Yves here. As the article points out, this Massachusetts effort comes what is probably too late for this first wave of the infection. But it may still prove valuable. Some fear Covid-19 comes back after lockdowns are relaxed or next fall because contracting the disease does not confer much immunity, so having worked out some of the bugs in contact tracing would be useful. But it is an open question as to whether this effort is well enough manned. And there are also concerns about whether there are enough resources committed to administering and processing tests.
MIT Technology Review discusses San Francisco’s plans to launch comprehensive contact tracing. I have to note that the Technology Review has regularly been sloppy in its coronavirus reporting. For instance, it has regularly depicted contracting the disease as conferring immunity, when that is an open question (for other coronaviruses, immunity is relatively short-lived, and there’s an additional worry that very mild cases might not produce a strong enough immune system response to be protective).
For the Technology Review piece, there’s a glaring disconnect between the headline, How San Francisco plans to trace every coronavirus case and contact, and the detail:
The task force will interview every patient who tests positive and provide necessary support to ensure that all are completely isolating themselves, down to helping them find and get to shelter if necessary. They also expect to reach out to between three and five people that patients came into contact with in the preceding days. They’ll alert them they may have been exposed, ask them to limit their contacts, and either encourage them to go in for a test or bring one to them. Those who test positive will trigger additional rounds of interviews and contact tracing.
Three to five people? In this lockdown world, that may be a reasonable number, but you can see this is nonsensically low for any “essential worker” who by definition is out and about.
However, these programs do not have to achieve 100% effectiveness to make a serious dent in disease propagation. And most of these approaches seems to assume everyone has a smartphone, when in fact, only 82% of US adults do.
By Martha Bebinger, who covers health care and other topics at WBUR, the NPR affiliate in Boston. She has won dozens of regional and national awards in 18 years as a reporter. Originally published at Kaiser Health News in partnership with WBUR and NPR
Massachusetts is launching an effort to reach everyone in the state who may have the coronavirus and get them tested and into isolation or treatment if needed. The ambitious goal is to stop — not just slow — the destructive power of COVID-19 through the tedious, yet powerful public health tool called contact tracing.
Contact tracing starts with a call to someone who has tested positive for the coronavirus, and then follow-up with everyone that person was in close contact with — family, friends, colleagues or others they got closer than 6 feet from for more than a brief encounter. Everyone on that list is interviewed about their contacts and symptoms.
This is a routine, resource-intensive public health strategy that’s been successfully used in the U.S. and around the world to contain infectious disease outbreaks — from measles to smallpox to tuberculosis to Ebola and more.
Local public health workers across the U.S. are already using this strategy with COVID-19 — a few cases at a time. Last week, Centers for Disease Control and Prevention Director Robert Redfield told NPR that “very aggressive” contact tracing would be necessary before the country could start to return to any sort of pre-pandemic normalcy. In Massachusetts, Gov. Charlie Baker had already begun a statewide effort.
“We need to get out ahead of this and do everything we possibly can here in Massachusetts, through and in the aftermath of the surge,” Baker said during a briefing about the project on April 3.
The state is partnering with the Boston-based nonprofit Partners in Health, and has begun hiring and training some of the 1,000, or so, people who will call everyone who tests positive.
Many of the thousands of Massachusetts residents who will receive calls won’t know that they may have been exposed to the virus. Callers will keep the name of the infected person private, although organizers acknowledge it may not be difficult for the call recipients to determine the source of their COVID-19 exposure.
In an ideal scenario, everyone who’s been in close contact with someone who is positive would be tested, even if the person receiving the call does not have symptoms. But Massachusetts, like most states, still doesn’t have the capacity to do that. As of Sunday, at least 25,475 people had tested positive. There were 6,499 tests conducted daily, on average, in Massachusetts last week.
Anyone who has had close contact with someone who is positive will be asked to quarantine for 14 days, even if they get tested and are negative. That’s because the incubation period for the coronavirus is believed to be up to two weeks. Close contact here is defined as spending 15 minutes or more within 6 feet of someone who is positive.
Public health experts say many more tests for the coronavirus are needed to cover everyone who will be identified by this project. And waiting up to five days for test results, as some people still do, is a problem.
“The delay in how long it takes to get the results remains too long to make contact tracing very effective,” said Dr. Sandro Galea, dean of the School of Public Health at Boston University.
But Galea noted that testing capability could change anytime.
“Yesterday, we probably did not have the tools,” he said. “Whether we’ll have the tools tomorrow remains to be seen.”
And then there’s the question of how to assist people who are not sick and need to be quarantined so they don’t spread the virus, or for those who are sick and need care in isolation. Some people will have enough space at home to stay relatively isolated from other members of their household. But many others — those who share bathrooms, kitchens and bedrooms, or who live with someone at increased risk for a severe case of COVID-19 — will be given options.
The Baker administration, which says it plans to spend $44 million on the contact-tracing project, is looking at setting up isolation units in dormitories and hotels. People in quarantine as well as those in isolation will need food delivery, possibly child care, and lots of additional help so that they don’t interact with others and spread the virus.
“It’s going to be a huge job,” said Dr. Joia Mukherjee, the chief medical officer at Partners in Health. “I know we will succeed somewhat and we will fail somewhat — we won’t be able to find every single person — but we will hopefully prevent a lot of deaths.”
Mukherjee said even if contact tracing can’t “stamp out” the coronavirus, it can “not only flatten but shrink the curve so that fewer people will get infected.”
Mukherjee, who has helped organize similar projects to fight Ebola in West Africa, calls contact tracing “going on the offensive” against the coronavirus. She argues a defensive strategy alone isn’t good enough.
“Let’s just spell out what the ‘defensive’ [strategy] is. The defensive is, ‘We’re going to get creamed, and let’s just make sure our hospitals are staffed,’” she said. “What we’re saying is, ‘Let’s use tools that can reach into that silent epidemic and start to cut that off.’”
Some public health leaders and infectious disease doctors are questioning the timing of this launch in Massachusetts. Galea said contact tracing is usually more effective at the beginning of an epidemic, before a disease like COVID-19 has spread.
“I don’t know that it’s too late — it’s certainly late,” he said. “Had we had the tests and were we organized enough to do contact tracing right upfront, it would have potentially taken us down a very different path in this epidemic.”
Baker said contract tracing is a “powerful tool” the state must try to prevent more infections. Galea said it might help Massachusetts control a second wave of infections that could come when stay-at-home orders and advisories are lifted.
Massachusetts may be rolling out the most robust expansion of contact tracing so far, but Utah, North Dakota and other states are also launching projects. The CDC’s Redfield said his agency has 600 staffers doing this work and plans to add more.
But it’s still not clear how much financial assistance states can expect from the federal government.
Partners in Health is collaborating with 36 community health centers in Massachusetts to conduct the tracing. Health centers say the deal means they can bring back employees who were furloughed recently when elective medical care stopped; Partners in Health is connecting the tracing project to clinics where people could be tested and speak to a nurse or doctor.
Neither making nor receiving these calls will be easy, and cultural sensitivity is important too, according to a task force from the Johns Hopkins University Center for Health Security that recently looked at what “case finding and contact tracing” might entail across the United States.
The contact tracer may be the first person to alert someone they may be infected with the coronavirus. Stacey King, director of practice at Harvard University’s Chan School of Public Health, has been working with student volunteers who’ve teamed up with local boards of health in Massachusetts to assist with contact tracing. King said building trust while asking about symptoms, contacts, recent activities and the health of family members will be challenging.
“Especially when people are under so much stress right now,” she said, “I think it will be one of the hardest things that we experience.”
Even if your state isn’t ramping up contact tracing efforts, you might still get a call from a local public health official if you’ve been exposed to someone with a confirmed coronavirus test result. In the event you get a call someday soon and are asked to trace your contacts, it might help to start keeping notes now, say public health workers: Who have you recently spent more than a few minutes with — and been within 6 feet of?
The Partners in Health project is set to continue through October and wind down in January 2021.
21 comments
Comments are closed.
the Technology Review has regularly been sloppy in its coronavirus reporting. For instance, it has regularly depicted contracting the disease as conferring immunity
I don’t doubt MIT has been guilty of this, but I can’t say I’ve noticed it, certainly no more than any other source. For example:
“About 80,000 people have recovered from the coronavirus already, and it’s likely they are now resistant, although the degree of immunity remains unknown. “I would be surprised, but not totally surprised, if people did not become immune,” says Myron Levine, an infectious disease expert at the University of Maryland. Some viruses, like the flu, do find ways to keep changing, which is why immunity against such seasonal germs isn’t complete.”
https://www.technologyreview.com/2020/03/17/905244/what-is-herd-immunity-and-can-it-stop-the-coronavirus/
“There are some serious problems with trying to use the tests to determine immunity status. For example, we still know very little about what human immunity to the disease looks like, how long it lasts, whether an immune response prevents reinfection, and whether you might still be contagious even after symptoms have dissipated and you’ve developed IgG antibodies. ”
“Alan Wells, the medical director of clinical laboratories at the University of Pittsburgh Medical Center, raises a similar point. He says that some patients who survive infection and are immune may simply not generate the antibodies you’re looking for. Or they may generate them at low levels that do not actually confer immunity, as some Chinese researchers claim to have found.”
https://www.technologyreview.com/2020/04/09/998974/immunity-passports-cornavirus-antibody-test-outside/
It is an almost constant and regularly unnecessary aside in the MIT Technology Review stories, on the order of “if we only knew how many people had gotten Covid-19, we’d know how many were immune.”
And as a publication holding itself out as having academic chops, I hold it to a higher standard than the New York Times or USA Today.
I don’t read everything they publish by any means, but I haven’t noticed that. Most MIT TR articles I’ve come across are quite careful to outline the problems and intricacies of both immunity and testing for it. That said, there is, as you say, often a disconnect between the clickbaity headline and the meat of the article, and like you, I’d have hoped they’d hold to a higher standard than the MSM press.
Just about every MIT Technology Review article sent to me in the last 2 weeks has this issue. The only exceptions have been ones with immunity as the focus of the piece.
This seems the best information I read on the virus.
https://www.cambridgeindependent.co.uk/news/cambridge-virologist-explains-what-we-know-and-dont-know-about-covid-19-9104220/
These are steps on the right direction. I guess that in Mass. there are enough research centres that could provide, if the state has authority to do so, for equipment and bio-safe labs plus trained people to greatly increase testing capacity. In order for this to work without delays there should be a central organization with some bureaucracy that would ensure fluidity and reliability in information flows. Each new lab in the system should pass a validation process.
IMO, it is never too late to put in place tracing teams. I would add checkpoints (mobile checkpoints) that would be deployed whenever and wherever clusters are detected or suspected and even as random surveillance points. All these teams must be properly protected. There is the question on how many people to be surveyed in the tracing process. The answer is that this would depend on how people observe social distancing and what are the social distancing measures recommended and/or enforced. So, very much depends on the collaboration of the population. Some cases would be easy to trace and some others not. An educational effort must be done. The alarm system should provide the State with authority to declare local lockdowns when and where it is seen necessary. The system should warrant that all personal information provided is kept safe in the system, used only for epidemic surveillance purposes, and erased when it is not longer needed for this purpose.
Coordination with limiting States would also be necessary.
Being a resident of MA, …actually regardless, I’m very pleased to hear of this. Your comment gives a good overview of things to look for in determining how serious (and successful) the effort. Here’s hoping it really does good.
I do wonder about contiguous states and traffic between. We have innumerable roads, both highways and small back roads connecting us to Rode Island, Connecticut, New York, Vermont and New Hampshire. I have no idea of the extent of flow, what rules are in place or how well they are enforced, nor what different flow rates would do to contact tracing and quarantine. These states, of course, face much the same problems should they make similar efforts.
Within the state, I strongly suspect that the average person (average financially) will, by in large, try to obey the rules being aware they are for everyone’s benefit. But besides the stray few who will always try and cheat the system, I also suspect the well to do will, more generally, assume they are exempt and thus pose problems. And those who are financially weakest and most vulnerable are also a question mark, but more along the lines of how they will be treated.
I call BS on this article.
Mass has 6.9 mil people, 28k confirmed cases.
They are going to coordinate testing how many of the 6.9 mil people?
They don’t even have a test that is 100% accurate, lots of false results.
And then they are going to ‘isolate’ those found to have tested positive?
Where are you going to put them? in hotels? across the state?
What if someone doesnt want to go? you going to arrest them?
forcibly relocate them?
And then you have to feed all those people at all those various hotels, 3 meals a day.
Sounds like an enormous effort, Mass cant even get their Registry working reasonably well,
how are they going to do something like this?
Takes less than 5 min to see so many things wrong with this idea
Takes less than 5 min to see so many things wrong with this idea
I think you are challenging feasibility more than idea. Perhaps you are also suggesting this is more for optics than for effect – can’t tell, but of course that may be correct.
Regardless, it indicates to me that people are at least aware of the only thing presently that will really allow us to move forward from an otherwise increasingly impossible to maintain t lock down (such as it is).
The results are not something easy to entirely cover up.
This Ars Technica article, We may need 300,000 contact tracers to defeat COVID-19. We have 2,200, sheds some light on the matter. [Maybe one of the many links above.]
But in places where there is widespread transmission—such as the case in much of the United States currently—contact tracing is an unmanageable and even unhelpful task. That’s the point at which public health officials switch to mitigation efforts, such as the stay-at-home orders now seen in many places in the country. Public health experts are now waiting for those mitigation efforts to dampen transmission enough to be able to switch over to relying on testing and contact tracing to control transmission.
“The concept is: once you get down to a manageable number of cases and scale up the public health system, then you will be able to pounce on any case or cluster to proactively identify cases, identify contacts, and follow up on those contacts,” Tom Frieden, a former CDC director, told STAT news recently. “When you get those things done, you can prevent the clusters from becoming outbreaks, prevent outbreaks from becoming epidemics, and prevent the epidemics from driving us into our homes again.”
Meanwhile, the state of Massachusetts is working with global health nonprofit Partners in Health to recruit 1,000 people to do contact tracing.
“Widespread testing and aggressive contact tracing have been key pillars of public health responses to infectious disease outbreaks for more than a century,” the nonprofit says on its website. “Along with effective isolation and quarantine measures, contact tracing has played an important role in highly successful control programs in Germany, the Republic of Korea, Singapore, Hong Kong, and China.”
First, I agree with Igancio. Out of hand dismissal is simply not helpful. That is not directed at you but rather it’s a point of view that I think particularly appropriate in this situation right now.
Second, I think – don’t know for sure – that Baker is putting this together now to have it ready later when numbers start leveling out; that is, that the timing is not counter productive as you suggest is possible. I’m also hoping that 49 million dollars and 1000 tracers is or turns out to be starter numbers, but be that as it may, I’m hoping that the effort pays off sufficiently to make public officials aware of its worth and of the value of increasing the effort.
Finally, I don’t think Baker is doing this for show. I think he is really involved even at a personal level. That’s mostly impression, I have no way to support it, but I am hopeful it becomes evident if this contact tracing and quarantine effort helps or not and if it does – for which I’m grateful to Ignacio for his thoughts – I think it may create its own momentum.
Not sure what you’re getting at – you say “not directed at you”, and maybe you were replying to edward finius – but I generally agree with Ignacio, and absolutely definitely think out of hand dismissal is counter-productive. The Ars Technica article seems to be saying contact tracing isn’t all that practical with widespread transmission and next to no preparation, but can be valuable when things are a bit more under control. That may not be exactly Ignacio’s take, but it seems worth considering even if it’s not.
Sorry for being unclear. Not at you, but at the proposition that contact tracing is not worth a shot or is counter productive. I’m aware from your general comments that you are not negative out of hand (and far from it ).
You offer the Ars Technica article in response to the Massachusetts plan so I assume you are suggesting or questioning that transmission is now too widspread in MA for contact tracing to be of value. I agree with Ignacio (assuming I’ve understood him and hopefully not putting words in his mouth) that even under imperfect conditions this plan is moving in the right direction. I don’t think we have a choice and I don’t think conditions will ever be good, never mind perfect.
Mostly, I’m really pleased that Baker and thus people making decisions are aware of contact tracing as a viable means of exit when things level off. I was more than a little concerned that the general consensus politically was to simply use on-off lock-downs followed by opening up commerce (relaxing social distancing) followed by new lock-downs when new waves of infections reached unmanageable thresholds. Such levels of bull-headedness are not with out precedent in the US.
Also, I’m hopeful this plan (meager as it may be) is being put in place now, but will be operative and/or improved in scale when things have leveled off a bit and tried to convey that sense of “hopefully” purposeful or planned lag in response to your point that we are still too deep in wide spread tranmission at this time for contact tracing to make sense.
I offered the article more as something for edward finius to consider, not as an alternative to the Massachusetts plan. If things aren’t too bad there, the plan, Ignacio, and the article more or less agree. If things are, or get, really severe the article suggests contact tracing may be difficult and not too practical or useful, which may be slightly different to Ignacio’s take, but that wasn’t really my point. And a large part, as I see it, of any difficulties would be for political, bureaucratic and cultural rather than scientific or statistical reasons. Witness countries that have got to grips with it.
The more like you, the more difficult to implement anything. You “know” that anything/everything will be a mistake.
Massachusetts also has the third highest number of cases per million in the United States and already 957 people have died there. They had better get their act together. And as to the question of what to do if people refuse to quarantine themselves for a fortnight, this is what you do-
https://www.abc.net.au/news/2020-04-15/man-jailed-for-breaching-coronavirus-quarantine-by-leaving-hotel/12149908
We have a term for such people in Oz. We call them d***heads.
I wonder if Massachusetts has given any thought to the homeless? There must have been perhaps 20,000 of them at the beginning of the year in this State and I doubt that many of them would own a smartphone either. The numbers can have only increased in the past two months since a big chunk of the economy went into a deep freeze. Any sort of social distancing would be problematical too so perhaps it would be wise to put them in all the empty hotel rooms at present and arrange to have people keep tabs on them. If you do not take care of the homeless in a pandemic it is like trying to hold out on an enemy while leaving the back door open-
https://www.usich.gov/homelessness-statistics/ma/
The achilles heel of any public health effort concerning COVID is validated, widely available and fast testing. Doubtless it is a tiresomely oft repeated question but WTF is up with the lack of capacity in this domain? Boggles the mind.
Another form of testing that must urgently be deployed is the serological arm of this effort which will help determining the reach of the disease. Only useful to determine who has had the disease.
Aside from the purpose of hiring contact tracers to find connection, a good idea in itself, here are 1000 new jobs in Mass when unemployment rates are skyrocketing. New jobs in this environment are also good thing in itself. imo.
Yes, and a large team could be trained with pay now for the fall resurgence and for future pandemics. The larger the team, the more effective, and the less unemployment. NY too apparently failed to anticipate this need. 3 days of training per year, $200/day, 5,000 people = $3 million/year to have them ready. Would have paid for itself in a few hours if shutdown could have been avoided.
Does anyone recall reading that it took 1800 teams of 5 to get it under control in Wuhan(10+million)? I dont remember if it was in an article or someone mentioned it here in the comments section on NC.
Pritzker, the governor here(il), finally mentioned today they are to talking to Massachusetts officials on a contact tracing program.