People walk on a path in front of the Golden Gate Bridge in San Francisco. | AP Photo
OAKLAND — California's plans to build an army of 10,000 people that can trace the trail of the coronavirus exposure could serve as a template for the nation and create a whole new sector of public health workers.
San Francisco this week is deploying its first group of about 50 volunteer contact tracers, many with no health care background — such as city librarians, attorneys and investigators. Officials elsewhere are watching the approach developed by University of California, San Francisco researchers with the hopes that they can scale it up quickly with workers from nonhealth sectors to meet the needs this unprecedented pandemic.
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Contract tracing involves tracking down the individuals and locations that an infected person may have exposed before being diagnosed with Covid-19. It is considered an essential tool to help states contain the virus once they lift stay-at-home orders, especially since many infected people can be asymptomatic carriers of the disease and expose others without knowing it.
"This is our Dunkirk moment for people to play their part in this work, and there's also the understanding that we're going to need a new vision of public health if we’re going to be able to address this," said Mike Reid, a UCSF infectious disease specialist leading the effort, referring to the World War II battle in which hundreds of private civilian boats aided in the successful evacuation effort of Allied troops.
California is among the few states considered to be ahead of the curve in developing their tracing programs. But no other state has to do it for nearly 40 million people.
The state initially used contact tracing as a containment strategy early in the pandemic before cases skyrocketed, back when there was hope that public health officials could isolate the virus and protect the greater public. But rapid community transmission in March, coupled with a lack of testing availability, forced states and the nation to shift toward stay-at-home orders.
The country may need about 100,000 contact tracers, according to the National Association of State and Territorial Health Organizations, although other estimates have placed that figure as high as 300,000 people.
California is working toward expanding its testing capacity to 60,000 to 80,000 tests per day statewide, then building out an army of tracers of at least 10,000 people — a goal Gov. Gavin Newsom said Monday he expects the state to meet sooner than anticipated.
Newsom said the state will build on the 22 counties that have robust contact tracing programs in place and supplement that with an online training platform being developed by a “well-known medical institution” that he plans to reveal in the coming days.
“We’ve been doing contact tracing for years and years and years, decades in California,” Newsom said, referring to track-and-trace efforts around tuberculosis, measles, HIV/AIDS and other STDs. Newsom has said he plans to rely on both paid workers and volunteers from many major organizations, including the newly established California Health Corps, the California Conservation Corps, CalVolunteers and AmericaCorps.
Given the state’s population, 10,000 tracers put the state on the low end but within the ballpark of what California would need, said Cyrus Shahpar, a Bay Area epidemiologist who serves as director of preventing epidemics at Resolve to Save Lives, a nonprofit that advises governments. The state would need a minimum of 12,000 to a maximum of 36,000 tracers, based on national estimates of 100,000 to 300,000.
“Historically, we’ve never done this before. It’s a new thing, so what happens in San Francisco and Massachusetts will help inform everyone else in the United States,” said Shahpar, who previously led the Global Rapid Response Team for the U.S. Centers for Disease Control and Prevention.
States need to start planning now for this effort, Shahpar said. The longer they wait to ease their restrictions, the more time they have to lower the number of infections, build sufficient testing capacity and develop contact tracing programs.
States, not the federal government, are leading this effort. The CDC last week released guidance to states on contact tracing, but didn’t tell them how many workers they would need.
Massachusetts on April 3 became the first state to announce a statewide contact tracing program, which is being outsourced to Boston nonprofit Partners in Health and plans to train about 1,000 people. Illinois plans to train a similar number with the same organization. New York last week announced its own massive contact tracing program, funded by $10 million from former New York City Mayor Mike Bloomberg.
Contact tracers would be charged with reaching out to people who may have come in contact with someone who tested positive for Covid-19 — work that has to be done in multiple languages and with sensitivity to a patient’s background and culture.
“For each of those persons that we are contact tracing, we want to be able to contact them. We want to be able to check their status, offer testing and recommend isolation or quarantine to start in isolation as necessary,” explained Mark Ghaly, secretary of the state Health and Human Services Agency.
San Francisco’s pilot program is considered one of the models for other jurisdictions, statewide and beyond. The city and UCSF have already trained nearly 250 people, including underutilized city employees, through a 20-hour online process that involves education about the virus, scripts and role-playing. The newly trained workers will contact individuals by phone, while health professionals will reach out to those who must be approached in person.
“It’s labor-intensive. You really have to get out there and talk to people and get them to voluntarily comply with the guidance from public health,” said Keslie Stewart, head attorney for public integrity at the San Francisco City Attorney’s office, who is coordinating training for about 40 workers from her office.
The training involves role-playing and relies on techniques such as motivational interviewing, sensitivity and avoiding biases — concepts Stewart likens to a combination of social work, counseling and investigative skills.
Experienced public health case investigators will first make the initial contact with the infected person and gather as much information as possible about the individual's potential contacts. Those details will be passed on to the contact tracers, who do the follow-up work.
While the region remains under shelter-in-place, the number of contacts remains relatively small — about 3.5 contacts per case, UCSF's Reid said. But once the restrictions lift, Reid expects the number of contacts attached to each case to increase exponentially — 40 to 75 contacts per case or possibly more. He said he's looking forward to additional information from testing and antibody surveillance studies to learn more about how widely Covid-19 can spread.
UCSF over the weekend launched a study of up to 5,700 people in the city's densely populated Mission District that involves testing for the presence of the virus, as well as blood tests to detect whether someone has antibodies. After initial testing is completed Tuesday, the researchers will retest participants two weeks later.
The San Francisco contact tracing program is using an app developed by Dimagi, a Cambridge, Mass., company that works with the CDC, to help support and monitor people. The app will allow those being monitored to receive texts to help track and report their symptoms, and to alert public health officials if they need follow-up or care.
The newly trained workers will be phased in under close supervision, Reid said. "It’s one thing to go through a lecture series and be introduced to the digital platforms we're using. It's another thing to use this platform to take calls and interface with people," he said.
George Rutherford, a UCSF infectious disease specialist and epidemiologist also leading the program, said technology can help but does not replace old-fashioned gumshoe techniques.
Rutherford underscored that Americans won’t put up with some of the hardcore surveillance techniques used in other countries like South Korea, where people who test positive for Covid-19 are required to turn over their cell phones and credit card information to the national police to track where they've been for the last 14 days. “How do you think that’s going to play in San Francisco or Berkeley?”
In a survey of more than 1,000 California adults released last week by the California Health Care Foundation, 22 percent said they would be unwilling to share their personal health information “under any circumstances.”
David Harvey, executive director of the National Coalition of STD Directors, emphasized the importance of relying on the past expertise built through contact tracing of HIV/AIDS and other sexually transmitted and communicable diseases. He said he’s been inundated with queries from people interested in learning how to become a contact tracer and sees this as a burgeoning field, especially as millions have lost their jobs and livelihood.
He sees this as an opportunity for public health to come out from "behind the scenes" and show Americans the value of this kind of work.
Contact tracers will be needed for potential coronavirus surges and for many years to come as new public health problems and epidemics develop. Without contact tracing, Bay Area epidemologist Shahpar said hundreds of thousands more people could get infected, leading to many more deaths and the return of restrictive stay-at-home measures.
"We really don’t have a choice,” he said.
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