Coronavirus: US needs 'army' of 100,000 contact tracers and $3.6B to recover from the pandemic, says analysis
The key to America’s recovery is to find every person who has fallen sick due to the COVID-19 virus and trace the contacts of each case, according to experts. The goal is to interrupt the disease’s chain of transmission. The national plan by Johns Hopkins researchers estimate that to make this massive effort possible, an additional 100,000 workers have to be employed in the US. This would need substantial funding to the tune of $3.6 billion, shows analysis.
The researchers explain that to relax community mitigation efforts and other measures to reduce COVID-19 transmission, it is essential to rapidly test all symptomatic cases of COVID-19, identify and isolate all positive cases, and conduct contact tracing for all close contacts of each and every case. This level of case-based intervention will help enable a lessening of social distancing measures, but it can be accomplished only by massively scaling up the local and state public health workforce.
“We need an army to do this,” says Dr Anita Cicero, deputy director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, and a lead author of “A national plan to enable comprehensive COVID-19 case finding and contact tracing in the US” in a statement.
Why does the US need such aggressive contact tracing? It is estimated that each infected person can, on average, infect 2 to 3 others. This means that if 1 person spreads the virus to 3 others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections, say experts.
“A national effort to scale up and expand local, state, and territorial case investigation and management is necessary before US communities can begin to return to “normal.” If we can find nearly every case, and trace the contacts of each case, it will be possible, in time, to relax the bluntest approaches: the extreme social distancing measures, such as stay at home orders, and realize the commensurate social and economic benefits,” says the report released by the Johns Hopkins Bloomberg School of Public Health.
The research team includes experts from the Johns Hopkins Center for Health Security and the Association of State and Territorial Health Officials (ASTHO).
“This needs an unprecedented and rapid scale-up of the public health workforce dedicated to case identification and contact tracing. To trace all contacts, safely isolate the sick, and quarantine those exposed, we estimate that our public health workforce needs to add approximately 100,000 (paid or volunteer) contact tracers to assist with this large-scale effort,” say experts.
The team explains that this workforce could be strategically deployed to areas of greatest need and managed through state and local public health agencies that are on the front lines of COVID-19 response.
Battered by budget cuts over the past 15 years, and job losses since the 2008 recession, state, and local public health agencies need a massive infusion of federal support for contact tracers, says the plan. “To do this (task), we also estimate that Congress will need to appropriate approximately $3.6 billion in emergency funding to state and territorial health departments,” says the research team.
The US is currently the worst-affected nation in the COVID-19 pandemic. Over 557,570 cases have been reported from across the US as of April 13, and over 22,100 have died, shows the John Hopkins tracker.
Lessons from other countries
Several countries have demonstrated that an approach of aggressive case-finding and contact tracing can be an effective measure in helping to control the spread of COVID-19. One example of extensive contact tracing comes from South Korea (population 51.47 million), a country that was able to develop contact tracing plans in response to the spread of a different coronavirus, Middle East respiratory syndrome (MERS) in 2015, says the report. “This experience also prompted the revision of several laws to help improve outbreak response.
Contact tracing in South Korea incorporates patient interviews as well as the use of medical records, cellphone GPS records, credit card transaction records, and closed-circuit television,” say experts.
A WHO-China joint mission report says that Wuhan employed 9,000 contact tracers (1,800 teams of 5 people) to undertake “meticulous case and contact identification.” These teams reportedly traced tens of thousands of contacts per day and followed up often with both cases and contacts, say experts.
Based on their experience from the 2003 SARS outbreak, Taiwan (population 24 million) and Singapore (population 5.6 million) have used technological approaches to augment traditional approaches to contact tracing. According to the researchers, Taiwan linked medical records, health insurance records, and travel history to contact tracing efforts and provided a toll-free hotline for reporting of potential cases.
“Singapore introduced the use of ‘TraceTogether,’ a mobile app that uses Bluetooth signals to determine when users are near each other. Records from TraceTogether are stored for 21 days and can be used by the health ministry to identify close contacts of confirmed cases. Singapore has freely released this technology to developers. A similar system is now being launched in Britain,” says the analysis.
New Zealand (population 4.8 million) and Iceland (population 364,000) have also found success through the use of aggressive traditional contact tracing measures supplemented with complementary technology.
“As of April 7, Iceland claims that approximately 50% of newly diagnosed cases found in the country had already been quarantined and linked to other confirmed cases, as a result of contact tracing efforts. As of April 6, New Zealand claims that 81% of total cases are linked to overseas travel (43%) or are close contacts of other cases (38%), with only 2% of cases occurring as a result of unidentified community transmission,” say experts.
They add, “Despite their small populations, both New Zealand and Iceland provide examples of useful ideas that could be considered as US states and territories implement case identification and contact tracing strategies to rapidly decrease COVID-19 transmission.”
What can the US do?
The researchers say the state, territorial, and local public health agencies in the US have the existing capacity to conduct contact tracing for infectious diseases as a core public health function. But this capacity is sufficient only to respond to isolated outbreaks or individual cases of infectious diseases. Tuberculosis and syphilis are examples of diseases for which case identification and contact tracing are used in the US to reduce infectious disease spread.
The experts say due to the vast range of state size and geography as well as state-specific population characteristics, state and territorial response efforts will vary greatly in the US.
The team explains that learning from what has worked elsewhere, when normalized by population, there would be 15 contact tracers per 100,000 population in Massachusetts, 4 in New Zealand, 81 in Wuhan, and about 7 for Iceland.
When applied to the US population, a New Zealand-like approach would mean a total of 13,000, and a Wuhan-like approach would mean more than 265,000 contact tracers in the US. “These are useful examples. But when considering the workforce needs for a successful US contact tracing effort, it is essential to take into consideration that the United States leads the world in numbers of cases, the virus was able to spread unabated for several weeks, ubiquitous testing is still not available, and international travelers are not the main drivers of the US outbreak,” says the analysis.
Accordingly, say experts, the US will need a much larger workforce than a country like New Zealand, which has its outbreak under better control, has reported significant compliance with physical distancing and stay-at-home measures, and can efficiently identify visitors and travelers to the country who may be COVID-19 positive.
“If we take the Massachusetts approach and apply it across the country, that will mean about 50,000 additional contact investigators are needed in the US. However, many more will likely be necessary, considering the large number of cases already in the US, that COVID-19 has been circulating widely for many weeks, and that we still do not have sufficient levels of testing,” says the team.
They add, “Therefore, it would make sense to at least start by adding an extra 100,000 contact tracers across the US. While this figure may be stunning, it is still the equivalent of less than half the number employed in Wuhan.”
Required training and funding
The experts recommend that to be effective, case investigators and contact tracers must receive training on the basics of disease transmission, and the principles behind case isolation and quarantine of contacts as a public health measure. They should also be trained in the ethics around public health data collection and use, risk communication, cultural sensitivity, and the specifics of local processes and data collection for the effort.
According to the team, scaling up a contact tracing workforce of this size should be managed by state and territorial public health departments. Local and tribal health departments, as well as other state assets and organizations, should also be involved, they add.
This initiative could provide an income to many who have lost their earnings as a result of the pandemic. The researchers estimate that based on the average pay for a community health worker of $17 an hour, the potential overall need for funding for a cadre of 100,000 contact investigators, absent a huge number of unpaid volunteers, would amount to approximately $3.6 billion. This is assuming that all 100,000 workers work full time for 1 year.
Workforce protection and safety are critical, and measures should ensure that any individuals going out into the community must have appropriate protective measures, say the team.
Technology must also be explored as a force multiplier so that 1 worker can connect with many more people in the community, say, researchers. They can also enable contact tracing without exposing workers to infection. The team emphasizes that if shortages in personal protective equipment continue, then phone- and internet-based contact tracing will be even more necessary to ensure the safety of the contact tracers.
Effective management will be key. The experts suggest establishing a robust management infrastructure at the state and local level to strategically deploy, guide, and supervise workers; and to properly manage the data coming out of this effort.