Was San Diego County's contact tracing program worth the effort?
Speaker 1: (00:00)
San Diego county has contacted tracing program was envisioned as a pillar in the fight to stop the spread of COVID-19. The idea was to identify people who had been exposed to COVID-19 and notify them. So they could quarantine KPBS, investigative reporter, Claire Traeger, sir, looks into how the county's program actually worked.
Speaker 2: (00:22)
It was the early days of the pandemic and Jessica wanted to do something, anything to help. So she jumped at the chance to be a case investigator for San Diego counties, contact tracing program.
Speaker 3: (00:34)
It was a pretty steep learning curve Weaver thrown into, um, into the mix within just a few days of training. But, um, after a few days of pretty rigorous training, um, I would say that I caught on pretty quickly.
Speaker 2: (00:54)
KPBS is not using Jessica's real name and has distorted her voice to protect her livelihood. She is part of a contact tracing program that at one point employed nearly 1000 people and has so far cost the county millions, despite this commitment, it became clear within months that it wasn't nearly enough to stop the spread during the summer surge of 2020, just 11% of people with COVID-19 were being contacted by a case investigator within a day, far short of the county's goal of 70%. Now more than 18 months into the pandemic experts are looking back on the program to examine how it could have been changed, to be more effective. Rebecca fielding Miller is an epidemiologist at UC San Diego
Speaker 4: (01:42)
Contact tracing is the most useful when you think of it as putting out flare ups rather than dealing with a wildfire. Um, so in the very beginning, um, February, March, April, um, yeah, it was really important to catch those flare ups as quickly
Speaker 2: (02:07)
Because we could county officials would not agree to be interviewed for this story, but county spokesman, Michael Workman insisted in emailed responses to questions that the program is worthwhile still. He acknowledged that even now the county is only able to reach an interview about 50% of people exposed. Jessica feels her work has made a difference, but the job has taken a significant toll on her mental health, especially since the COVID vaccine became available and the virus became even more politicized. People will scream at her and tell her she can't control them. And that COVID is a myth.
Speaker 3: (02:48)
There are folks who just don't want that information or potentially are going out into the community after perhaps they've tested positive or have been exposed, knowing that they are potentially probably exposing other people.
Speaker 2: (03:10)
Then another setback as vaccination rates increased and case counts decreased in the spring and early summer, the county cut back its contact tracing staff by nearly half then as the Delta variant surged, the county tried to hire back the contract tracers who'd been laid off cases will likely surge again over the holiday season, but in 2022 and beyond, as COVID becomes endemic, not a pandemic contact tracing will prove, especially useful. So says fielding Miller, the epidemiologist,
Speaker 4: (03:45)
The wildfire analogy. We will be more in a place where we're keeping our eye out for hotspots. The quicker you can stop a hotspot from spreading the better off everybody is going to be.
Speaker 2: (03:57)
Meanwhile for Jessica, the heartbreak continue
Speaker 3: (04:00)
The news. I just had someone call me yesterday asking me if the county could help in any way. Um, because she was going to miss 10 days of work and her employer was not providing any kind of sick pay for her,
Speaker 2: (04:16)
Right? The stress she will keep working as long as she's needed.
Speaker 1: (04:22)
Joining me is KPBS investigative reporter, Claire Tresor and Claire. Welcome. Thank you. Now, last year COVID testing was more difficult to get and took longer to get results than it does now. So how did that affect the contact tracing program?
Speaker 2: (04:37)
Right. Well, first of all, you just didn't know necessarily, uh, whether you were positive or not. I mean, if we think back to, it's hard to remember, but back in March and April, 2020, and people were getting sick and they just weren't able to get a test necessarily, um, you had to have pretty severe symptoms. Um, and so then people weren't testing positive and therefore weren't getting calls from contact tracers and contact tracers. Weren't reaching out to the people that they had close contact with. And then the other thing is just that if you got a call from a contact tracer saying, you know, someone you've been in close contact with has tested positive, there weren't necessarily tests available for you then to go out and see, uh, if you had picked up the virus from that person. And when
Speaker 1: (05:25)
I didn't test positive for COVID during the height of the pandemic, were there obstacles that got in the way of getting those contacts traced,
Speaker 2: (05:33)
Right? Yes. So as we said in the story early on, when there weren't as many people who were testing positive, they were doing okay, because the goal was always just that they would start a case investigation within 24 hours of someone testing positive. Um, so that means, you know, getting them on the phone and going through the list of who they'd been in close contact with, but then they reopened, you know, lifted stay-at-home orders. Restaurants were open, people were back out and we had that first real surge in summer 2020, the case investigators and contact tracers were just overwhelmed. The number of new cases, they were able to start within 24 hours dropped to 11%. So they basically just did not have enough people to be calling all of the people who had tested positive and doing that thorough interview with them. Uh, Rebecca fielding Miller, the D epidemiologist mentioned that in Asian countries like China or Taiwan, where they were really doing serious contact tracing, they just had thousands and thousands more contact tracers working, uh, than we did in the United States to be able to keep up with everything.
Speaker 1: (06:43)
Can you remind us Claire, how contact tracing works? In other words, what does the tracer ask the person who tests positive?
Speaker 2: (06:51)
Right. So you get this call, um, if you have tested positive and they, they go through, you know, everything that you have done, basically in the last two weeks, what stores you have visited, you know, whether you've been out to eat, whether you've gone into work, gone into the office, um, and then, you know, who you live with, who else you might've been in close contact with? And I think the definition was always that you'd spent 15 minutes or more with a person. So you would really try and remember everything that you'd done, um, so that they could collect all of those business names and then, uh, collect all the names and contact information. If you had it, of people that you had been in close contact with,
Speaker 1: (07:34)
And then what do they do with that information? What do they tell the people on the other end?
Speaker 2: (07:38)
Right. So, so that's the role of the case investigator who goes through someone who is a case who's a positive case. And then they pass those contacts on to the contact tracers who then reach out and say, um, you know, someone you've been in close contact with has tested positive for COVID. And so you are now, um, required, or we're asking you to, uh, stay home for the next two weeks to quarantine and, you know, get tested, monitor your symptoms, uh, things like that. So the idea is to stop those people from then, if they go on to test positive from spreading the virus further. And is
Speaker 1: (08:16)
The contact tracing program still going on now?
Speaker 2: (08:19)
Yes. Yes it is. Um, they decrease, they cut in half the number of contact tracers they had after, um, vaccines became more widely, widely available. And we started to see cases drop, but then, uh, the Delta variant emerged and cases went back up and they tried to hire people back. And so, yeah, it's, it's still going on. In fact, about a month ago, I got a call from a contact tracer because, uh, someone in my son's class had tested positive. Of course I already knew from the school, but, uh, she did call and told me to that my son needed to quarantine for two weeks, which we already knew that as well. But that's, that's how the call goes, I guess.
Speaker 1: (09:03)
And this angry pushback that Jessica in your story says that she's getting, has that increased?
Speaker 2: (09:09)
Yes. She says that, um, that it's just become a whole different world. Um, early on people were really, you know, thankful and grateful for the information. They were scared, you know, they didn't know what was happening. And she says, now a lot of the calls she gets are people who are just refusing to cooperate with her. They won't give out the contact information of anyone they've been in close contact with. They say, I'm not staying home. You know, COVID is a myth. The government can't control me, things like that. And, you know, yelling at her. And so it's just, it's become a whole different ball game. She says,
Speaker 1: (09:47)
You know, it's surprising that Dr. Fielding Miller says when COVID changes from a pandemic to an endemic virus, then contact tracing will be most valuable. Can you explain why? Yeah,
Speaker 2: (09:59)
I think the idea is that contact tracing really only works when you can kind of keep on top of the number of cases. So when there's just, you know, rampant spread and people everywhere are testing positive, you know, it's kind of useless, I guess, in some ways to be trying to call everyone and trace the cases, but when it's become less of a common thing that fewer, hopefully fewer people will be having it, then it really does make sense to say, okay, you know, this isolated person has tested positive. Let's get in touch with all of their close contacts and, you know, try and stop the spread that way. When it's something that's more of a rare virus.
Speaker 1: (10:42)
And does the county believe enough contact tracers are in place now in case there is an uptick in COVID cases over the holidays?
Speaker 2: (10:50)
Well, you know, as I said in the story, um, they wouldn't make anyone available to do an interview with me. Um, I think that they would say, you know, that as they hired people back after the summer, that they have been able to stay on top of cases and that, you know, hopefully they would have that ability to further increase their staffing if they needed to. Um, if cases do go up over the whole,
Speaker 1: (11:16)
I've been speaking with KPBS, investigative reporter, Claire Tresor and Claire. Thank you so much. Thank you.
It was the early days of the pandemic and Jessica wanted to do something, anything, to help. So she jumped at the chance to be a case investigator for San Diego County’s contact tracing program.
The county was following the lead of health departments around the world in establishing systems to identify people who had been exposed to COVID-19 and notify them as part of the overall effort to prevent outbreaks. Jessica (KPBS is not using her real name to protect her livelihood) had no experience in such work but was willing to learn.
“It was a pretty steep learning curve, we were thrown into the mix within just a few days of training,” she said. “But after a few days of pretty rigorous training, I would say that I caught on pretty quickly.”
The county spent millions on the program, eventually hiring upwards of 1,000 people. But within months it became clear that it wasn’t enough. In July 2020 during the initial surge, just 11% of people with COVID-19 were being contacted by a case investigator within 24 hours — far short of the county’s goal of 70%.
Now, more than 18 months after the start of the pandemic, experts are looking back on the program to examine how it could have been changed to be more effective. Contact tracers would not agree to be interviewed for this story, but county spokesman Michael Workman insisted in emailed responses to questions that the program is worthwhile.
“The county is able to reach and interview about 50% of the cases and close contacts,” he said. “There are several indicators that are tracked across California counties which indicate that San Diego is experiencing better ... contact tracing outcomes and with case rates, death rates and hospitalization and vaccination rates.”
Health experts widely agree that contact tracing programs should continue to play a role in fighting COVID-19 and future pandemics, but one local epidemiologist said the county will need a more robust approach if COVID-19 surges again, or if another pandemic emerges.
“Contact tracing is the most useful for putting out flare ups rather than dealing with a wildfire.”Rebecca Fielding-Miller, epidemiologist at UC San Diego
“Contact tracing is the most useful for putting out flare ups rather than dealing with a wildfire,” said Rebecca Fielding-Miller, an epidemiologist at UC San Diego. “So in the very beginning, it was really important to catch those flare ups as quickly as we could, but testing was so hard to get ... Then when we got into the peak of the virus, we could not tamp down that wildfire with contact tracing.”
Still, Fielding-Miller said, any program that helps stem the spread, even in small measures, has value.
“At least some people did not go to Thanksgiving when they were told they were exposed to COVID,” she said. “But on a broader public health level, trying to use individual phone calls in that massive spread is like using a hand screwdriver instead of a really powerful tool.”
Jessica feels her work has made a difference. But the job has taken a significant toll on her mental health as the pandemic became more and more politicized after the COVID-19 vaccine became available early this year. People who earlier in the pandemic might have simply been dismissive of her now will scream at her and tell her she can’t control them, and that COVID-19 is a myth.
“So it can feel like a Sisyphean task at times when there are folks who just don't want that information or potentially are going out into the community after perhaps they've tested positive or have been exposed, knowing that they are potentially exposing other people to this virus,” Jessica said. “Knowing that there are some people who don't stop to think about how that can be affecting other people in their own community, it's a heartbreaker.”
A revolving door
As vaccination rates increased and case counts decreased in the spring and early summer, the county cut back its contact tracing staff. The number of contact tracers went from 203 in June 2021 to 101 in July 2021, while the COVID-19 disease response investigation team went from 924 to 738.
“In June, a weekly incremental demobilization process was occurring resulting in the ending of assignments for the temporary staff,” said Workman, the county’s spokesman. “Staff were given two week’s notice before their assignments came to a close.”
But that cutback was short-lived. As the delta variant surged, the county tried to hire back the contact tracers who’d been laid off.
“When the delta surge started its upward trend in the summer, the county put a pause on the demobilization process for several weeks watching to see how steep the surge would go,” said Workman. “As the delta surge continued upward across California and in San Diego County, the county began to remobilize staff who were demobilized in recent months.”
By the beginning of September, the county was back to 163 contact tracers.
Big spending on FedEx
One thing that surprised Jessica was the county’s heavy use of FedEx. When a case didn’t have an email address, she would send the person a letter via FedEx telling them to isolate and quarantine.
“It's shocking to many of us working on this project that those letters are sent out through FedEx, which I believe is like maybe $11 or $12 a letter, to get it to them as quickly as possible, when we have the post office that could be doing the same service,” she said. “A lot of us are confused as to why a government agency is not also using another government agency to do this work, especially knowing the dire straits that the post office is in currently.”
Workman confirmed that from March 2020 through the end of July 2021, there were 45,057 letters sent out via FedEx at a total cost of more than $535,000.
“Each case and contact receives an isolation or quarantine letter. Most cases like to receive these by email. FedEx is used for those who prefer the delivery in paper or used for those for whom contact is not made after several attempts by phone or if a wrong phone number is received,” Workman said. “The benefit of FedEx is a more timely and trackable delivery.”
“The county did consider using (the U.S. Post Office) but given the nature of the seven day a week operations, need for timely and trackable delivery of information, FedEx was the choice for delivery,” he added.
However, other large California counties, including Los Angeles and San Francisco, didn’t use FedEx at all. Still, Workman defends the practice, saying it “highlighted the seriousness of this pandemic.”
More funding, more support next time
Fielding-Miller, the epidemiologist, said contact tracing can be successful. But it needs to be supplemented with other methods for controlling the virus spread, including stay at home orders and even paying people to stay home.
She predicts cases will surge again over the holiday season, but then in 2022, as COVID-19 becomes endemic, not a pandemic, contact tracing will prove especially useful.
“If we get to a place where COVID-19 is endemic, then think of the wildfire analogy, we will be keeping an eye out for hotspots, and the quicker we can stop a hotspot, the better everyone will be,” Fielding-Miller said.
Meanwhile, for Jessica the heartbreak continues.
“I just had someone call me yesterday asking me if the county could help in any way because she was going to miss 10 days of work and her employer was not providing any kind of sick pay for her,” she said.