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Contact Tracing Is Harder Than It Sounds Contact Tracing Is Harder Than It Sounds
(about 16 hours later)
How likely are you to answer an unknown number popping up on your caller ID? And if you were to pick up, how likely is it that you would disclose personal information about yourself and your family, friends and colleagues to the stranger on the other end of the line?How likely are you to answer an unknown number popping up on your caller ID? And if you were to pick up, how likely is it that you would disclose personal information about yourself and your family, friends and colleagues to the stranger on the other end of the line?
Ask any census worker, public opinion pollster or cold caller, and they will tell you the answer to both questions is “not likely.” Indeed, the pickup rate for unfamiliar or unidentified numbers in those circumstances is as low as 6 percent. And the people who do answer are often wary and uncooperative, if not abusive.Ask any census worker, public opinion pollster or cold caller, and they will tell you the answer to both questions is “not likely.” Indeed, the pickup rate for unfamiliar or unidentified numbers in those circumstances is as low as 6 percent. And the people who do answer are often wary and uncooperative, if not abusive.
That resistance is the crux of the problem with contact tracing, which health experts say is essential to containing the coronavirus.That resistance is the crux of the problem with contact tracing, which health experts say is essential to containing the coronavirus.
The idea is to reach out to everyone who has tested positive for the virus, find out whom they might have inadvertently exposed and encourage them all to avoid infecting others. But an army of 180,000 contact tracers provisioned with telephone headsets and scripts does not guarantee that anyone will want to talk to them, much less follow their advice.The idea is to reach out to everyone who has tested positive for the virus, find out whom they might have inadvertently exposed and encourage them all to avoid infecting others. But an army of 180,000 contact tracers provisioned with telephone headsets and scripts does not guarantee that anyone will want to talk to them, much less follow their advice.
A storied group of venereal disease investigators from the last century provides some clues on what it might take for contact tracing to be effective and whether the current patchwork of city and state programs is missing the mark.A storied group of venereal disease investigators from the last century provides some clues on what it might take for contact tracing to be effective and whether the current patchwork of city and state programs is missing the mark.
“The best contact tracers that we have ever had came out of the V.D. investigation program started after World War II,” said Dr. William Foege, a former director of the Centers for Disease Control and Prevention who is credited with devising the global strategy that led to the eradication of smallpox in the 1970s.“The best contact tracers that we have ever had came out of the V.D. investigation program started after World War II,” said Dr. William Foege, a former director of the Centers for Disease Control and Prevention who is credited with devising the global strategy that led to the eradication of smallpox in the 1970s.
This was an elite cadre of carefully vetted and trained individuals, who, starting in 1948, were tasked by the Public Health Service to contact trace cases of venereal disease, particularly syphilis. Syphilis was a scourge back then; during wartime, approximately 25,000 positive tests were reported annually in New York City alone.This was an elite cadre of carefully vetted and trained individuals, who, starting in 1948, were tasked by the Public Health Service to contact trace cases of venereal disease, particularly syphilis. Syphilis was a scourge back then; during wartime, approximately 25,000 positive tests were reported annually in New York City alone.
The shame associated with syphilis made it especially difficult to get infected people to talk. And tracking down contacts was a challenge when often all you had to go on was, “the girl who frequents the red-door bar downtown” or “a guy who said he was a brush salesman from Topeka.” Nevertheless, public health advisers, or P.H.A.s, as the investigators were called, were astoundingly effective. By the mid-1950s, syphilis rates were the lowest they had ever been. (Also of note, it was a relentless P.H.A. who blew the whistle on the infamous Tuskegee experiment.)The shame associated with syphilis made it especially difficult to get infected people to talk. And tracking down contacts was a challenge when often all you had to go on was, “the girl who frequents the red-door bar downtown” or “a guy who said he was a brush salesman from Topeka.” Nevertheless, public health advisers, or P.H.A.s, as the investigators were called, were astoundingly effective. By the mid-1950s, syphilis rates were the lowest they had ever been. (Also of note, it was a relentless P.H.A. who blew the whistle on the infamous Tuskegee experiment.)
“They had to be psychiatrists, detectives and problem solvers all at once,” Dr. Foege said. He worked closely with many public health advisers who ended up at the C.D.C. spearheading efforts to contain other infectious diseases, such as smallpox, measles, H.I.V./AIDS, cholera and Ebola.“They had to be psychiatrists, detectives and problem solvers all at once,” Dr. Foege said. He worked closely with many public health advisers who ended up at the C.D.C. spearheading efforts to contain other infectious diseases, such as smallpox, measles, H.I.V./AIDS, cholera and Ebola.
The boss of the operation was the poker-playing biostatistician Lida Usilton. Under her direction, all P.H.A.s went through the same selection process. They had to have a college degree, liberal arts preferred, and a variety of work experiences and backgrounds was a plus. One put himself through school working as a dishwasher and a lumberjack. Another was a former farmhand and football player. Some were prisoners of war.The boss of the operation was the poker-playing biostatistician Lida Usilton. Under her direction, all P.H.A.s went through the same selection process. They had to have a college degree, liberal arts preferred, and a variety of work experiences and backgrounds was a plus. One put himself through school working as a dishwasher and a lumberjack. Another was a former farmhand and football player. Some were prisoners of war.
The thinking was that contact tracers had to be able to talk as easily with a Wall Street banker as with a migrant worker. They were interviewed extensively to see whether they had the kind of emotional intelligence that made people want to talk to them and whether they could easily manage conversational curveballs, like when a female contact revealed she was biologically a man.The thinking was that contact tracers had to be able to talk as easily with a Wall Street banker as with a migrant worker. They were interviewed extensively to see whether they had the kind of emotional intelligence that made people want to talk to them and whether they could easily manage conversational curveballs, like when a female contact revealed she was biologically a man.
“They didn’t have to be rocket scientists but they had to be able to connect with other people — to talk in a way that indicated to us they were very approachable and reasonable human beings who could be sensitive and persuasive,” said Frederick Stuart Kingma, a 92-year-old retired P.H.A. who trained and recruited other tracers in the 1950s.“They didn’t have to be rocket scientists but they had to be able to connect with other people — to talk in a way that indicated to us they were very approachable and reasonable human beings who could be sensitive and persuasive,” said Frederick Stuart Kingma, a 92-year-old retired P.H.A. who trained and recruited other tracers in the 1950s.
Today the process is different. Coronavirus tracers are hired according to various state or local health authorities’ requirements, for jobs paying from $15 to $30 an hour. In New York City, where 10,000 people have applied for 2,500 coronavirus contact tracing jobs, officials said preference was being given to clients of local food-assistance and social-support organizations. In San Francisco, they are hiring primarily furloughed city employees, such as librarians, city attorneys and tax assessors. And in Massachusetts, where 45,000 people applied for 1,700 positions, résumés were sorted first by algorithm and final decisions were based in large part on videos that applicants submitted explaining why they wanted the job.Today the process is different. Coronavirus tracers are hired according to various state or local health authorities’ requirements, for jobs paying from $15 to $30 an hour. In New York City, where 10,000 people have applied for 2,500 coronavirus contact tracing jobs, officials said preference was being given to clients of local food-assistance and social-support organizations. In San Francisco, they are hiring primarily furloughed city employees, such as librarians, city attorneys and tax assessors. And in Massachusetts, where 45,000 people applied for 1,700 positions, résumés were sorted first by algorithm and final decisions were based in large part on videos that applicants submitted explaining why they wanted the job.
“We’re still learning who the best people are to do this,” said Dr. John Welch, who is overseeing recruitment and training of contact tracers for Massachusetts in collaboration with the nonprofit Partners in Health. “A furloughed doctor or nurse may not have that empathetic ear that’s critical.”“We’re still learning who the best people are to do this,” said Dr. John Welch, who is overseeing recruitment and training of contact tracers for Massachusetts in collaboration with the nonprofit Partners in Health. “A furloughed doctor or nurse may not have that empathetic ear that’s critical.”
Updated June 5, 2020Updated June 5, 2020
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.
Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.
The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
Training is similarly all over the map, with some health agencies requiring online courses lasting a few hours and others demanding eight to 20 hours of in-person training, or a combination of both. Much of the training focuses on education about the coronavirus, confidentiality rules and data entry protocols. Relatively little instruction is given on how to build rapport with and earn the trust of people, particularly when they might be reluctant to reveal their contacts, like, say, a married lover or an undocumented employee.Training is similarly all over the map, with some health agencies requiring online courses lasting a few hours and others demanding eight to 20 hours of in-person training, or a combination of both. Much of the training focuses on education about the coronavirus, confidentiality rules and data entry protocols. Relatively little instruction is given on how to build rapport with and earn the trust of people, particularly when they might be reluctant to reveal their contacts, like, say, a married lover or an undocumented employee.
For example, just one hour of the six-hour online training program developed by Johns Hopkins Bloomberg School of Public Health, which New York City and the state of New York are using, is devoted to interviewing techniques. It recommends memorizing catchphrases to use during calls such as “I hear you” and “This is a difficult time.” That is, the kinds of canned responses that might send someone into a blind fury when calling tech support.For example, just one hour of the six-hour online training program developed by Johns Hopkins Bloomberg School of Public Health, which New York City and the state of New York are using, is devoted to interviewing techniques. It recommends memorizing catchphrases to use during calls such as “I hear you” and “This is a difficult time.” That is, the kinds of canned responses that might send someone into a blind fury when calling tech support.
Dr. Emily Gurley, an infectious-disease epidemiologist who developed the Bloomberg training, said that if people realize that the person on the other end of the line is trying to help them, “then I think your interviewing skills don’t need to be that great to really get and give the information that you need to.”Dr. Emily Gurley, an infectious-disease epidemiologist who developed the Bloomberg training, said that if people realize that the person on the other end of the line is trying to help them, “then I think your interviewing skills don’t need to be that great to really get and give the information that you need to.”
P.H.A.s, by contrast, were taught that everything depended on their interviewing skills. They were sent away to a kind of interpersonal-skills boot camp where they spent an intense two weeks learning interviewing techniques, shadowing other contact tracers and interviewing people themselves under close supervision. Their success in the field was then closely monitored in terms of numbers of cases reached and contacts generated, as well as how many contacts got tested and treated.P.H.A.s, by contrast, were taught that everything depended on their interviewing skills. They were sent away to a kind of interpersonal-skills boot camp where they spent an intense two weeks learning interviewing techniques, shadowing other contact tracers and interviewing people themselves under close supervision. Their success in the field was then closely monitored in terms of numbers of cases reached and contacts generated, as well as how many contacts got tested and treated.
An informal survey of coronavirus contact tracing programs across the country revealed that none had settled on definite metrics of success. “We are looking for a set of various measures,” said Dr. Umair Shah, the executive director of Harris County Public Health in Texas, which serves Houston and the surrounding area. “But ultimately the juice is worth the squeeze — if you’re only reaching 5 percent of the people, at some point you have to ask why and decide maybe this is not the tool we should use.”An informal survey of coronavirus contact tracing programs across the country revealed that none had settled on definite metrics of success. “We are looking for a set of various measures,” said Dr. Umair Shah, the executive director of Harris County Public Health in Texas, which serves Houston and the surrounding area. “But ultimately the juice is worth the squeeze — if you’re only reaching 5 percent of the people, at some point you have to ask why and decide maybe this is not the tool we should use.”
This brings us back to getting people to pick up the phone, on which so much depends. Some health authorities are sending text messages first, encouraging people to answer, while others are working on social media campaigns and radio jingles to raise awareness and improve participation. It recalls P.H.A.s in the 1950s driving around the countryside broadcasting songs about syphilis over loudspeakers. They passed out comic books about venereal disease with titles like “Little Willie” and “That Ignorant Cowboy” and gave out free samples of Dentyne chewing gum to anyone who got tested.This brings us back to getting people to pick up the phone, on which so much depends. Some health authorities are sending text messages first, encouraging people to answer, while others are working on social media campaigns and radio jingles to raise awareness and improve participation. It recalls P.H.A.s in the 1950s driving around the countryside broadcasting songs about syphilis over loudspeakers. They passed out comic books about venereal disease with titles like “Little Willie” and “That Ignorant Cowboy” and gave out free samples of Dentyne chewing gum to anyone who got tested.
“It was a long time ago,” said Mr. Kingma, who, some 70 years after working as a P.H.A., can still make you want to tell him everything moments after getting on the phone with him. “But maybe some of the things we learned back then can be of use.”“It was a long time ago,” said Mr. Kingma, who, some 70 years after working as a P.H.A., can still make you want to tell him everything moments after getting on the phone with him. “But maybe some of the things we learned back then can be of use.”
Kate Murphy is a journalist in Houston who contributes frequently to The New York Times and the author of “You’re Not Listening: What You’re Missing and Why It Matters.”Kate Murphy is a journalist in Houston who contributes frequently to The New York Times and the author of “You’re Not Listening: What You’re Missing and Why It Matters.”
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