When people are first diagnosed with COVID-19 in Lorain County, they receive a call from someone like Mitch Dandurand, an epidemiologist at Lorain County Public Health. He asks them to think about whom they have been in close contact with in the past few days.
This is the first step in contact tracing, which has been effective in tracking and preventing the spread of infectious diseases, such as SARS in 2003 and Ebola in 2014, and now in the COVID-19 pandemic.
After helping those with COVID-19 recall their close contacts, people known as contact tracers then call each one and tell them to self-isolate for 14 days. The contact tracer calls them daily to check in.
"You have to think about the overall goal of contact tracing to begin with," Dandurand said. "And that is to identify their close contacts and quarantine, while also not quarantining anybody that shouldn't be quarantined."
Because contact tracing is a labor-intensive process, the Ohio Department of Health (ODH) is planning to hire 1,750 part-time contact tracers across the state within the next 12 to 18 months, specifically to track COVID-19. Local health departments are ramping up their contact tracing efforts as well.
Melanie Amato, press secretary for ODH, said there are three ways in which Ohio plans to reach its target number of contact tracers.
"One, local health departments will reach out to their communities to see if anybody would like to volunteer as a contact tracer," she said. "Two, ODH will provide funding to the local health departments so they can hire additional contact tracers; or three, ODH put out a job application to hire about 100 contact tracers across the state that would work virtually, to help any local health department that needs it."
In surrounding states, like Michigan, state health departments also are preparing to hire contact tracers to deploy to local health departments that need extra help.
Jonathan Warsh, chief of staff at the Michigan Department of Health and Human Services, said local health departments across the state already have several hundred people doing contact tracing and the state health department is prepared to hire up to 1,000 people.
"If that number expands and we need 2,000 or 3,000 people, then we'll meet the demand," he said. "But we want to be less dogmatic about just hiring 'X' number of people, versus really understanding what the disease and the conditions on the ground demand."
In his daily media briefing on April 24, Ohio Gov. Mike DeWine announced the state will significantly increase its testing capacity. "Beginning this coming Wednesday, (Apr. 29), our capacity will be at least 7,200 tests a day and that number will go to 15,000 by May 6, 18,500 by May 13 and 22,000 by May 27," DeWine said.
This increased testing, paired with the "robust, aggressive system" for contact tracing that DeWine announced, will help public health officials better track the virus and prevent further spread. On May 11, the state Controlling Board approved the use of federal COVID-19-related funding, freeing up $12.4 million for local health departments to perform contact tracing in May and June.
To help state and local health departments hire more contact tracers, Ohio is working with Partners in Health, a Boston-based nonprofit healthcare organization.
While contact tracers hired at the state level will complete training online and then work from home, Amato said local health departments can have their own policies in place to handle contact tracing in their communities.
Lorain County Public Health is working with its core team of contact tracers, including nurses, sanitarians and epidemiologists. But Kat Bray, a health education specialist in the department, said more contact tracers may need to be hired to support the existing team.
"We're looking to continue to ramp up our contact tracing, because as Ohio reopens, we may potentially have more contacts of those confirmed cases, since the stay-at-home order is going to be expiring," she said on May 15, before the original order expired on May 29.
Sherry Smith, director of nursing services at the Stark County Health Department, said it has a communicable disease unit consisting of epidemiologists and public health nurses, where reports of COVID-19 infections are received. Smith said they haven't hired any contact tracers yet, but the department has received some assistance from nurses from the schools of nursing and other health-related prevention programs in the county. She explained the department has contracted with local schools of nursing, allowing students to work with experienced public health nurses for their clinical experience, and also to help with contact tracing.
According to Smith, Stark County was seeing double-digit numbers of COVID-19 cases on a daily basis for most of March and April. But with the stay-at-home order and implementing other healthy behaviors — like social distancing, mask wearing and hand washing — they were able to stop the number of cases from increasing.
"I do feel it (contact tracing) is very effective," she said. "As long as it's done properly and the local health department knows about sick individuals; and sick individuals are reported to the local health department, so we can effectively identify contacts and get them put in quarantine — or at least, doing best practices if they're not in quarantine, while they're at work or wherever they need to be."
The contact tracing structure in Lorain County consists of four teams, with information passed among them, as Dandurand explained the contact-tracing process.
The first is the interview team, which receives the initial notification of a positive COVID-19 case.
"We like to keep our interview team small and consistent," Dandurand said. "That way, we're not having different interview techniques. They kind of dictate how you collect your information, so we try to keep that as consistent as possible."
The interview team calls the individual with the positive case to determine all their close, recent contacts. Dandurand said it's important that the interview team knows the date of symptom onset, because they identify close contacts around that date, as well as up to three days before symptoms started, which is when the person is most infectious.
"The definition of close contact is six feet or closer for a prolonged period of time," he explained. "We're using about 15 to 20 minutes or longer. We also collect information on mask-wearing, just to gauge the risk."
The interview team compiles the data on a form and lets the individual know that they'll receive a call every day from a public health nurse, and the contacts they've listed will be under quarantine from the health department.
Next, the interview forms go to the quality assurance team, where Dandurand or another epidemiologist goes over the details with the interviewer. They want to make sure interviews are remaining consistent, and they're not stretching the definition of a 'close contact' too far and unnecessarily quarantining anyone.
From there, the quality assurance team adds the names and any phone numbers the interview team gathered to a line list, a table that contains key information about each case in an outbreak, sorting the start and end dates of their quarantines.
The quality assurance team passes its information to a team of lead nurses, known as the quarantine introduction team. This team is responsible for calling the people on the line list to inform them of their need to quarantine and answer any questions they might have.
"They'll say, 'On this date, you were exposed to a confirmed case of COVID-19; your mandatory quarantine starts on this date and it will end on this date,'" Dandurand said. "And you can imagine, if you got a call that said, 'You're under quarantine,' you're going to have a lot of questions (and) you might have different resources that you need links to."
Dandurand said they've been dropping off thermometers to people who don't have them so they can take their daily temperatures, linking people with unemployment resources if needed, and grocery delivery services, to name a few.
After the quarantine introduction team, each case is passed on to the active monitoring team, which consists of many school health nurses.
"Obviously, schools have been closed, so they've had a lot of time freed up and they do the active monitoring piece," Dandurand said. "Those contacts are then called, every single day for their 14-day quarantine period, to get their symptoms and/or lack thereof. If they do become symptomatic (and) they fit that clinical definition, the active monitoring team will chart that in the case logs. The lead epidemiologists review the case logs daily and determine if somebody's symptoms fit the criteria to become a probable case."
Once the 14-day time period is over, the active monitoring team lets the person know they're released from quarantine. This ends the contact-tracing process.
Contact tracers must have a solid variety of "soft skills," like empathy, to be able to make these phone calls and deliver news they may be terrified to hear - that they've been in contact with someone who tested positive for COVID-19.
"You have to be empathetic, of course, but you have to inform them why you're doing things," Dandurand said, stressing that it's much more than delivering a quarantine start and end date. "It's more of working with that person to say, 'Listen, you live with a case.' They're shedding the virus. It is very easy for you to take that virus into your workplace.
"We understand it's a very unique time, a very strange time in our world," he said. "We've got to do these strange things that seem very out of the ordinary. It almost seems like an overstep sometimes, but you have to explain the science behind it, and that they're actually doing their community a big favor. Most of them start to come around, once you inform them that what they're doing is protecting the community."
While contact tracing has proven to be useful, Dandurand said one thing he's learned during this whole ordeal is that nothing is certain.
"Something that might make sense one week — the next month, you might look back on that and say that's not really a great decision," he said. "So I can't say with certainty, 'Yeah, we need to invest in contact tracing to the max.' Contact tracing is very difficult for this type of illness. It's a flu-like illness. You might not have it one day-and then, you go to the grocery store and you can get it virtually the next day. However, where it will come into benefit is basically the household contacts, and keeping them out of the workplace exposure."
When they identify a close contact, Dandurand added, they also inform the contact's employer. If the contact is an essential worker and can come back to work in a mask, their employer can decide if they would rather keep that person off the job until their 14-day quarantine is over. That's a situation in which Dandurand thinks contact tracing is well worth it, especially in big factories or large places of employment.
"It can spread quick enough where it can shut down a factory," he said. "It's already done that for food -and it can just shut down operations, and a lot of employers don't like that. And that's where public health can really come in to help, is protecting those critical workers, avoiding workplace exposures and keeping businesses going."