Amid coronavirus surge, Texas has a contact tracing problem: reporting cases by fax

"We're asking people not to depend on contact tracing at this stage of the outbreak," one health official in Texas said as cases spread across many states.

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By Erik Ortiz

Manual, archaic technology and people's mistrust of government agencies are blunting contact tracing efforts, even as the persistent rise in coronavirus cases forces several Western and Southern states to dial back their reopening plans.

Dr. Anthony Fauci, the nation's top infectious diseases expert, raised a question Friday as to whether contact tracing is even worth the endeavor. And in Texas, a health official in Austin revealed this week that information about hundreds of new cases is pouring in daily across the state via an archaic form of technology: the fax machine.

That has made the confirmation of positive cases extremely time-consuming, the official said, which in turn has hindered contact tracing, a labor-intensive commitment that involves calling people who are confirmed ill with COVID-19, asking for their recent contacts and reaching out to those people to determine if they need testing and if they should self-isolate, all in the hopes of breaking the chains of infection.

"The cases we receive come in by fax machine," Dr. Mark Escott, the interim medical director and health authority for Austin Public Health, told Travis County commissioners. "And sometimes those faxes are positives and sometimes they're negatives. Sometimes they have information like the person's phone number that was tested and sometimes they don't. So we have a whole team of people who have to sort through more than a thousand faxes a day to sort out the positives versus the negatives."

The system remains a "very manual and archaic process," he added, because nearly all of the labs and the hospitals in the state report coronavirus cases through fax, and those results must then be manually entered into a computer.

Contact tracing didn't ramp up in Texas until after businesses had reopened and residents stopped isolating at home, making the effort more challenging; it is also less realistic to expect that it will have the same impact that it did in countries where tracing started while the economies were still closed, Escott said.

"Right now, what happens when you call somebody that's a positive and ask where they've been over the past week, they've been everywhere. They've been at grocery stores and restaurants and bars and friends' houses. They've had contact with hundreds of people," he said at a news conference Wednesday. "Contact tracing in that circumstance is not going to be as effective. So that's why we're asking people not to depend on contact tracing at this stage of the outbreak."

Since the beginning of the coronavirus pandemic, public health experts and Democratic lawmakers have been vocal about the need for local and state health agencies to perform contact tracing, in addition to ramping up of testing for COVID-19, the disease caused by the coronavirus.

But a lack of consistent messaging from the White House, the Trump administration's apparent delay in distributing billions of dollars in funding appropriated by Congress in April for testing and tracing, and the woefully inadequate number of contact tracers needed nationwide to appropriately handle the growing caseload have derailed the efforts to create a robust tracing program, experts add.

Fauci, director of the National Institute of Allergy and Infectious Diseases, said during a press briefing Friday that the hurdles to effective contact tracing remain, in part because of the spread of the virus among asymptomatic individuals, as well as the difficulty of getting people who may have been infected to answer their phones when a contact tracer calls.

He said that the mistrust of government agencies is already in about half of the population, and that "if you live in a community that's mostly brown or Black, you're in a different situation where maybe 70 percent don't want to talk to you."

"That is what's not working," he added.

In Texas, the stay-at-home order expired April 30 and businesses began reopening in a limited capacity May 1. The state was supposed to have "fully mobilized" up to 4,000 contact tracers by mid-May, but as of last week, officials said they were still about 20 percent short of that goal.

The upswing in cases statewide forced Gov. Greg Abbott, a Republican, to reverse course Friday and order all bars to close and restaurants to reduce capacity after the number of hospitalizations set a record Thursday for the 14th straight day.

The Texas Department of State Health Services did not immediately respond to a request for comment Friday on contact tracing, but spokesman Chris Van Deusen previously said that the state has adequate personnel.

Lauren Ancel Meyers, a professor of integrative biology who leads the COVID-19 Modeling Consortium at the University of Texas at Austin, said the use of faxes to report coronavirus cases in the state is a way to ensure a person's privacy is protected. While state-of-the art tracking and tracing technology would be helpful, she added, it "just doesn't exist because we never had a need for it before."

Other states experiencing a recent surge in COVID-19 have also lagged in hiring tracers. In California, Gov. Gavin Newsom, a Democrat, had said in April that the state would bring on "an army of tracers, beginning with the goal of 10,000," and eventually doubling that number by July. Earlier this month, state heath officials said they had about 3,000 staff within local health departments and were hiring another 3,400 people.

In North Carolina, where Gov. Roy Cooper, a Democrat, announced he is issuing a mask mandate beginning Friday and delaying phase three of the state's reopening plan by at least three weeks, there are more than 1,500 full- and part-time contact tracers. But a George Washington University analysis estimates that the state would need nearly 7,800 contact tracers to keep up with the rise in cases.

"As cases continue to increase, we know we need more and continue to ramp up hiring," state Department of Health and Human Services spokeswoman Kelly Haight Connor said in an email.

This week, Arizona, where some elected officials eschewed mask requirements during the pandemic, hit a record single-day increase in new cases, prompting Gov. Doug Ducey, a Republican, to warn Thursday that hospitals are "likely to hit surge capacity very soon."

Ducey released a video Tuesday explaining how contact tracing works and only last week mobilized the Arizona National Guard to help assist in tracing, with about 1,000 Guard members available to support local health officials. But given the dramatic rise in cases in Arizona since Memorial Day, the George Washington University analysis estimates that the state needs about 12,700 contact tracers.

The state health department did not return a request for comment about its contact tracing.

Florida, which saw its stay-at-home order end May 4 and is now grappling with record COVID-19 cases, including nearly 9,000 new ones reported Friday, has more than 1,600 contact tracers available, including epidemiologists and public health students at the University of South Florida. The George Washington University analysis estimates the state needs more than 16,700 contact tracers.

The state health department told NBC News that a third-party call center, Maximus, will help hire an additional 400 contact tracers and 200 disease investigators and is "prepared to further expand the number of contact tracers, if necessary, based on operational need."

Dr. Marissa Levine, a professor and director of the Center for Leadership in Public Health Practice at the University of South Florida, said she's heard of local health agencies so inundated by the spike in cases that they believe contact tracing now is "not going to make a difference" and there's the fear that "we're likely behind the eight ball."

But Levine said contact tracing alone can't be expected to slow the virus, and that people need to wear a mask in public, wash their hands and stay home if they feel sick.

"I think there's been a lot of mixed messaging or absent messaging, and when we reopened, lots of places like Florida left the door open that we can simply go back to the old normal — not that we need to create a new normal that we adapt to living with COVID," Levine added.

Florida Gov. Ron DeSantis, a Republican criticized for his state's slow response to social distancing measures as people packed the beaches in the spring, agreed Friday to ban drinking at bars to help curb the spread of COVID-19 — a stark reversal from last week when he said, "We're not rolling back."

The concept of contact tracing has been used effectively to control other disease outbreaks, including tuberculosis and SARS.

President Donald Trump, however, had rarely mentioned contact tracing in the early weeks of the pandemic, saying in April during a news briefing that "we've gotten good at tracing" — a claim that only befuddled public health experts. During a White House news conference May 11, it was Assistant Secretary for Health Brett Giroir who stressed that "if you need to be contact traced, be contact traced and cooperate with your local public health" department.

Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security, which released a report in April estimating the need to hire 100,000 contact tracers as part of a nationwide workforce, said there's been a noticeable lack of a "top level embrace of contact tracing."

While she said she's "heartened" by states and local health agencies that moved to ramp up contact tracing efforts ahead of reopening their economies, including in Massachusetts and New York, she is "disheartened by the lack of support from our federal government on this."

"It's not an all-or-nothing thing," Watson said. "Any amount of contact tracing will help us and save people's lives."

For some contact tracers, convincing people who may have been exposed to the coronavirus to participate in tracing, which is voluntary, has only become more difficult as the pandemic rages on.

"People understood in the beginning," Jade Murray, a contact tracer for a rural Utah health department, said. "But now that things have opened up and it's nice outside, people don't want to be compliant and they're being lax."

The number of new cases in Utah has jumped in recent weeks after hair salons, gyms, restaurants and bars reopened May 1. But Dr. Angela Dunn, the state epidemiologist, has warned that the state could move to a "complete shutdown" if cases don't fall to 200 or below by July 1.

"This might be our last chance for course correction," she wrote in a letter to leaders of Utah's coronavirus response. "Contact tracing and testing alone will not control this outbreak."

Murray said she's gone from a few new contact tracing cases a day to 40 or more. The workload, while overwhelming, is necessary, she believes, and is more effective than contact tracing apps and helps epidemiologists fundamentally understand how the coronavirus is spreading within communities.

About 30 percent of people still give her pushback after she contacts them, Murray said, but there are also many who are grateful for the guidance on what to do.

"I've had people crying on the phone because they felt so bad that they didn't take the virus seriously," Murray said.