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Delta variant cases overwhelm contact tracing in hard-hit states

County and state health departments in places like Missouri and Texas are making tough calls about whom to trace.
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Health departments nationwide scaled back their contact tracing in late spring or early summer when Covid-19 cases started to decrease as vaccination efforts took center stage.

Then delta hit.

Now state and local health departments are trying to build back operations with depleted resources as Covid fatigue among their workers and the public alike complicates those efforts.

“Contact tracing from the start of this pandemic provided us with really kind of invaluable information,” said Dr. Amanda Castel, a professor of epidemiology at George Washington University. Castel said it is still “a fundamental part of our response.”

As is Covid testing, especially for those who are vulnerable or unvaccinated, such as children under age 12. Yet numerous departments now find themselves with fewer contact tracers and less robust programs. Like testing, contact tracing seems to have fallen by the wayside.

Contact tracing is a resource-intensive operation, requiring workers to quickly call people who test positive for a disease and offer medical advice and then to identify and reach out to anyone with whom the infected came in close contact. The hope during the pandemic is to prevent spread of the coronavirus and to observe how it is changing. Public health officials have used the process for decades to stop disease transmission.

But many public health departments were overwhelmed by the onslaught of Covid. Last winter — before vaccines provided relief — they were unable to stay ahead of the virus through contact tracing. And as case counts dropped because of increased vaccination rates in the spring and early summer, more than a dozen state health departments scaled back their workforces, said Crystal Watson, a senior scholar and assistant professor at the Johns Hopkins Center for Health Security. The resources were needed for vaccination initiatives and to restart other public health programs.

The situation has grown critical in a number of states during the past month or so as local health officials find themselves once again behind the curve as the delta variant drives up case counts. Resources are already stretched, and the politicization of Covid has left local officials to make tough calls about whom to trace in places like Missouri and Texas. And some states just do not have enough personnel to do the job. The army of disease detectives more often than not included temporary staff members or civil servants from outside the health departments. In Kentucky, the former contact-tracing director is now the Aviation Department commissioner. The state Public Health Department said he has a successor, but it declined to name who.

The highly contagious delta variant makes the job harder. Cases can stack up quickly. Public health departments, which are chronically understaffed and underfunded, must pick and choose which tools will serve them the best.

“Some places have done a good job at retaining a kind of reserve workforce that they could call back up. And I'm sure that's coming in handy right now. Other places did not. And they're probably going to be quickly overwhelmed,” Watson said. “It's also hard to say because there's not a lot of public reporting.”

Arkansas, where Republican Gov. Asa Hutchinson now says it was an error to have signed a law in April banning mask mandates, is averaging about 2,000 new cases a day, one of the steepest surges among states. But the state Health Department has significantly fewer contact tracers now — 192, compared to 840 in December, when case counts were at the same level, according to the department and data collected by Johns Hopkins.

Danyelle McNeill, a spokeswoman for the Arkansas Health Department, said contractors performing this work have been authorized to increase their staff sizes. She also said the agency is triaging cases, prioritizing people who tested positive for or were diagnosed with Covid within six days of specimen collection or onset of symptoms, which the Centers for Disease Control and Prevention has recommended when capacity is limited. She said vendors are not calling all positive cases the same day they receive lists when infections near 2,000.

You have a public who is really not supportive of contact tracing and quarantine.

In states that have opted to downplay contact tracing, county and city health officials are left to fend for themselves. In Missouri’s hard-hit southwestern region, the flood of cases has overwhelmed a staff already stretched thin, said Katie Towns, director of the Springfield-Greene County Health Department, so the department pivoted to conduct contact tracing only in cases involving children younger than 12, who do not have access to vaccinations, Towns said.

Lisa Cox, a spokesperson for the state Department of Health and Senior Services, said “local health departments will work to triage and prioritize case investigations and will work with them if assistance is needed.” Her department expects financial support through the federal American Rescue Plan, but funds have yet to be appropriated. Ultimately, local strategies will come down to priorities. “We’ve made it clear that local jurisdictions need to make decisions locally based on their unique situation.”

The Springfield-Greene County Health Department's surge capacity has diminished as team members have been redeployed to other health programs, which had been neglected during the pandemic. But Towns said that even if she had unlimited resources, she questions how effective investing it all in contact tracing would be: Covid is rampant, and compliance with public health measures has waned. She would be more likely to deploy more people to vaccination outreach and distribution.

Kelley Vollmar, executive director of the Jefferson County Health Department in eastern Missouri, said the delta surge is hitting a community polarized against public health efforts. “You have a public who is really not supportive of contact tracing and quarantine, as well as the funding for contact tracing and infrastructure is not there like it was last year,” she said.

Controversy over contact tracing

The Texas Department of State Health Services is “winding down” its contact-tracing program to meet the requirements of the budget. In the new budget, which takes effect Sept. 1, health departments are expressly banned from using taxpayer dollars for Covid contact tracing.

“We will still be doing case investigations and other public health follow-up,” Chris Van Deusen, the state health department’s director of media relations, said by email, “but won’t be providing contact tracing for local health departments.”

The Texas Education Agency, which oversees primary and secondary education, also said this month that schools are not required to conduct contact tracing.

Contact tracing has been clouded by controversy in Texas. Five legislators sued Republican Gov. Greg Abbott and the health department last August for awarding a contract to conduct the program.

“The contract tracing policy has never been established as a policy accepted or supported by the Texas Legislature,” the suit said. Another lawsuit filed the same month by dozens of Texans alleges that the adoption of contact tracing violates their constitutional right to privacy.

In Texas’ Williamson and Bexar counties, where community Covid transmission is high, local health officials are troubled by the lack of statewide tracing.

Williamson County turned to the state health department for help in contact tracing and case investigation as 50 to 100 new cases a day were being reported.

The county health department, which is separate from the county government, also trained more than half of its staff members to do contact tracing, from clinical staff members to media officers, said Allison Stewart, lead epidemiologist for the Williamson County and Cities Health District, but the 65 people, including external staff members and volunteers, could not keep up with cases. Some worked seven days a week or 12-hour days, but now the county relies on the state for the work.

“We can’t return to those days now, because all the people that we used actually are doing their real jobs,” she said. “We’re trying to figure out right now what the plan is come Sept 1. And it may mean the plan is that we don’t do case investigation or contact tracing.

“Honestly, we don’t know,” she said.

San Antonio in Bexar County, one of the country’s largest cities, has its own contact tracers, but it leans on the state whenever there is a surge, said Rita Espinoza, the city’s chief of epidemiology. San Antonio is relying on the state and is thus able to handle the load without backlogs, Espinoza said. She worries what will happen in the fall, after school starts and there are more opportunities for transmission. The staff is already operating at a reduced capacity of 80 people.

“The specific impacts are unknown, but it may impact efforts to enhance other infectious disease investigations,” Espinoza said.

Florida, where Covid has become a political buzzword, is another state where the tension is playing out. Broward County Mayor Steve Geller said he has asked about contact-tracing capabilities, including how many investigators the state Health Department has, but he said he is told only: “We're working on it. It's under control.” Contact-tracing data are not publicly available; Republican Gov. Ron DeSantis once told local reporters that contact tracing “has just not worked.”

Geller has not pushed health officials for information given that “contact tracing doesn’t work well when everyone has Covid” and that Covid data have become contentious in Florida.

“I’m not looking to create any new martyrs,” he said.