State health officials said this week that they're prepared for a likely increase in demand for coronavirus contact tracing as schools and colleges reopen this fall. This process involves finding out exactly who an infected person might have exposed to a communicable disease.
Gov. Chris Sununu has described New Hampshire's contact tracing program as one of the best in the country. But the state hasn't shared many details on the program until now.
NHPR spoke to Beth Daly, the chief of the state’s Bureau of Infectious Disease Control, about how health officials are keeping tabs on the spread of the virus, preparing for the reopening of schools, and trying to prevent new infections.
Here's what you need to know about what we learned.
What does a contact tracer do? How much contact tracing has the state done since the pandemic arrived in New Hampshire?
Contact tracing happens when the state confirms a new case of coronavirus or any contagious disease and tries to identify who else that person might have exposed. Tracers are responsible for ensuring that any potentially exposed people don’t spread the infection further.
“It’s really about containment and mitigation – preventing further transmission,” Daly says.
Daly says over decades, the state has typically done more than 8,000 case investigations and contact tracings a year for more than 60 different diseases, including food-borne illnesses, measles, mumps, chicken pox, tuberculosis, hepatitis, and HIV and AIDS.
She says the process for COVID-19 most resembles a sexually transmitted infection or a respiratory ailment like pertussis – all spread from person to person through close contact.
But COVID is different in its scale and sense of urgency. Daly says contact tracers, within 24 hours of a new confirmed case, will call the infected person and ask them a series of questions, based on this Centers for Disease Control script.
The tracers want to know: When did the person’s symptoms begin or when did they test positive for COVID-19, if they’re asymptomatic? And in the two days before they tested positive or their symptoms began, who did they have contact with, where did they go and what did they do?
From the start of New Hampshire’s coronavirus outbreak through Aug. 12, when Daly was interviewed, she says contact tracers had interacted with 22,157 people about possible exposures – including all 6,861 of the state's confirmed COVID-19 cases to that date, and 15,296 others who had contact with infected people.
What happens when tracers find out that an infected person may have exposed others?
Under CDC guidelines, tracers will contact anyone with whom the infected person thinks they had “prolonged, close contact.” Daly says the state defines that as being within 6 feet for more than 10 minutes - stricter than the CDC standard of 15 minutes.
“We think the risk is low for anyone who didn’t have close contact with someone,” Daly says. “Right now, because we have widespread transmission in the United States, we could all be coming potentially into contact very briefly with people who have COVID-19 unknowingly, and so that’s why we all need to be taking precautions – to stay six feet away, wearing masks.”
For example, Daly says infected people don’t typically have “prolonged, close contact” with their server at a restaurant or cashier at a grocery store. Instead, tracers will want to call people their subject went out to eat with, or potentially their employer if they went into work.
Tracers don’t tell these contacts who exactly might have exposed them to the virus, but they do ask more questions – using another CDC script.
Then they ask people who may have been exposed to quarantine themselves, if they don’t have symptoms, or to self-isolate, if they do or have tested positive for the virus. Tracers will check in on quarantined or isolated people every day of the prescribed period by phone, or sometimes text or in-person if needed, to make sure they’re doing OK and following those rules.
What if a tracer has reason to believe an infected person may have exposed a larger group of people, and officials can't pinpoint exactly whom or when?
In this case, the state would make a public notification that people might have been exposed at a certain place or time. This has happened a few times throughout the pandemic – including on bus trips, and at a tavern in Raymond last month after a bartender tested positive for the virus.
Daly notes that they’d have made a public notification if there were confirmed COVID cases at high-profile gatherings like the recent NASCAR race in Loudon. She says they do not believe anyone there was exposed to the virus – but she cautions that symptoms can take a while to manifest, and some attendees at that event came from out of state, so it’s not a sure thing yet.
What if tracers can’t get in touch with an at-risk person? What if someone doesn’t want to follow a tracer’s instructions to quarantine or isolate?
Daly says this happens, but rarely, and the state does have options to deal with it.
If they can’t get ahold of someone within about 24 hours of finding out they’re infected or might have been exposed, they’ll visit the person at home.
She says the tracers work to make sure a person has the support they need to quarantine or isolate, but did not immediately respond to a follow-up request for details on how that happens.
If the person refuses to comply with guidance given over the phone or in person, Daly says the state will visit their home with a legal order to self-quarantine or self-isolate. Throughout the pandemic, Daly says the state has issued five legal isolation orders, and two legal quarantine orders – out of thousands of other contacts where this was not required.
A person can respond to this by requesting a court hearing where the state must present evidence of why they believe the person is a health risk and a judge can make a ruling. Daly says this has not happened during the pandemic.
If a person refuses to comply without asking for that hearing, the state can get its own court order enabling police to enforce the quarantine or isolation through physical detainment. Daly says the state has also not had to take this step during COVID-19.
In general, she says, “we try to gain voluntary compliance. So sometimes it’s actually just a matter of having someone else talk to the person and try to connect with them and explain why it’s important. Sometimes the initial shock of having to isolate or quarantine – it’s a lot to take in.”
She says people often have family or financial concerns that make them reticent at first. In this case, the state will give the person time to absorb the news and call back a couple hours later.
How many contact tracers does New Hampshire have? Where do they come from and how are they trained?
The contact tracing staff has grown and shrunk along with the scale of the coronavirus outbreak in New Hampshire over the past several months. Daly says the state started out with its preexisting, dedicated staff of 15 tracers at the start of the outbreak earlier this year.
In March, they brought in “surge staff” from elsewhere at the Department of Health and Human Services. They had about 40 tracers in March, and 80 in April. In May, as cases rose, they added contractors and support from the National Guard – for a total of about 105 tracers in May, and 120 in June.
Daly says they’ve let some of the reassigned DHHS staff go back to their normal roles now, with about 110 tracers remaining on the job. She says they have the capacity to increase that number as needed, including as schools and colleges reopen this fall.
Daly says the contractors are assigned to this job through December, and could be extended.
She says new tracers undergo days or sometimes a week of training. They take an online course through Johns Hopkins University about how contact tracing works, along with training in cultural sensitivity, security, confidentiality and information technology. Tracers also receive mentoring and get a chance to practice their phone calls.
Daly says one way COVID-19 differs from other diseases they investigate is how rapidly its science is still evolving. Tracers receive periodic updates on new research about the virus and emerging risks to look out for in their work.
The Manchester and Nashua Health Departments have their own contact tracers, with whom the state coordinates. The state also participates in an interstate notification process with other states’ contact tracing programs, particularly elsewhere in New England.
Does the state plan to expand its contact tracing efforts as schools and colleges reopen?
Daly says she believes the state’s current contact tracing strategy can handle any potential increase in cases this fall. She says they can add more tracers to their staff as needed.
"When I think of what's going to happen with schools, it's partnership," Daly says. Schools have been asked to be in touch with the state about cases or potential exposures, and the state will be in touch with them.
She says they began a weekly standing call with school administrators and nurses after the state released its school reopening guidance, including issues related to reporting infections, last month.
School officials still have plenty of questions on how to implement that guidance, Daly says, "so we are trying to support them as best as we can."
Likewise, she says the state worked with the state's colleges and universities on their reopening plans. She says their coordination with schools is similar to what occurred during the swine flu or H1N1 outbreak of 2009.
State health commissioner Lori Shibinette said at officials' press conference Thursday that she fully expects more contact tracing will be needed when schools reopen.