Contact tracing remains inadequate in most states
At this point in the unfolding coronavirus crisis, political leaders have been on notice for months that effective contact tracing will be critical to minimizing harm to human health and the national economy. With a vaccine or an effective therapeutic still months away, federal and state authorities must rely on traditional public health measures to limit the spread of the virus. That means identifying the COVID+ and their close contacts as quickly as possible so that they can be removed from public circulation. While there has been some progress in building capacity over the past three months, the overall condition of contact tracing nationwide remains very poor and bodes ill for what might transpire for the rest of the year.
There is ample evidence that contact tracing works. South Korea, Singapore, and Germany have demonstrated the ability to contain new infections by identifying potential cases based on their close proximity to a confirmed COVID+ individual. Without this tool, a country does not have the ability to limit outbreaks before they turn into uncontrollable epidemics.
A recent study modeled the effectiveness of contact tracing alongside other population-based strategies. It showed that a program relying on widespread testing and home isolation of positive cases and their families would lower the reproduction rate (R) by 37 percent. Using contact tracing to identify positive cases in places of work and schools would lower it further, by a combined 53 percent. And contact tracing that went beyond school and work to acquaintances and also used cell-phone based technology to identify additional potential cases would lower it by 66 percent compared to unchecked viral spread. Assuming an R of 2.5 as a baseline, a 66 percent reduction would ensure the epidemic would slow because each positive case would lead to less than one transmission.
In the U.S., there is widespread concern about the privacy of cell phone-based tracing. But even without its use, contact tracing can still be effective in reducing the transmission. It just means heavier reliance on person-to-person communication, which means larger numbers of contact tracing personnel.
There are various estimates of the size of an effective contact tracing workforce. The National Association of County and City Health Officials supports 15 contact tracers for every 100,000 people as a non-pandemic standard, and 30 such workers during a pandemic. Nationwide, meeting that threshold implies a workforce of about 99,000. Currently, there are about 44,000 contact tracers across all state and local public health departments, which is a substantial improvement over the pre-pandemic level of 11,000 but well below what anyone expects will be sufficient to contain the virus in the coming months.
Even more worrisome is the uneven distribution of progress across the states. Some states have moved aggressively, while others have been far too passive. Massachusetts already employs 2,500 contact tracers, which puts it at 35.8 per 100,000 residents. New York now employs 9,600 tracers, or 49.4 per 100,000 state residents, and plans to hire an additional 7,400 workers in the coming weeks.
By comparison, many of the states that are now “hot spots” for viral spread have small teams of contact tracers and inadequate plans for scaling up. Florida now employs 1,500 contact tracers, or only 6.8 per 100,000 state residents. At the moment, the state’s trend in new cases per day indicates an R of 1.38 — the third highest in the country.
In Texas, the state has 3,192 contact tracers and plans to increase the workforce to 4,000, but that will still leave it with only 13.6 tracers per 100,000 residents. Texas has an R of 1.18 and is trending in the wrong direction.
Of the top ten hot spot states, only South Carolina and Utah have plans to hire a workforce that meets the 30 per 100,000 standard for a pandemic.
Some state officials may contend that they do not have sufficient resources to build larger contact tracing workforces. The last emergency bill passed by Congress provided $25 billion to support improvements in testing and tracing nationwide, of which $11 billion went directly to states and territories. Still, if funding is seen as an impediment, the next emergency bill, likely to be negotiated in July, should direct additional federal resources toward this essential tool. The expense is small when compared to the economic costs from the lockdowns that become necessary with rapid viral spread.
Congress might also stipulate that building state-based contact tracing teams meeting minimum national standards is not optional but is a requirement for receiving federal funds. It is unlikely that imposing such a mandate would be supported by the Trump administration, but both parties in Congress should press forward with it anyway.
The nation’s public health leaders also need to reinforce the importance of contact tracing in public messages. Americans are anxious to see the virus well contained so schools and places of work can reopen, but many are also wary of public health authorities gathering up information about who is and who is not infected. Privacy is central to gaining public acceptance, but it is also critical to communicate the necessity of rapid identification of cases and thus the need for public cooperation with local health authorities.
The U.S. had its first peak in late April, and now is experiencing a second one because reopening occurred before the virus was contained. To repeat making that mistake again, the federal government and every state must get serious about contact tracing. It is one of the keys to moving toward normalcy even without a vaccine.
James C. Capretta is a columnist for State of Reform and holds the Milton Friedman Chair at the American Enterprise Institute.