Contact tracing could help avoid another lockdown. Can it work in the U.S.?

To contain the spread of Covid-19, Alaska is planning to triple its number of contact tracers. Utah has retrained 150 state employees. And New York and other states are hiring thousands of people.

And that, health experts say, might not be enough.

To suppress their epidemics to manageable levels, countries around the world have turned to contact tracing — tracking down people who might have been exposed to the coronavirus to ensure they don’t pass it to others, a way of stalking routes of viral spread and severing them before they reach more people. And, to varying degrees, it has worked. But, for it to succeed in the United States, experts are cautioning that it’s going to take more people, more money, and more cooperation than the country has in place.

“We’ve never had something at this scale,” said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials. “And clearly we need a lot more people to take this on.”

Ultimately, the hope is that, together with speedy and widespread testing and isolating cases, contact tracing can help keep outbreaks at a wieldy simmer, and buy the country time until better drugs and vaccines arrive. If the U.S. so far has been in a defensive stance against the virus — shutting down large swaths of the economy in the process — contact tracing is a way to go after the virus and keep it at bay.

But some experts fear that the technique might not work as well in the U.S. as it has in other countries.

Many Americans may not understand they might be asked to quarantine for up to two weeks if they’ve been exposed, introducing logistical questions about how they wall themselves off from their families and avoid losing their jobs. People who have the virus might resist cooperating with tracers and divulging where they’ve been and with whom they’ve had contact. Experts wonder how compliant the public will be given that some individual responses to the pandemic — whether people wear a mask or feel they have a right to shop, drink, and worship when and where they want — have become political statements.

Beyond that, although the number of cases the country is reporting is down from its peak, there are still some 20,000 new Covid-19 infections each day. That’s a lot of people to interview, and a lot of contacts to hunt down, and there are only so many tracers hired so far. Former government health officials have suggested the Trump administration should deploy as many as 180,000 tracers.

“It’s clear that you can do a lot of control if you do contact tracing really well,” Marc Lipsitch, an epidemiologist at Harvard’s T.H. Chan School of Public Health, said last month. But if there are too many cases, or testing limitations mean you can’t identify cases quickly enough, “it’s easy to overwhelm a relatively constrained group of people.”

In March, states began instituting versions of lockdowns because surveillance systems to follow the virus — including testing and tracing — could not keep up. As the virus was racing through communities, the only way to get ahead of it — and to keep it from swamping more hospitals in more communities — was to get everyone away from each other.

But if chains of transmission can be quickly cut by separating just people who have or might have the virus, some semblance of what society used to look like can come back into place. Mass gatherings might not happen, restaurants and stores will have capacities, and some venues will still be shut; if there’s a local burst in cases, some targeted closures will likely be in store. But it could help keep things under control enough that the health system can handle the cases that do occur without requiring broad shutdowns.

On the other hand, if the virus is still circulating widely and states haven’t “staffed up their contact tracing and trained them and have them ready to go, I worry that transmission will start to get out of control,” said Crystal Watson, a public health preparedness expert at the Johns Hopkins Center for Health Security.

Contact tracing is not a new tool. The state and local public health departments being entrusted with it have decades of experience doing it for other diseases, like tuberculosis and HIV. Globally, it’s been used to corral Ebola outbreaks. And although it’s harder to track a respiratory pathogen than one that’s passed through sex or blood, departments can lean on that experience, and just need federal funding and support to ramp up their operations, officials say.

“It’s a very successful track record,” David Harvey, the executive director of the National Coalition of STD Directors, said about the history of contact tracing in the United States. “Overwhelmingly people want to do the right thing. People don’t want to put their families and close contacts at risk for this deadly infection.”

Contact tracing does not need to be perfect to make a serious dent in case counts. If the goal is to keep the number of people getting sick below the point where hospitals are overwhelmed — not to eliminate the virus — not every contact needs to be found and not every person needs to follow recommendations. If health officials can identify half of symptomatic cases of Covid-19 (some people don’t show symptoms), and trace 40% of their contacts, “the ensuing reduction in transmission allows the reopening of economic activities while attaining a manageable impact on the health care system,” a preprint of a modeling study found, relying on transmission dynamics in the Boston area.

If tracing resources are limited, focusing on burgeoning clusters of cases can also be more impactful than taking aim at tendrils of spread, experts say.

“We’re not trying to get rid of Covid-19 altogether — that would be great, but probably unrealistic,” said infectious disease epidemiologist Emily Gurley of the Johns Hopkins Bloomberg School of Public Health. “But even if we can’t stop all transmission, it’s still a really important effort to keep case counts low.”

To build the necessary workforces, states have taken different approaches. Massachusetts is working with the global medical organization Partners in Health, Washington has tapped its National Guard, and Florida has turned to students from the state’s public health schools. Others are relying on temp agencies and job placement programs — a symbiotic partnership at a time when millions have lost their jobs. To train them, groups including Johns Hopkins, as well as the Association of State and Territorial Health Officials and National Coalition of STD Directors, have developed online courses.

To be a contact tracer requires knowing about the disease you’re following, and how to gain people’s trust and coax them through the process of absorbing bad news. Tracers are often the ones who tell people they have the virus, and as they provide information about Covid-19, they also ask about where that person has been in recent days and with whom they’ve interacted. (The Centers for Disease Control and Prevention says that in the case of Covid-19, a contact is someone who spent at least 15 minutes within 6 feet of a case, starting two days before that person started feeling sick.)

Then tracers have to reach out to those contacts and ask them to quarantine. Tracers keep in touch with both cases and contacts, monitoring their health, making sure they have a way to get food, and, in some cases, finding a place for them to stay away from their families. They also have to work quickly; people become infectious just a few days after contracting the virus.

In North Dakota, which has earned praise for its rapid buildup of testing and contact tracing, the majority of both cases and contacts have been willing to help, said Vern Dosch, who’s coordinating the state’s efforts. When contacts are told they’ve been exposed, they are invited to the next drive-through testing event in their area and are asked to quarantine until they get their results back.

“This is a pretty rural state, and the governor has been very, very transparent with them,” Dosch said. “He talks a lot about individual responsibility, and what we say is, if you test positive, you have a responsibility to help us in that tracing effort.” When people are unwilling to help or quarantine, Dosch said, “we just have to say, ‘OK, thank you, we understand that’s your prerogative.’”

Still, he said, “Because we got after it early, we’ve been able to stay in front of things. It’s never perfect — sometimes people don’t cooperate, sometimes we miss a contact — but by and large it’s very effective.”

Experts who are skeptical about how successful contact tracing will be in the United States have noted that even Singapore, with its famed health surveillance system, has at times lost sight of the virus and had to impose physical distancing restrictions (though disruptions to life have been much more limited than those in the United States). In South Korea, a new cluster formed this month among people who had been at nightclubs, sending authorities scrambling to find and test thousands of patrons based on credit card information and cellphone tracking.

Those kinds of technological tactics are likely out of reach in the U.S., where privacy concerns carry more weight. Already in Washington state, for example, Gov. Jay Inslee softened his initial expectation that restaurants would keep a log of diners when they reopened to say that diners could volunteer such information.

Further complicating the U.S. response: State and local health agencies that manage most contact tracing programs have seen the bottom fall out of their budgets as a result of the pandemic’s economic collapse. The earlier coronavirus stimulus bills have included money that public health agencies could use to build digital tools to track the virus, as well as billions for the CDC and state, local, and tribal government responses. But health officials involved say they need dedicated funding to build their contact tracing forces. A bill passed by the House earlier this month included $75 billion specifically for testing and contact tracing, but it is a nonstarter in the Senate, and serious negotiations haven’t made progress.

There is also the increasing politicization of the U.S. pandemic response. In a Twitter thread that inspired a robust debate among public health experts, Keith Humphreys of Stanford University, who is from West Virginia, said his “colleagues are greatly over-estimating the likelihood that the U.S. can mount a national test, trace, and isolate program,” not because of technical prowess, but because of “a political-cultural challenge.” (Humphreys works on epidemiological models for opioid use, not infectious diseases; he acknowledges this is not his specialty.)

“I’ve always been aware when I’m here in Palo Alto that other parts of the country have really big disagreements with things that are taken for granted here,” Humphreys told STAT.

Humphreys said that if someone were to be told they had been exposed to the virus and needed to quarantine for two weeks, that person might respond, “Well, guess what, my rent is due, and I work at a fast-food restaurant and I don’t show up for 14 days, I’m going to get fired. And I think this is all bullshit anyway. I turn on the TV and the president’s not wearing a mask. Don’t tell me what to do.”

In their responses to Humphreys, some public health experts pointed to polls showing that most people supported stay-at-home measures, and that most people, even the majority of people who have lost their jobs, are worried about communities lifting lockdown restrictions too quickly. They say that people flagrantly violating public health recommendations are a vocal minority. Researchers have also found that people have limited contact with others — as well as embraced hand hygiene — without government policies in place. Those individual actions can greatly reduce viral spread.

But it’s possible that willingness to go along with expert advice might be diminishing for some people. A Politico-Harvard poll released last week showed a growing divide between Republicans and Democrats and their feelings toward reopening.

“I’m hoping I’m wrong,” Humphreys said. “I would love for this to work. I’m just afraid that it won’t.”

Experts said that’s one reason why state and local agencies take the lead on contact tracing. Whether people are in a household of immigrants or ideologically distrust the government, they are more likely to cooperate with efforts that don’t directly involve the federal government.

Similarly, epidemiologists also say it’s important to look beyond national case counts. Even if the number of new cases across the country seems daunting, in many communities, there are few enough cases for contact tracing to work if the infrastructure is in place.

“With thousands and thousands of new cases a day, it’s impossible,” said Jeff Engel, a senior adviser at the Council of State and Territorial Epidemiologists. “However, there are some communities that can keep up. They may have 10 to 20 new cases a day. Or a state may have 500 new cases a day, but they’re divided into 20 local health departments, and the local health departments can keep up. And if the local health departments are overwhelmed, they can call on the state for help.”