Not since AIDS swept across America in the ‘80s have we had such an overwhelming need to track back and trace where infections have originated to ascertain how many people may have been infected from an initial source. Welcome to the novel coronavirus, COVID-19, which has blazed across the world like a wildfire out of control, catching public health officials completely off guard.
“We lost our ability in the first wave of this virus to do any contact tracing because numbers were just coming too fast,” said Dr. Susan Hassig, associate professor of epidemiology at Tulane University’s School of Public Health and Tropical Medicine. “In order to interview the people who have just tested positive, you need to have people designated for this sort of field work.”
Public health experts say that, along with extensive testing, the ability to do mass contact tracing will be key to reopening the economy while minimizing the risk of new waves of infections. The White House’s guidelines for reopening the country, released last week, identify contact tracing as a “core state preparedness responsibility.”
“Currently, Massachusetts and California are actively looking for people to do this work in anticipation of what could easily be a second wave of infections, if we begin to open up the country before we have adequate testing to know who’s infectious. To be safe, this sort of organizing needs to take place across all 50 states,” Hassig said.
Earlier this month, Massachusetts was the first state to begin ramping up a large-scale contact tracing effort, budgeting tens of millions of dollars to hire 1,000 workers for the program. Local governments in the San Francisco Bay Area have also begun work on staffing contact tracing programs. Louisiana is still in the very early phases, state officials said at a Monday press briefing. The state needs about 700 contact tracers, Assistant Secretary of the State Office of Public Health Alex Billioux said. It currently has about 70.
When AIDS came on the scene nearly forty years ago, contact tracing was difficult. There were no privacy laws to guide public health officials, so patient privacy often became the domain of individual physicians.
In New Orleans, one of the infectious disease specialists on the frontline was Dr. Tlaloc Alférez, who had her own system for protecting patients, long before HIPAA (Health Insurance Portability and Accountability Act of 1996) enforced the rights of patients to safeguard the privacy of their medical records.
“At the time, the state of Louisiana was supposed to keep a list of people who had tested positive for HIV,” Alférez said. “But several states across the U.S. declared there was no such thing as anonymity, and Florida [one of those states] released a list of HIV patients, which was then published. With the stigma at the time, it ruined people’s lives. They lost their jobs, their friends, and many lost their apartments. When people don’t understand how something spreads, it invokes fear.”
Alférez knew that without contact tracing, the spread could be exponential. She devised her own system to ensure the patient’s privacy, and yet allow public health officials to do their jobs of tracing the patient contacts and notifying any potentially infected people so that they could be tested.
“As an infectious disease specialist, I would test my symptomatic patients, and give them a number,” explained Alférez.
“I kept that number in a file in my desk. When I submitted the sample to the lab, only a number went with it. The state soon ruled that names had to be attached to samples. The lab, upon receiving a sample, would notify the state so we had good record-keeping, and then would call the physician to see if he or she knew if it had been acquired through sexual transmission or needles. They would then ask us if they could contact the patient to initiate contact tracing.”
Phase One
The state now has multiple ways of keeping track of just how many positive cases they have, but that’s where the process currently ends. Although there were early attempts made by LSU Health Sciences Center New Orleans officials when the first coronavirus was reported on March 9, the problem very quickly became so overwhelming that a stay-at-home order was implemented by the state. Since then, there’s been no attempt to figure out just who these positive patients have come in contact with.
“Contact tracing is going to become an important part of coping with any surge of cases which arises from the gradual reopening of our country,” Hassig said. “However, that’s just one component of what needs to be done here. Just because your state hasn’t seen a lot of cases yet doesn’t mean it isn’t coming, and hasn’t been brewing. Look at the Smithfield Foods meatpacking plant in South Dakota. It now has over 900 cases just in that one pork processing plant. And South Dakota has rejected any stay-at-home orders. How many people did each of those people infect?”
That plant has now been closed, but South Dakota has been mentioned as one of the states that could enter a Phase One scenario, the first part of the White House’s Three-Phase plan to reopen the economy beginning as early as May 1. Gov. John Bel Edwards said last week that the state has yet to meet federal criteria for Phase One, but with daily case counts and hospitalizations showing a recent pattern of decline, he hopes to get there in the coming weeks.
Part of Phase One includes returning to work in phases, and re-opening sit-down dining, sporting venues, places of worship, and gyms. But just what would that entail? We know about antigen testing, which determines who is infected with COVID-19, but just as important to the process of preparing for a re-opening is finding out who’s had the virus, and now possesses immunity. That can only be done through antibody testing.
“Before we even contemplate any sort of social gatherings, we need good serologic tests … enough of them,” said Hassig. “At this point in time, we’ve barely scratched the surface as to who’s had this virus and may not even know it. Allowing people to return to work, when we know they already have immunity, will put everyone’s mind at ease.”
Immunity testing has yet to be done in large numbers. And many states are still struggling to administer enough tests to find out who has the virus right now.
With about 141,000 reported tests completed in Louisiana, or about three percent of the population, the state has been at or near the top of tests performed per capita. But Edwards and Louisiana Department of Health officials have repeatedly said that even those rates of testing are not enough.
Indeed, researchers at Harvard University have suggested that the U.S. cannot safely reopen unless it conducts more than three times the number of tests it is currently administering over the next month. As of late last week, 3.6 million tests have been conducted, and Harvard estimates we will need another 500,000 to 700,000 daily tests to have the sort of information we would need to engage in any sort of re-opening by mid-May. That equates to about 152 tests per day for every 100,000 people. At the moment, Louisiana is the highest in the nation with 124 tests per 100,000 people, but our neighboring states are lagging far behind, particularly Texas, at 27 coronavirus tests. Mississippi is at 84, Alabama at 44, and Arkansas at only 35. With more than 788,000 cases as of Tuesday, the U.S. has the highest number of known cases in the world.
“No one is promoting universal testing,” Hassig said. “But we need information immediately. So, at a work site where there are more than 10 people, we need to space employees and have them wear masks. We need to take temperatures upon arrival and then ask the worker if anyone in their household has been sick with a respiratory infection. Anyone with a fever goes immediately to the company’s health unit where they’re tested, and if positive, put into isolation. All rules will have to be mandatory… not suggested.”
Contact tracing is going to have to reach new levels of sophistication, making the gathering of information faster, easier, and more inclusive. At the moment, Google and Apple are working on a collaboration that would involve an app on your phone with a tracking device. If you opt in, every time you’re within six feet of someone for 15 minutes, it would add that GPS coordinate to a list of places you’ve been, which includes a time-stamp. So if you become infected, you reach out to those you’ve been in close contact with so they can be tested.
“This gets a little more complicated if you’re on a subway train and your phone begins to ping as a result of any number of people being six feet away for more than 15 minutes, but it’s a start,” Hassig said. If you’re in a grocery store, for example, then the grocery store would be alerted that at noon on Sunday, an infected person was walking through the store. Perhaps the information could be posted online. This sort of information would release us from requiring the sort of manpower needed to coordinate contact tracing on a broad basis. There are a couple of caveats here. This would have to be an opt-in system, for privacy reasons. Unless we envision some sort of ‘1984’ scenario here. And, if the virus turns out to be transmitted in an aerosolized form, rather than droplets, the range is too big to pick up.”
Scientists have worried that if indeed the virus were actually transmitted in an aerosolized form — from simply breathing or talking — as it is when nurses intubate patients to be put on ventilators, that aerosol could hang around in the air for three hours, infecting anyone who walks through that particular area.
Considering that we don’t have any idea who is walking around infected, testing is the only realistic scenario for a reopening of America. We now know that people are shedding this virus before they have symptoms (pre-symptomatic), they shed virus when they have no symptoms (asymptomatic) and they are shedding virus for anywhere between 2-3 days and 2 weeks after their symptoms are gone (post-symptomatic).
A recent article in The New England Journal of Medicine recounted a recent incident at a New York City hospital that illustrated this point. Two hundred women coming into the hospital to deliver babies were tested. The tests revealed that 15 percent of those women were infected, and nearly 90 of those were asymptomatic, and never developed symptoms. It reveals just how many people are walking around thinking they are well, while contaminating others. But it also tells us that many people are getting COVID-19 and are never aware they’re sick.
Antibody tests are important, as well, and a good finger prick test we are told is coming, but in the meantime the World Health Organization has admitted that the tests don’t effectively tell us what sort of immunity we actually have, and for how long.
“There is no evidence to date that anyone would get reinfected with a similar strain,” said Dr. Robert Garry, professor of microbiology and immunology at Tulane Medical School. “Tony Fauci has said that he’d stake his reputation on that fact— that people do have immunity for some period of time. It’s probably at least a year, although two years is probably a pretty good bet. The truth is, however, we just don’t know.”
When the pandemic began in Europe in January, Sweden made a decision to go with a “herd immunity” philosophy.
They decided not to impose restrictions or closures, advised people to practice safe health practices, and assumed those who became ill would survive and move on with immunity, eventually providing a large segment of the population with protection.
But when Sweden eschewed any draconian policies, the virus spread rapidly. It took horrific death rates in Sweden before the country finally implemented restrictions of any sort, just three weeks ago. Compared to other bordering Scandinavian countries,the percentage of deaths was much higher. Sweden has now seen 15,322 cases with 1765 deaths, an 11.5 percent death rate. Norway, on its western border has had 7,191 cases and 182 deaths, with a 2.5 percent death rate. Denmark’s death rate is at 4.5 percent and Finland’s is 3.5 percent. The population of Sweden is just over 10 million, compared with 330 million in the U.S., where death rates are just over 42,000, a rate of .01%. Sweden has paid a very high price for lack of restrictions.