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As Cases Rise, Counties Dial Back On Contact Tracing

Some counties have pared back on trying to trace every contact that someone with COVID-19 has had because they can’t keep up with the surge in cases.
Oregon Health & Science University staff collect samples of 600 people a day at two mobile testing sites in the Portland area. | OHSU
November 18, 2020

The spike in COVID19 cases is forcing Oregon counties to rethink their approach to contact tracing and pare back the mammoth undertaking as cases overwhelm workers. 

Some counties are asking people with COVID-19 to reach out to family and friends who may have been exposed. Other counties are no longer making daily calls to check the symptoms of people in quarantine who have not tested positive. Public health officials want to make all the contacts possible, but as cases grow, it’s a matter of resources and the need to focus them on populations that have the highest risk. 

When COVID-19 began spreading in Oregon, public health officials set up systems of contacting everyoe who came into contact with someone who had tested positive for COVID-19. Contact tracing is a basic tool used by epidemiologists to curtain the spread of an infection. This past spring, Gov. Kate Brown factored in each county’s ability to trace the network of possible infections in her decision on letting them open up. The purpose of contact tracing is to inform people who’ve been exposed to the virus but don’t have symptoms that they should self-quarantine while waiting for test results to prevent further spread of the disease. 

Now, the high number of cases -- near or above 1,000 a day statewide -- means that each new COVID-19 case may not get the attention it once did from public health teams. Many don’t have enough contact tracers to keep up. 

The strained system demonstrates how far and wide the virus has spread in communities. Health officials say contact tracing still has merit because people can go into quarantine to avoid spreading the virus. But health departments cannot keep up. Public health officials want people to notify their friends and family members after they get a positive test. They are partnering with community organizations to notify people. The patchwork of tools represents a new reality: COVID-19 notifications are no longer just a job for public health workers. They are everyone's responsibility. 

Each county’s ability to follow the web of new infections depends on its  resources and the number of new cases.

On Wednesday, the Oregon Health Authority reported nearly 1,100 new cases, bringing the state’s total to almost 60,000. Ten more Oregonians died, with a statewide total of 788 deaths. The new cases stretch from the urban core of Portland to rural eastern Oregon. There were 210 new cases in Multnomah County and 33 new cases in Malheur County.  Across the state, 406 COVID-19 patients were in hospitals, with nearly one-quarter of them in intensive care beds. 

To prevent more illnesses, counties use contact tracers. The process starts with an interview between a public health worker and a person who has tested positive for COVID-19. The workers try to identify other people who may have been exposed to ask them to get tested and self-quarantine while awaiting results. The interviews help contract tracers determine whether a person may have exposed others in a high-risk setting like a nursing home or other long-term care facility. More than half of the deaths from COVID-19 involved these residents. They are more susceptible to suffering serious complications from the virus because of their age or underlying health problems like diabetes or heart disease. 

The system usually helps to  curtail outbreaks. But state data show that many Oregon public health workers are falling behind on contacting each new person who tests positive. The state wants counties  to contact at least 95% of positive cases within 24 hours of receiving the test result. 

The statewide average falls well below that, with contact tracers reaching just 75% of positive cases within 24 hours. Some counties, however, still meet or exceed the state’s 95% threshold, while others fall well below it. Washington County is at 99%, while Multnomah and Clackamas counties are each below 60%.

The Oregon Health Authority has pared back its guidance for health departments as cases have mounted. Its current recommendations include prioritizing contacting high-risk individuals who may have been exposed, limiting interactions to a single interview and eliminating active monitoring of people who have been exposed to the virus and may test positive in the near future. The new recommendations are intended to direct resources to vulnerable populations. 

County approaches vary as public health officials look for ways to adjust during the current surge of cases. 

In Multnomah County, officials are urging people who test positive to notify their close contacts -- people who may have been exposed -- instead of waiting for the health department to call them. This gets people to start quarantine sooner and allows the health department to focus on contact tracing in high-risk settings like nursing homes and other facilities where people live together in the same facility. Other high-priority settings include addiction treatment centers, homeless shelters and other places where people gather and live.

“It accelerated very rapidly over the last two weeks, and we have not been able to keep up with all of the cases that needed interviewing,” Kim Toevs, Multnomah County’s head of communicable diseases told The Lund Report. The county wants people who test positive to  contact others who were within six feet of them for more than 15 minutes during the time they were likely infectious, which might be two days before symptoms appeared. Researchers have determined that it takes about 15 minutes being close to someone to become infected. 

“We will eventually likely reach them,” said county spokeswoman Julie Sullivan Springhetti of newly diagnosed cases. “But because of systemic delays, it may take more than a day or two, and time is of the essence when someone has been exposed.” 

Public health teams ask people with COVID-19 about who they may have infected and how to notify those individuals.

Like other counties, Multnomah County officials knew that cases would eventually overwhelm their contact tracers. 

“We knew since February that at some point we would probably have enough cases during a pandemic that it would probably outstrip our capacity,” Toevs  said. 

‘Washington County, however, is reaching 99% of people with COVID-19 within 24 hours, state data show.

Washington County epidemiologist Kimberly Repp said the county is no longer doing daily calls to people who came into close contact with COVID-19 cases to monitor their symptoms.  

“We’re still calling the contacts,” Repp said. “We’re still advising them, but we will not be calling them every day for two weeks to check on their temperature.”

The county is struggling to keep up with cases, and it is asking people who test positive to notify their friends and family who may have come in contact with them. 

Washington County has bulked up its workforce like other health departments. Before the pandemic, the county had about eight to 10 people in its disease prevention department. 

Now, the county has a workforce of more than 150 that works on  contact tracing and investigates cases with some officials focusing on outbreaks in  nursing homes, long-term care facilities and other residential facilities. Workers also help people in quarantine access support services.

Umatilla County, which was hit hard with cases this summer and is experiencing another surge,  has continued to reach out to people who may have been exposed to COVID-19, said Joseph Fiumara Jr., the county’s public health director. The county has a team of professionals that makes the initial contact with people who’ve been recently tested positive for the virus. The county depends on  community organizations to make daily checks on people who are in self-quarantine because they’ve been exposed but have not tested positive yet. 

The county was in a different situation in July, when Umatilla County had so many cases that it had to prioritize contacts.
“As busy as we are right now, we’re still at about half of what we’re seeing in July,” Fiumara said. “For us, we’ve gone through that bit.”

In Washington state, health officials are taking similar steps. Clark County recently changed its response to recently identified cases. County officials no longer identifies, notifies and monitors close contacts of confirmed cases. Instead,  the county is focusing on interviewing everyone who tests positive to determine whether there were exposures at schools, long-term care facilities, the jail and food processing plants. 

The changes will allow the county to more quickly interview cases, ensure they are isolated while contagious, and identify priority locations, said Dr. Alan Melnick, Clark County’s public health director. 

In an interview with The Lund Report, he said resources are stretched thin amid the current surge. In the last four weeks, the county has had 2,000 new cases, with an average of more than 100 new cases each day.  On Monday, 277 people tested positive for the virus.

“The bottom line is that our staff are getting further and further behind,” Melnick said.

You can reach Ben Botkin at [email protected] or via Twitter @BenBotkin1.