‘The State We’re In’: Contact tracing in NH, a Q&A with 2 epidemiologists

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Contact Tracing

Cases of Covid-19 are rising in states across the country, and New Hampshire is no exception; there is new evidence of increasing community transmission in the region. New Hampshire’s two largest cities, Manchester and Nashua, are both experiencing this rise in community transmission. Additionally, a smattering of schools and sports teams are also seeing clusters of the virus pop up.

One of the keys to mitigating spread quickly is contact tracing. Dr. Elizabeth Daly, Chief of the Bureau of Infectious Disease Control at the New Hampshire Department of Health and Human Services, and Angela Consentino, Epidemiologist for the City of Nashua’s Division of Public Health and Community Services, are here with The State We’re In host Melanie Plenda to explain what it is and how it works.

Watch the 30-minute video above, or read the program transcript below:

Dr. Elizabeth Daly: Contact tracing is actually a public health approach to trying to mitigate the spread of infectious diseases. That goes back in public health practice well before COVID-19 started, so we routinely use this practice to identify close contacts of individuals with infectious diseases. We do it for tuberculosis, we do it for sexually transmitted disease investigations, and diseases like pertussis or whooping cough, this practice goes very far back in the history of public health practice. It’s an effective approach to trying to mitigate the spread of those diseases that are spread from person to person.

For COVID-19 obviously we’ve had to ramp-up the type of contact tracing that we do, we’ve never before had to do this amount of contact tracing for any infectious disease in at least recent history, but we’re using a lot of the same principles and practices that we have been using. The other thing that’s different now too, is just our access to technology and that being able to assist us with our contact tracing efforts that we maybe we didn’t have in the past either.

What contact tracing entails is whenever there is an infectious disease reported to us, in this case COVID-19, we interview that individual to identify who they came into close contact with. For COVID-19 specifically, we’re looking at anyone they had contact with for more than 10 minutes and were within six-feet of that person during that time frame; and that’s a cumulative of 10 minutes. Obviously the more that you’re around someone, the greater your risk increases. We’re looking at the time that we believe that person was infectious. We look at the two days before their symptoms started, or the two days before they tested positive, and then any time that they were out in public while they had symptoms as well.

Of course, we hope people weren’t out in public while they were experiencing symptoms, but we do identify that period of interest for us and then ask them about who they came into contact with. Where did they go? Did they participate in any activities or attend school? Then those individuals who are identified as close contacts are notified about their potential exposure and advised to quarantine in the case of COVID-19 and get tested.

Melanie Plenda: How are you using technology to help you with that job?

Dr. Elizabeth Daly: We’ve set up a contact tracing system that assists our practice and helps us be more efficient in our work. In this situation in New Hampshire, it’s a business system that allows us to queue up individuals who require calls because our call volume is incredibly high right now. We’re investigating almost a hundred cases every day, and then there are hundreds more of those close contacts we have to call to notify. In order to maintain our operation of over a hundred people working on contact tracing, this system allows us to enter their information in a secure system and then queue up those calls.

If you’re a contact tracer, you’re sitting in our response location at your computer and you log in to the system, see who the next person is who needs to get a call, and then call that individual with whatever information, whether it’s an investigation to do or a notification to do. That technology has been really helpful to us in terms of queuing up those calls rather than using a paper or manual system of doing that. It also allows us to monitor our volume and how we’re doing in terms of making those timely notifications.

Melanie Plenda: Let’s talk a little bit about the contract tracers themselves. About how many contact tracers are there in New Hampshire? Who are they, and how do you go about recruiting them and training them?

Dr. Elizabeth Daly: Our regular staffing at the health department around investigations like this is small. We have 10 or so public health nurses or other disease investigators who can do this work, so initially, during the response, we pulled in other individuals from across the division of public health services, and then more broadly across the department of health and human services in order to train those individuals to do this work.

As we continued to experience more cases, we started to bring on contracted staff and then even the National Guard, and the National Guard helped us out through our surge in April, May, and into June. Eventually, we let them go as our case counts declined over the summer and we didn’t need that staffing. Now we’ve actually brought the National Guard back on board to assist us again, so we’ve been able to maintain this robust flexibility in order to increase our number of contact tracers and then decrease them as needed as well. Right now we have over a hundred individuals, maybe close to 120 or so as of today who are doing this work at the state health department. The state health department is responsible for all of the individuals in our state, outside of Manchester and Nashua, and then the cities of Manchester and Nashua have their own health departments who work in partnership with us and under the same protocols to do the investigations and contact tracing for the individuals who live in their respective communities.

Melanie Plenda: As we move into the colder weather and we see spikes in certain areas of the state, are we going to have enough contact tracers to handle the rise in cases? Are you looking ahead again to see where you might need to bring in more people like out of that pool you were just talking about it? Is that enough, even if our cases continue to get higher?

Dr. Elizabeth Daly: We’ve had the ability to expand and contract as needed, so we do have the ability to continue to bring on more contact tracing staff who are contracted or through the national guard to be able to support the work going forward. We have seen an increase in additional cases now and we know that some of this transmission has been limited by the effective protocols and procedures that are in place. A lot of our congregate settings like schools have put into practice the distancing within the classrooms and mask use, and all those things help us to keep our case counts low. We haven’t had many clusters in those settings so we hope our case counts won’t further increase, but if they do we’re certainly prepared to be able to onboard additional contact tracers as needed.

Melanie Plenda: According to the New Hampshire Health Commissioner, the emergence and increased use of rapid tests has caused delays with contact tracing. Can you talk us through that? Why is this?

Dr. Elizabeth Daly: We’re excited about the opportunity to have increased access to testing in our state, and that includes those antigen tests that are now available. The issue of the antigen tests is that they are “point of care,” which means that they’re delivered and performed at the bedside of the patient or wherever the patient presents for testing, so the test results then are not coming from a laboratory that already has established communication pathways with our health department.

For PCR testing, for example, many of the laboratories that are doing that testing have an automated data exchange in place where those test results get automatically reported to us from their own electronic system to our electronic system, and that’s been very helpful in timely investigations. For these point-of-care tests where it’s literally a healthcare provider doing this testing right there in the setting, those test results do not automatically come to us. We’ve done a lot of outreach to our healthcare providers who are doing this testing to just remind them that there is no automated reporting of those test results.

It’s really incumbent upon them to report those cases to us so we can follow-up on them in a very timely manner. In fact, we’ve had people call us and say, “Hey, I tested positive a few days ago and nobody’s reached out to me yet.” People assume that that’s a failure of the state health department, but actually that test result has not been reported to us yet. We can’t respond to it if we don’t know about it, so we really need those providers doing that rapid testing to report those test results to us. We recently just rolled out a system for them to do that electronically on our website; they can actually go online and report those test results to us. Hopefully, that will help with that reporting so that they’re not just hand-filling out a case report form and sending it to us. 

Melanie Plenda: Going back to the process of the actual contact tracing, I know I’ve heard anecdotally, even in national stories, where they talk about some people are reluctant to give the names of the people that they’ve been in contact with because that might mean that that person then has to quarantine for 14 days, or they’re just concerned about privacy, or things have been politicized and they just don’t want to talk with authority. Has this been an issue at all here? If so, how do you address those challenges? Do you ever have to go out into the communities to personally talk to people? How does that work?

Dr. Elizabeth Daly: Early on in the response, we had very little pushback from individuals. People recognized that we were in a pandemic, people were afraid to become infected, and a lot of people took to heart the guidance to stay at home and to do the isolation and quarantine as we recommended. Now, isolation is for people who have the disease, and they generally isolate for 10 days. Quarantine is if you don’t have the disease, but you’ve been exposed, and then you need to stay at home for 14 days because that’s a potential period of time that you can develop symptoms or test positive after you’ve had an exposure.

Initially early on, people were willing to do that, but now that we’ve been in this pandemic for many months, people are fatigued. They don’t want to stay at home anymore and we are seeing more pushback on quarantine in particular. I think most people still understand they need to stay home if they have COVID-19, but if you’ve had that exposure, it’s really inconvenient to stay home. There’s personal and professional implications, financial implications, and we absolutely understand all of that, but we’re in a really unusual circumstance right now. We’re in a pandemic. We have concerns about our vulnerable populations becoming hospitalized and dying, so it’s really incumbent upon all of us to make sure that we’re taking precautions and following the quarantine guidance when we provide it to people who have been exposed.

Now, a lot of times people are just caught off guard or have an initial shock when they learn that they have been exposed, so sometimes it’s just a matter of working through that person, letting that initial shock, kind of wear in, calling them back a few hours later to check in with them again, and in the vast majority of the time we’re able to get people to voluntarily comply with the quarantine that we’re asking them to take. It just might take a couple of different people talking to them, the time for the news to set in and to think about how they can make this work in their life.

Most people very rarely are we having to take legal action to issue isolation or quarantine orders. We do have that ability in New Hampshire to take that next step, though, if we need to, for someone who’s not going to follow the rules. First, we’ll visit them at their homes to follow up with them, talk to them in person, make sure that they’re staying at home like we’ve asked them to do. If we’re not able to get them to voluntarily agree to do it, we will issue a legal order that requires them to do it by law and can be enforced by law enforcement. We don’t like to take that measure, and usually, we’re able to talk through that with an individual to help them see why it’s important for them to do that isolation or that quarantine.

Melanie Plenda: What’s the legal remedy there? What is the consequence if someone does violate that order?

Dr. Elizabeth Daly: If you’re not staying at home and you’re required to, we can appoint a location for you to serve out that isolation and quarantine period to protect others around you from you being out in the environment or going to work or whatever it is that you feel like you need to do. Sometimes it’s a matter of people feeling like they don’t have resources to carry out the quarantine, like they don’t have someone to bring them food, and those types of issues we’ll absolutely work through with the individual, make sure that they can access medication and food and all the things that they need to access while they’re on quarantine.

Melanie Plenda: With in-person classes and school sports, children are having close contact. Can you talk us through how the state is working when it comes to contact tracing in schools? Is it any different than the normal process, or are you working individually with schools?

Dr. Elizabeth Daly: Whenever we identify someone who has been present while infectious in any congregate setting, whether it’s a workplace, long-term care facility, or school, we reach out to that organization to let them know that they’ve had a case in that environment and then ask them to help identify any close contacts because, of course, they know their environment best. They know if people are practicing social distancing and how they have those layouts set up. Schools for example, they know are they three feet away or six feet away? Is everybody wearing masks? Who do we think has come into contact with the individual who now has COVID-19? They are our partners in doing this contact tracing. We work very closely with the schools to do the work, and they’re part of the team in helping to identify who those close contacts are.

Then we still carry out our function of also collecting close contact information for people outside of that setting with the individual, like people who have been in multiple settings: they have home contacts, friends and family contacts, and then they also have contacts in the school. It’s really looking all around that individual to identify the close contacts and when we’re doing it in the congregate setting, we do that in partnership with the organization.

I think it’s important if I may just mention confidentiality because I wanted to address this when I answered the contact tracing process and notification of people. When we notify close contacts that they have been exposed to someone with COVID-19, we do not tell them who they were exposed to. We hold that information confidentially, so I think that part of the frustration of getting a quarantine notification is because we’re not able to tell you exactly who it is you were exposed to. In some cases, that’s the hard part for people to accept, that they have to trust us with this information. In terms of the person who has COVID-19 sharing that information with us, they can be assured that we don’t tell other individuals that they have COVID-19 or who the person came into contact with is in the case of these congregate settings.

However, we are able to share information with employers, for example, that someone has COVID-19 for the purposes of excluding that person for work or doing that contact investigation. They in turn are required by law to hold that information confidentially. They can’t share that with anyone else, and they just need to use that information to help us do our work.

Melanie Plenda: Finally, is there anything else that the public should know about contact tracing, or just COVID as we head into fall and winter?

Dr. Elizabeth Daly: We want people to answer our phone calls so that we can work with them if they have COVID-19 or if they’ve been exposed. We want them to know that so they can take the right precautions and protect the people around them from getting COVID-19. This is a very effective strategy in limiting further spread of COVID-19, and we want people to answer the call and take our requests very, very seriously and know that while it might not seem necessary to them, or they don’t feel like they’re going to develop COVID-19, the reason why we’re asking them to do this is to prevent other people from getting COVID-19. You have to think bigger than yourself and what’s right for you and your family, and think about our broader community at large, because the only way we’re going to come out of this is to prevent further transmission and quarantine is an effective way to do that.

Many people who go on to develop COVID-19 when we interview them, they say, “Well, I was exposed and I’ve been in quarantine, so I haven’t exposed anyone else.” We love those calls when someone tests positive, when we call them up and we find out that they were sticking to their quarantine and didn’t expose anyone else.

Melanie Plenda: Thank you Dr. Elizabeth Daley, Chief of the Bureau of Infectious Disease Control at New Hampshire Department of Health and Human Services. Joining us now is Angela Constantino, Epidemiologist for the city of Nashville’s Division of Public Health and Community Services. From what we understand, there’s community spread in Nashua and Manchester. Can you explain what that means exactly?

Angela Consentino: Community spread is determined by three metrics set by the state: new cases per day, hospitalizations, and percent positivity rate. In Nashua, we’re exceeding one of three of those indicators, and that is the number of new cases per day per a hundred thousand over the past two weeks.

Melanie Plenda: How did this happen in Nashua? Was it related at all to contact tracing or challenges that exist with contract tracing?

Angela Consentino: We’ve been keeping track of all our new cases per day, all of our numbers throughout the whole pandemic. We had sort of a wall over the summer where we had less cases and less contacts, but then at the end of August, beginning of September, things really started to pick up for us in Nashua. It was a slow pickup at first and then over the past three weeks, we really started to see an increase, and our numbers got up to where they had been back in May. We think that with the cooler weather and activities moving indoors and people doing indoor dining that the opportunity for infection increased, and then we started to see more cases.

Melanie Plenda: Once there is community spread, is contact tracing still effective and how does it work? Do you have to do it any differently when there’s more cases, for example?

Angela Consentino: We’re still doing contact tracing. Now we just have more hands in the pot; we need more people to help with contact tracing because there are so many more contacts for every case. It’s still important to keep those people at home and not going to the grocery store or other community spaces because that’s just going to increase the number of cases that you have. It’s important for the context of cases to stay home for the 14 days, so that’s why we’re continuing the contact tracing, especially now when we’re seeing such mild illness. We’re seeing people with just a tickle in their throat or something that they thought was allergies, so them staying home and not going to work with a little tickle or a little bit of allergies will really prevent illness in the long run.

Melanie Plenda: We were speaking with Dr. Daley from DHHS about the reluctance of some people to participate in contact tracing, sometimes out of fear that the people they’ve mentioned may have to quarantine or miss work, or even just the basic mistrust they may have of government officials asking personal questions. Are you seeing that in Nashua? And if so, talk us through how you address that challenge. How do you build that trust and get the information that you need?

Angela Consentino: We do see a little bit of that. The most important thing is we just need to get that original contact with the person, because then we can build a relationship with them and start to gain their trust. When we make that first contact with the case, then we start to develop a relationship with the case, and it’s important to be a person that is there for them. A lot of people who are diagnosed with COVID are scared, or they don’t know what’s going on and they don’t know what they should do, and they don’t know who to tell that they have COVID, so it’s nice to be a resource for those people and to be able to talk them through a difficult experience.

People really are looking for advice; they want to know who of their family needs to be quarantined and for how long. With the household members of that person, it’s easier to develop a relationship because they live in the home with the case so they already know that the person’s positive. We can talk them through any questions that they have, and we call them every other day to check on their symptoms, so we kind of developed a relationship that way. The same thing with the non-household contacts, we just check in regularly and try to alleviate any fears that the person may have and also try to offer all the benefits that we have. If they need help going into the grocery store, the United Way has a shopping program so we can offer that for them. If they need medications or if they need us to contact our welfare department, we can do all those things. We try to be a hub of resources for the family that’s experiencing quarantine or isolation.

Melanie Plenda: In terms of contact tracers, who are they and how many do you have? Do you have enough now that you’re seeing a spike and especially heading into what could be a really rough winter for folks?

Angela Consentino: Our contact tracers, the other people that do the disease investigations and the original contacts with the family and the contacts. That person is typically a public health nurse, or myself or someone else at the division. Then we have contact monitors, those people that call the family every couple of days to check-in and see how they’re doing, check their symptoms, and those people are either support staff from community health, or we also are utilizing our other departments. We have four departments at the division so we can utilize folks from those departments to help with the contact monitoring. Now that we’re starting to see an uptake in cases, we’re looking at where we can pull people from out of the divisions to help with disease investigation, contact tracing, and contact monitoring. We had an all hands on deck approach back in the spring, and we’re looking at doing that same sort of model now.

Melanie Plenda: How many folks did you need in the spring? Do you think that that’s how many you’ll need now, or will you need more going into the winter?

Angela Consentino: In the spring we had our whole division, so we had, give or take, 30 individuals, then we also had volunteers. We were utilizing all those folks, and not everybody was doing contact monitoring and disease investigation and contact tracing. We also have a lot of other COVID activities: we have our testing clinic, we have our COVID-19 hotline, and we have a communications team that puts out information for the media and Facebook and social media. Back in the spring, we were all doing COVID, and we’re at the point where we’re still maintaining our other services, so we haven’t been hit as hard as we were in the spring yet. In the event that we do get hit that hard, we will return back to all being COVID.

Melanie Plenda: With where we are in the pandemic, from a public health standpoint, what’s the biggest challenge in educating people and getting the word out? What are you seeing are the biggest challenges? What are people not doing that they should be? 

Angela Consentino: I think the biggest thing is people who are going to work or school or to their family’s homes with just allergy symptoms or mild illness, because when that person goes to work with something that they thought was a cold they expose however many people they worked with – which could be an awful lot of people –  then we have to go ahead and make those calls to those individuals. It makes more work in the long run and it also creates more cases in the long run. I think the biggest challenge is getting people to stay home when they’re sick, and understanding that we’re coming into the flu season where colds are increasing. Even if it is a cold, even if it is the flu, we still have to stay home because it could be COVID.

Melanie Plenda: Is there anything else that we haven’t talked about that you’d like people to know about contact tracing or COVID heading into flu season that would help?

Angela Consentino: I think that it would help if people knew that we’re not out to get anybody, we’re not here to make people’s lives more difficult. We’re here to be a resource for people and we’re here to help them through a difficult time. It makes people feel better to be able to talk to us because they know that someone is on their side, especially when people have issues with employers or issues getting paid time off. It’s nice to have us at the health department to be able to be that liaison for them and help them out. I just want people to know that we’re nice at the health department, we have me and other public health nurses, and we’re just trying to help.

These articles are being shared by partners in The Granite State News Collaborative. For more information visit collaborativenh.org.