only complicate matters.
DPH released a 90-second video last month underscoring that tracers don't collect information like Social Security numbers, immigration status or Bluetooth data. But that hasn't stopped skepticism.
"In some cases, the contacts actually hang up the phone on the contact tracers when they try to identify themselves," said Dr. Otto J. Ike, DeKalb County's chief epidemiologist.
Others demand proof that tracers are who they claim to be.
DPH is working to make tracers’ calls appear as “GA COVID Team” on caller ID, but the process is slow going. In the meantime, many trackers must repeatedly dial contacts and send letters urging them to respond.
Read more: Georgia contact tracers' first obstacle? Gaining public trust
Most cooperate, even if it takes some persuading, local epidemiologists said. Public health authorities have avoided visiting contacts in person, a method used in other outbreaks. They’ve also largely shied away from the most powerful tool in their arsenal: legal threats.
Credit: Steven Senne
Credit: Steven Senne
When eight people infected with COVID-19 at a party refused to cooperate with contact tracers in Rockland County, New York last month, authorities issued subpoenas that carried $2,000-per-day fines. The party-goers quickly complied.
Toomey said authorities here reserve the right to use similar tactics, but it’s a step she’d prefer to avoid.
It’s unclear how many cases ultimately were tied to the Lovett outbreak, which Paxton previously said likely stemmed from social gatherings following a drive-thru graduation celebration. But Paxton said she suspects most who got sick sought a test.
A Lovett parent who contacted health authorities became an intermediary and urged people to get tested on a Lovett parent text chain, Paxton said. The school eventually sent emails encouraging cooperation, she said, but school officials declined to connect her agency’s tracers with the physician with Lovett ties.
“If we’d known then how long it was going to take to bring them around to doing the simple things, like sending out an email, we’d have been more forceful from the beginning,” she said.
Courtney Fowler, a Lovett spokeswoman, defended the school’s response. Lovett alerted the state on May 21, as soon as it learned of the first positive case, she said. Graduates and their families were notified the next day and given information about the county’s COVID-19 hotline and testing. Additional alerts to parents followed, she said.
Lovett also provided family contact information to county health officials and stayed in touch as the confirmed cases climbed to 18 over the next few days, Fowler said.
At the request of Fulton health, the school sent an email to families on May 29 urging them to answer contact tracers’ calls.
“During that time, a physician member of the Lovett community offered to test graduates and their families,” Fowler said in an email. “Pertinent results of those tests were duly reported to the Department of Health.”
Positive tests are required to be reported by law.
The school continued communicating with Fulton through mid-June, Fowler said.
In Cobb and Douglas counties, roughly 70% of positive COVID cases and about 60% of their close contacts have been cooperative with tracers, said epidemiologists Gurleen Roberts and Rachel Franklin. Only in one instance did tracers feel the need to reach out to local law enforcement to serve orders to a COVID patient who wasn’t willing to quarantine.
“Of course, the last thing we want is for cases to be out in public while they are infectious,” said Franklin.
‘Undone any good’
Regardless of how effective contact tracing is or isn’t, states have suffered in the absence of a national containment strategy, said Brian Castrucci, a former DPH official who’s now president and CEO of the de Beaumont Foundation, a Washington, D.C.-area nonprofit that supports public health agencies.
“The minute you open nightclubs, bars, gyms, restaurants and movie theaters, you have undone any good that contact tracing can do,” he said. “You’ve created new cases faster than the contact tracers can find (them).”
The fact that it’s still taking some people upward of a week to receive their test results is also to the detriment to tracers, who need to reach the potentially infected immediately to quarantine them and minimize their risk, said Georgia State’s Heiman.
There’s also a question of how DPH is following up with people who were exposed to the virus.
Late last month, the YMCA notified parents of an outbreak of COVID-19 and closed children's camps on Lake Allatoona and Lake Burton in North Georgia.
DPH previously confirmed at least 30 campers and staff have been infected. Parents of several Lake Burton campers who tested positive told the AJC they have heard little from the state after initial contact about the infections.
Parents of five campers said no contact tracers from DPH or local health departments have communicated with them. In at least two cases, the parents notified the state of the positive results. The parents, who agreed to talk to an AJC reporter on condition of anonymity out of medical privacy concerns, said in the absence of contact from public health officials, parents are doing their own contact tracing, notifying close family and friends and isolating themselves.
“That is a complete and utter absence of leadership,” Castrucci said.
Dave Palmer, a spokesman for the state Public Health District 2 that includes the camps, said staff members compiled a spreadsheet of the infected campers. All the families who resided in District 2 were contacted by epidemiologists for tracing, Palmer said, and the rest of the names were sent to the other public health agencies where those children resided.
“We don’t really have the resources” to trace people who don’t live in District 2, Palmer said. “It’s up to each district to do their own contact tracing.”
DPH spokeswoman Nancy Nydam said the state has the capacity to add more tracers if the need arises.
“Depending on how long the increases continue at the current pace, we will look to bring on additional staff,” Nydam said. “At the same time, we are also discussing how cases might be prioritized if the need arises.”
Staff writers Greg Bluestein and John Perry contributed to this article.
What is contact tracing?
Public health authorities use contact tracing to help contain infectious diseases by tracking its spread within a community. They urge people who may have been exposed to quarantine to prevent further transmission.
How it works:
Tracers interview people who have tested positive for COVID-19 and ask them to recall who they’ve been in close contact with while they may have been infectious. Close contacts are people who have been within six feet of the infected person for at least 15 minutes while the person was experiencing symptoms and the 48 hours prior.
The tracers then reach out to those close contacts via phone and urge them to quarantine for 14 days, get tested and track their symptoms. They do not disclose the identity of the person who may have exposed those contacts to the virus.
What contact tracers ask:
- Your name
- Your contact information
- Your date of birth
- Your symptoms
- Your close contacts
- Your workplace
What they don’t ask about:
- Your Social Security number
- Your citizenship or immigration status
- Your financial information
- Visiting your home to clean or perform a test
They may:
- Direct you to a free testing site
- Offer resources to help you quarantine if you're unable to do so or require assistance such as child care
Recent contact tracing in Georgia
June 23 to July 8
Confirmed COVID-19 cases: 37,962
Confirmed cases interviewed by tracers: 14,029 (37%)
Close contacts identified: 31,039
May 15 to June 22
Confirmed COVID-19 cases: 29,951
Confirmed cases interviewed by tracers: 17,889 (60%)
Close contacts identified: 43,239
-Analysis of Georgia Department of Public Health data by AJC Data Specialist John Perry
