Successfully reopening Michigan’s economy requires government officials to know who has COVID-19 — and who they could have spread it to.
Without that, health experts say reopening the state may be a major gamble marked by waves of new infections spread by people who don’t yet know they’re sick.
As Gov. Gretchen Whitmer begins gradually loosening restrictions on residents’ movement, Michigan and other states are building armies of volunteer health investigators to monitor movements of those who have the illness.
“That’s really the best and only way to contain this virus quickly,” Chief Medical Executive Dr. Joneigh Khaldun said Thursday.
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A common practice among health officials during outbreaks of sexually transmitted diseases and other illnesses, contact tracing is less well known to the public. That’s bound to change in the age of the coronavirus, as the federal government has allocated $11 billion to states for a host of testing programs including what likely will be the largest contact tracing effort in history.
Until a vaccine is widely available — 2021 at the earliest — contact tracing is key to containing the coronavirus without issuing blanket stay-home orders, said Josh Petrie, an epidemiologist at the University of Michigan School of Public Health.
“You’re limiting your restrictions to those who are infected, so you’re not having to lock down the whole population,” he said.
Michigan officials aren’t yet sure how much the state expects to receive for its program but the state’s 3,500 contact tracing volunteers have already begun working with local health departments that primarily lead the effort. The state may hire more professional tracers to do the disease-tracing technique, which is time tested, labor intensive and often raises concerns about privacy.
In some other nations, contact tracing involves phone-based apps that track movements of COVID-19 patients. They likely won’t be used in Michigan and most U.S. states, but the effort still involves gathering troves of data on patients and those with whom they have come into contact.
And before it started, Michigan’s effort raised controversy when state officials last month canceled a contract with a Democratically-aligned firm hired to manage the state’s contact tracing volunteers after Republicans decried the deal over concerns that patient data could be given to campaigns.
The state announced Saturday that it had signed a more than $1 million contract on May 3 with Rock Connections, a call center company that is part of Detroit billionaire Dan Gilbert’s business group.
Here’s a crash course on contact tracing, the issues surrounding it and why it’s so vital to get it right to stop the spread of COVID-19.
What is contact tracing?
It’s essentially public health detective work.
Every day, thousands of Michiganders are tested for COVID-19. After testing, labs send results to local health authorities who follow up on new positive cases in their community.
The first step is contacting COVID-positive patients, asking them to isolate at home and quizzing them on recent activities and the identity of recent close contacts. Because Michiganders’ social circles have shrunk dramatically under the statewide stay-home order, building that contact list is fairly easy.
But once Michigan’s economy reopens, the job will become far harder, said Erin Johnson, disease control and prevention program supervisor at the Grand Traverse County Health Department.
“One person could have 30 contacts you’re trying to follow up with,” Johnson said.
What is a close contact? It’s not standing in line at the grocery store next to a COVID-positive shopper, said Doreen Byrne, communicable disease coordinator at the District Health Department 10, which covers 10 counties in the northwestern Lower Peninsula.
But chatting with a fellow shopper without wearing a mask? Maybe.
“They’ve got to be close to someone who was positive — within 6 feet — for 10 to 15 minutes in a small area,” Byrne said.
Once they have a list of recent contacts who may have been exposed to the disease, tracers set about contacting each person on the list to request that they, too, go into quarantine for 14 days.
Throughout that time, tracers are in regular contact with the quarantined people, asking questions about their health and potentially their other needs such as help with groceries.
“I tell everybody, you shouldn’t leave your house unless it’s on fire, or you need medical attention, or there’s a flood,” said Christina Zilke, a Washtenaw County Health Department nurse who has been working as a contact tracer.
If a quarantined person starts to develop symptoms, tracers launch a new round of investigation to identify anyone they may have infected within their social circle.
Multimillion dollar effort
Continuing to contain the virus once the economy reopens will take “a massive expansion of professionals and trained volunteers,” according to the National Association of County and City Health Officials.
The association recommends a ratio of 30 contact tracers for every 100,000 people. In Michigan, that translates into just under 3,000 workers.
For now, Michigan’s contact tracing capacity is limited to staff and volunteers at local health departments, along with 130 state workers, said Jonathan Warsh, the Michigan Department of Health and Human Services chief of staff who is leading the state’s contact tracing efforts.
But the state has tapped into a database of more than 7,000 unpaid volunteers, around 3,500 of whom have been trained in tracing and can start work when needed.
Other states are making similar plans. New York plans as many as 17,000 tracers, while Ohio will deploy 1,750 in partnership with local health departments and Indiana will contract with a private company to staff a call center with 500.
Michigan also could eventually hire contact tracers. Massachusetts, a state with 3 million fewer residents than Michigan, spent around $44 million hiring 1,000 people to do contact tracing over the coming months.
Warsh said that’s a comparable cost to what Michigan could expect to spend.
Michigan’s need for tracers will largely depend on the success of social distancing measures. If the coronavirus becomes widespread in communities, “it’s just impossible to trace everyone,” said Petrie, the U-M epidemiologist.
That’s been Detroit’s experience. Although the city’s daily rate of new confirmed cases has waned, the virus is still so widespread that local public health officials are not conducting contact tracing among the general population.
Instead, Detroit Health Department spokesperson Vickie Winn said, the city’s epidemiologists are focusing their efforts on nursing homes and long-term care facilities.
Winn said the department will tap into the state’s volunteer workforce once those volunteers are available to help. It’s not clear when that will be.
Deploying the army
As with the shortages of PPE, ventilators, testing supplies and more, the fact that everyone is experiencing the virus at the same time is posing a unique challenge, Warsh said.
“Normally states have the ability to surge support to one another,” he said. “But everybody has to contact trace now.”
The 3,500 volunteers who have been trained to help out have only recently begun working.
That’s partly because the state only this week secured a contract with an outside entity capable of managing the massive volunteer workforce. The state announced Saturday that Detroit-based Rock Connections, LLC will manage volunteers, and Deloitte will manage technology for the tracing program.
The state lost ground on its effort to get a contact tracing program up and running after it canceled an earlier no-bid, $194,250 contract with Great Lakes Community Engagement to manage the volunteers.
The campaign outreach company is connected to a Grand Rapids-based firm owned by Democratic strategist Mike Kolehouse, according to state business records. The company was planning to use EveryAction, data collection software from a tech vendor for progressive campaigns, NGP VAN.
Whitmer, herself a Democrat, canceled the contract after Republicans objected. Attorney General Dana Nessel is now investigating.
The uproar over the contract highlighted privacy concerns about contact tracing, since it involves collecting massive amounts of data about people with illnesses.
State health spokesperson Lynn Sutfin said the state has taken numerous precautions to protect privacy: Volunteers only have access to names, phone numbers and the county where a close contact lives. Addresses, health insurance, financial information and test results are kept private and volunteers must pass a background check and get trained on confidentiality and privacy.
Warsh, the state health official, said Michigan officials are also looking into using an automated tool that allows people to opt-in to receive a text or email notification if health officials believe they’ve been exposed.
What happens in the meantime
While the state staffs up and Whitmer begins to dial down COVID-19 social distancing requirements, local public health officials are bracing for a surge in cases.
Lifting restrictions before the volunteer workforce is available, experts say, could lead to disaster.
Many local health departments are stretching existing staffing to the limit to meet current contact tracing needs. But staffers currently reassigned to the tracing effort will eventually need to resume performing immunizations, promoting reproductive health and combating addiction.
“We’ve been able to have all hands on deck at this point, because we haven’t been able to offer our full complement of services,” said Johnson of Grand Traverse County, but the COVID-19 response will be years long.
“As these restrictions start loosening up, it’s going to be a very scary time for us.”