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When contact tracing fails: Testing delays thwart California COVID-19 trackers

Sacramento Bee logoSacramento Bee 7/26/2020 By Sophia Bollag, Tony Bizjak, and Alexandra Yoon-Hendricks, The Sacramento Bee

A surge in COVID-19 cases and a shortage of contact tracers has for weeks hampered Sacramento County’s efforts to contact and warn people exposed to coronavirus. Now, an additional hurdle is inhibiting the county’s contact tracing: testing slowdowns.

Delays to get test appointments and longer waiting periods while labs turn around results mean cases land on investigators’ desks long after a person should have been told to start quarantining.

In some cases, the county receives cases more than 14 days after a person was exposed, the period of time most people are thought to be infectious.

“The effect of contact tracing is being able to get to people quickly. If not, those are opportunities lost for doing intervention,” said Dr. Olivia Kasirye, Sacramento County health officer. “If it is beyond the 14 days, there is no point.”

Across the state, officials and contact tracers in hard-hit counties report similar problems. Compounded by staffing shortages, the delays make contact tracing harder and less effective as the state fights to lower infection rates.

“It’s a story I’m hearing more and more,” said Brad Pollock, associate dean for Public Health Sciences at the UC Davis School of Medicine. “Timing is really critical. If you can’t get to these people in time ... it’s useless.”

Contact tracing delays

Once someone catches the coronavirus, scientists estimate it takes four to five days before the virus multiplies in their body enough to infect others, Pollock said. About 14 days after infection, scientists studying COVID-19 believe most people can no longer spread it, provided they don’t have symptoms.

Contact tracers and disease investigators call infected patients and their contacts to tell them to quarantine so they don’t spread the virus further, and are given scripts to follow during those phone conversations.

People who test positive are instructed to quarantine for at least 10 days after their positive test, while their contacts are told to quarantine for at least 14 days from the time they were exposed, according to contact tracing scripts obtained by The Bee. If people develop symptoms, they are advised to quarantine until after their symptoms subside.

Several contact tracers in hard-hit counties who asked not to be identified by name for fear of repercussions at their jobs told The Bee case assignments trickle in slowly, often days after a person has tested positive.

One tracer working for Los Angeles County said she’s only assigned about three new cases per day, most of which go straight to voicemail. Of the three cases she received Wednesday, two were past their isolation period. The third had died.

Records of communications among other contact tracers in Los Angeles County obtained by The Sacramento Bee show other tracers were also assigned cases many days after the infected person was tested.

The Los Angeles County Department of Public Health said in an email that the department is seeing delays for lab results, meaning some tracers receive cases days after a patient was tested. Workload for contact traces varies based on the number of cases the county receives each day, the department said, but tracers call nearly all positive cases within 24 hours of receiving an assignment.

A contact tracer in Imperial County noted that of the more than 20 contacts assigned to her team Monday, only seven were within the 14-day window, according to emails obtained by The Bee. Ten of the contacts did not include a name or phone number, she wrote, making them impossible to reach even if they were within the time frame.

In Stanislaus County, officials are scrambling to add more contact tracers and shorten test turnaround times as investigators and contact tracers work through a backlog of positive cases.

Bonnie Davies, director of public health nursing in Colusa County, said testing delays and other hurdles are so significant that she isn’t convinced tracing is worthwhile.

Her county saw an increase in cases over the last few weeks, landing it on the state monitoring list. Many people do not get their tests back for days or even a week. If it takes another couple of days for tracers to reach them, people they may have infected have already had time to infect others.

In those cases, “you are like a dog chasing your tail,” she said.

COVID contact tracing is taking all the staff time, she said, with no assurance anyone they call will listen to their advice to quarantine.

“I don’t know how effective contact tracing is. We are spending a lot of time,” she said, but “there is no enforcement behind it and no monitoring. I don’t know how many are quarantining.”

Trace your own COVID-19 contacts

In Yolo County, 30 to 40 new cases every day and delayed test results have forced investigators focus on contact tracing for potential outbreaks in high-risk populations first, such as those in skilled nursing facilities, jails and homeless shelters.

After that, cases are prioritized based on the most recent test results to reach people still in the recommended quarantine period. In many cases, the county sees testing delays of nine to 12 days, county spokeswoman Carolyn Jhajj said.

On Friday, the county released new guidance for people taking COVID-19 tests, urging those with symptoms or who know they’ve been exposed to quarantine at home even before they get results.

In Sacramento, when a case gets to the county after two weeks, health officials may set it aside and jump on fresher cases, Kasirye said.

As a workaround, Sacramento County’s health office is asking health providers to tell people getting tested to quarantine if they test positive even if the county doesn’t contact them.

It also asks them to contact people they have been in close touch with to inform them they likely were exposed to the virus, which gives that person the chance to quarantine and take a test.

In a press conference Tuesday, California Health and Human Services Secretary Dr. Mark Ghaly said that approach – essentially having people do their own contact tracing – may be effective in convincing close contacts to quarantine.

Dr. Melissa Marx, Assistant Professor in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health, said California’s contact tracing struggles aren’t unique.

“It is happening everywhere,” she said. “Testing turnaround time is not enough to keep up.”

Marx, who is leading the Bloomberg School’s support of the Baltimore City health department’s response to the COVID-19 pandemic, said she’s also recommending that people do their own contact tracing.

“We recommend anyone getting a test should assume they are positive and tell all their contacts that they might be positive,” she said. “That is the only way I can think of that we can get ahead of this.”

Priorities for coronavirus testing

In the meantime, Ghaly has acknowledged contact tracer shortages and testing delays make it harder to contain the virus’ spread.

Amid the testing delays, the state’s Department of Public Health announced new testing priority tiers, with hospital patients and testing related to contact tracing and case investigation as the highest priority. It applies to both testing appointments and to the order in which labs process tests.

The new priority system comes as the state experiences a dramatic rise in coronavirus cases and the state runs low on testing supplies, causing bottlenecks for testing and forcing people to wait longer for results, Ghaly said.

In a press conference Tuesday, he acknowledged that the state has too many new infections to investigate and trace each case.

“At the level of transmission we’re seeing across the state, even a very very robust contact tracing team in every single county will have a hard time reaching out to every case,” Ghaly said. “No one has anticipated building a program to contact trace the level of cases we’re seeing here.”

Kasirye said she is “cautiously optimistic” the recent closures ordered by Gov. Gavin Newsom and many counties will lower infection rates in the next couple of weeks.

“I think we will get to a point we can start breathing a little easier,” she said. “But right now it is a strain.”

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©2020 The Sacramento Bee (Sacramento, Calif.)

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