An NPR survey of state health departments shows that the national coronavirus contact tracing workforce has tripled in the past six weeks, from 11,142 workers to 37,110. Yet given their current case counts, only seven states and the District of Columbia are staffed to the level that public health researchers say is needed to contain outbreaks.
Contact tracers are public health workers who reach out to each new positive coronavirus case, track down their contacts, and connect both the sick person and those who were exposed with the services they need to be able to safely isolate themselves. This is an essential part of stamping out emerging outbreaks.
To understand how that picture had changed since NPR's initial contact tracing survey in late April, NPR reached out again to all state health departments, as well as Washington, D.C., and the U.S. territories. In total, NPR reporters were able to assemble data from all 50 states along with D.C., Guam and the Northern Mariana Islands.
Many states are still planning to hire more contact tracers, reassign existing government staff, or train outside volunteers. Some already have a bank of trained staff or volunteers in waiting, able to pivot to tracing contacts if new positive cases spike. Many of them are relying on the National Guard, AmeriCorps, volunteers or part-time workers to fill these ranks. With the plans to hire and reserve staff, the national workforce grows to 68,525 contact tracers.
"I think it's amazing that the workforce scale-up has gone this far in such a short period of time," says Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security and a lead author of the center's white paper on contact tracing capacity. "But I'm also — at the same time — concerned, because we're seeing these increases in case numbers in a lot of different states."
Tom Frieden, former director of the Centers for Disease Control and Prevention, agrees that NPR's survey shows some progress has been made, but that it's "not nearly enough and not nearly fast enough."
Public health experts say tracing the contacts of each positive case and asking them to quarantine is crucial for allowing communities to safely reopen — those who are sick or have been exposed stay home while the rest of the public begins to return to normal life. If communities don't have enough tracers to quickly call and investigate each positive case and to effectively follow up with contacts, that strategy to curb transmission falls apart.
In the U.S., many places are reopening before fully establishing the robust tracing system public health leaders were calling for months ago. "We're reopening before we have the system ready to stop cases from becoming clusters and clusters from becoming outbreaks," Frieden says.
How many tracers is enough?
To estimate how many tracers is enough for each state, NPR analyzed each state's current need based on the number of cases in each state over the past 14 days, using the Contact Tracing Workforce Estimator developed by the Fitzhugh Mullan Institute for Health Workforce Equity at The George Washington University.
The analysis assumes workers are calling 10 contacts per case and that contacts are followed up with every other day. Ten contacts may be a conservative estimate, considering that many places have begun to ease social distancing measures, and when people go out to restaurants or shopping, the number of contacts can grow quickly. The analysis also assumes that tracers reach 45% of contacts, since sometimes it's not possible to track people down — that's a midpoint of three strategies outlined in a contact tracing workforce tool recently published by the Centers for Disease Control and Prevention.
Those inputs are designed to represent the real-world challenges contact tracers might have in reaching all possible contacts. "It's hard to get a hold of people," says Watson. "There are many other factors that may make people unwilling or unable to do this, including its historic issues with trust in government [...] I do think any amount of contact tracing does help."
The results of NPR's analysis show that several states have enough contact tracers estimated to be needed to investigate their current burden of recent cases. Seven states — Alaska, Massachusetts, Montana, New York, Oregon, Vermont and West Virginia — along with Washington, D.C., and the territories of Guam and the Northern Mariana Islands, currently have enough tracers, given local transmission. Six more states — Colorado, Connecticut, Idaho, North Dakota, South Carolina and Washington — have enough when reserve staff are included in their staffing count. Thirty-seven states do not have enough contact tracers, according to NPR's analysis.
Still, many states indicated that they felt they did have enough tracers to reach out quickly. With 1,500 contact tracers, a spokesperson for the Florida Department of Health wrote to NPR, "This is successfully meeting the current operational demand, which is reassessed daily as additional cases are confirmed."
By NPR's analysis, Florida would need about three times the current number of contact tracers to be able to investigate and follow up with contacts for every coronavirus case. Florida is one of more than a dozen states where cases of COVID-19 are currently rising.
Every place is different. A county with only a few new coronavirus cases a week might be able to manage contact tracing with only a few staffers tracing part time. But with a highly infectious virus, that set-up is risky, public health experts warn. A spike can happen suddenly and get out of control without adequate contact tracing.
Testing is also critical. It's the first step in the test, trace and isolate strategy public health leaders have emphasized needs to be in place. If a community isn't testing enough, positive cases can't be identified and traced.
Piecing together a workforce
States cited a range of creative strategies to staff up. Some, such as New York, which has support from Bloomberg Philanthropies, have turned to private philanthropy to hire workers. Others have partnered with universities, bringing on graduate students to help. Others, such as California, are training and reassigning government workers who do other roles.
A number of states cited volunteers as part of their strategy for handling the workload, turning to service groups such as Americorps or signing up individuals willing to help. Michigan, for instance, has relied primarily on volunteers and hired a contractor to manage that workforce. They've signed up 9,500 people willing to help and have 422 volunteers currently making calls — "making contact with about 90 percent of all contacts within 24 hours," Lynn Suftin, public information officer for the Michigan Department of Health and Human Services, wrote to NPR.
Epidemiologist Abdul El-Sayed has been critical of Michigan for relying on volunteers. "What we're saying is — implicitly — we don't value this enough to pay for it," he says. "This is a place where you need the kind of accountability, you need the kind of sensitivity, and you need the kind of training a professional staff can give you."
And, he adds, with more than 40 million people filing for unemployment benefits, "it's not like we don't have the workforce available to employ."
A patchwork system
One reason it's hard for the U.S. to have a cohesive contact tracing strategy is that the public health system is a patchwork of different governance systems. In most states "the local health departments are independent of the state health department," explains Adriane Casalotti, chief of government and public affairs at the National Association of County and City Health Officials. Some states have completely centralized public health departments, and others are a mix of the two systems.
In many of these local health departments, a small team of public health workers do many different jobs and are now adding on coronavirus contact tracing. County staff in Wyoming, for instance, "do much of the work but have other responsibilities too so it's not a simple count of staff," Kim Deti of the Wyoming Department of Health wrote in an email to NPR. "I don't have a number for that."
However, in Montana, where public health departments are independent and local, the state public health department recently did a survey to figure out how many staff members there were across the state, and found a capacity of more than 500 who could turn to contact tracing if needed.
Candice Chen, a professor of health policy at George Washington University who worked on the Contact Tracing Workforce Estimator Tool, hopes other local control states follow Montana's lead and ask, "Can we do what Montana did? And that way, can we be prepared if we start to see cases in certain counties that hadn't seen cases?"
Another complexity: The task of contact tracing is usually broken out into several different roles, for which different degrees of expertise is required.
"The way that we think of it is it's this contact tracing system," explains Casalotti. There are the front-line workers making phone calls to investigate new cases and reach contacts. In addition, you need supervisors, and she says, "we also need epidemiologists — not just at the state level, but also at the local level — who can then take in the data in real time" to identify possible spikes.
A call for federal leadership
The total reported by states is far less than the more than 100,000 contact tracers some influential public health experts have called for.
Part of the reason for the gap is clearly a lack of funding. A group of former federal officials who wrote a letter to Congress calling for increased contact tracing support estimated that $12 billion in federal funding would be needed to pay for the hires. The HEROES Act, which passed the House last month, includes $75 billion for testing and contact tracing efforts but is not expected to pass in the Senate. It's not at all certain whether a new bipartisan relief bill would include federal funding specifically for contact tracers.
The CDC provides staff to support local contact tracing efforts. Director Robert Redfield told NPR in April that the agency has about 500 staff currently deployed to help state and local health departments and that it would support another 650 positions with $45 million from the CDC Foundation.
It's unclear how many of those hires have been made. In a statement, CDC spokesperson Scott Pauley told NPR that the "CDC's efforts to support state contact tracing are underway and hiring through the CDC Foundation continues," and Pauley pointed to the interim guidance and communications toolkit available on the CDC website.
Numerous public health leaders have called for more leadership — if not funding and staff — from the federal government to support state and local health departments' contact tracing efforts.
"We have needed a federal response on this from Day 1 and we haven't had one," says El-Sayed. "We need federal funding for contact tracers and we need it now."
"I hope that we can keep this at the top of our national agenda — to continue to increase our workforce and our commitment to doing contact tracing," Watson, of Johns Hopkins, says. With rising cases in many states and social distancing measures easing up, she says, "it's only going to become more challenging to do contact tracing going forward."
Rachel Cohen, Anh Gray, Aviva Okeson-Haberman, Caroline Kelly, Connie Hanzhang Jin, Natalie Krebs, Sean McMinn, Bram Sable-Smith, Ruth Talbot, Julia Wohl and Carmel Wroth contributed to this report.
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