Two months ago, the Tennessee Department of Health’s contact tracing program was merely a simplistic, uncontroversial tool to prevent the spread of highly contagious diseases.
If a college student contracted a sexually transmitted disease, contact tracers from the health department would reach out to the student’s partners to inform them they had been exposed. If a measles outbreak sprung up at a daycare, the contact tracers would identify which toddlers were possibly exposed to the disease and educate families about treatments. In short, contact tracing was a commonly used healthcare practice that most people didn’t know existed.
But, since the COVID-19 pandemic ravaged Tennessee, the state’s contact tracing program has soared in its importance to public health and in the intense political scrutiny it has received.
From the right, politicians have expressed concerns that the very act of bureaucrats calling up sick people and asking personal questions is an invasion of privacy. And from the left, leaders have blasted the state’s contact tracing program for not hiring enough people, failing to articulate a formal plan and not tapping into federal CARES Act funds that could bolster the daunting effort.
As of Saturday, 22,566 Tennesseans are known to have contracted the highly contagious virus and 364 people have died. While Gov. Bill Lee has been lauded for ramping up testing, especially offering the test for free even to those who are asymptomatic, the state’s contact tracing effort has largely flown under the radar.
Public health experts say contact tracing is the equally important companion to the state’s testing efforts. Nations with robust contact tracing programs such as South Korea and Austria have used the decades-old strategy to snuff out COVID-19 in a matter of months.
“Why are we using contact tracing on COVID-19, but we don’t use it on influenza or something like that? I think there’s two big reasons,” said Marie Griffin, director of Vanderbilt University’s master of public health program. “One is that COVID-19 has what’s called an incubation period – it takes longer than something like flu for a person to become sick. With COVID-19 it’s like five to seven days so you have a window of opportunity to identify people before they become sick. That’s different from flu where your window of opportunity may only be one to three days.
“The other thing with COVID-19 is there’s what’s called a pre-symptomatic period where people who are going to become ill can transmit the virus before they become ill, especially in the two days before they become ill.”
TN bulked up contact tracing
Since the pandemic hit Tennessee earlier this year the health department has trained existing workers, in some cases moving employees from other agencies, and now has 350 employees handling contact tracing. Another 150 employees provide support to contact tracing efforts, a spokeswoman said.
Once a person tests positive for the virus, a contact tracer attempts to reach them by phone. The goal is to contact the individual as quickly as possible since, as Griffin described, the pre-symptomatic period is when the virus is likely to spread.
A document on the health department’s website details the script a contact tracer uses to ask the person who tested positive a series of questions. “Was anyone else staying in the same place as you? What is your work environment like? Where did you go to dinner? Have you been to any other social gatherings?”
The answers to those questions provide the tracer a list of people to contact to alert them they may be sick.
In a phone call with lawmakers earlier this month, Health Commissioner Lisa Piercey emphasized that those contacted by the department are not forced to cooperate. Piercey said the first line of defense against the virus – primary prevention – is washing hands, staying six feet apart and wearing masks in public. She described contact tracing as a secondary prevention tactic.
“If you are at risk of something, then knowing that sooner and mitigating any potential risk, or catching a disease process earlier is a secondary prevention strategy, which is also incredibly important,” Piercey said. “And that’s what contact tracing does.
“It’s really important, but I do want to stress the point that it’s just another voluntary tactic that we use to help reduce the spread so we can get back on our feet in the midst of this infection.”
The state handles contact tracing for 89 counties and the six largest counties with their own health departments have their own contact tracing programs. The counties and state use the same software program to track their tracing efforts and share the data with each other.
GOP leaders fear government overreach
In a letter to the General Assembly on May 11, state Rep. Scott Cepicky (R-Culleoka) expressed concerns about contact tracing and the practice of sharing COVID-19 patient lists with first responders. The Tennessee Lookout first reported about sharing patient lists with first responders, a practice Lee’s administration decided to end last week.
Cepicky said he was worried that the state keeping sick lists could motivate people who think they may have the virus not to get tested.
Although state officials have used cell phone data to track how much Tennesseans are moving around amid the pandemic, the state has not utilized cellular data for contact tracing efforts. In Europe, several countries including Switzerland and Austria utilized a voluntary contact tracing app where citizens could check to see if they visited a location with a known outbreak.
“Most recently, an issue of great concern is the infringement of personal privacy and liberty that is happening right now in Tennessee,” Cepicky wrote. “As you know we now have contact tracers in place and sick lists being distributed to first responders and law enforcement. These lists are being used to single out people that have tested positive for the virus.
“However, 98 percent of those that contract the virus may experience little to no symptoms and will recover normally without any assistance. I am concerned that these reports and lists will have an adverse effect on testing. As a result, Tennesseans will stop getting tested to protect their privacy.”
In a Q and A on Twitter last week, U.S. Rep. Tim Burchett (R-CD 2) was asked his rationale against contact tracing.
“I fear the constant overreach of government,” Burchett tweeted.
Cepicky and Burchett are Republicans, but while they fear the state’s contact tracing program goes too far, some Democrats are concerned the efforts are not going far enough. State Rep. Mike Stewart (D-Nashville), the House Democratic Caucus chairman, has taken the lead on questioning the health department’s contact tracing program.
Top Democrat: state lacks a formal plan
Stewart first inquired about the department’s contact tracing plan in a letter on April 13. He followed up with letters on April 27 and May 6 before Piercey finally responded. Stewart told the Tennessee Lookout that Piercey’s response was inadequate. Stewart said he’s concerned the department is dropping the ball on contact tracing as Lee continues to reopen the state and loosen restrictions on public gatherings for most of the state.
“Is there a document that explains what state and local resources are currently devoted to contact tracing and how they are deployed and managed?” Stewart asked the commissioner in his May 6 letter. “If so, can you please provide it? Secondly, have additional resources, in terms of money and/or equipment, been devoted to contact tracing since the COVID-19 outbreak occurred? If so, what resources have been devoted to contact tracing and how are they being utilized? Is there a list or other document that outlines all state funds and equipment devoted to contact tracing to date? What persons within the Administration are responsible for implementing contact tracing in Tennessee?”
Stewart said the state should be hiring more outside contact tracers, marketing the program so that those infected with the virus are aware of why it is useful and hopefully will be more willing to cooperate, and using federal funds from the CARES Act to improve Tennessee’s response. Reporting by the Chattanooga Times Free Press detailed Stewart’s concerns over contact tracing early in the pandemic.
New York state has made marketing its contact tracing program a part of its response to the pandemic. A Twitter ad, shared by Gov. Andrew Cuomo, encourages people to answer the phone when called by a contact tracer.
According to a study by the Association of State and Territorial Health Officials, Tennessee should have 2,081 contact tracers based on its population size. The department didn’t answer questions about its plan to promote the contact tracing program so that more people cooperate when contacted.
“The bottom line is we don’t have a plan, and we’re more than two months in and more people are going out in public and so it’s more important than ever,” Stewart said.
Health department spokeswoman Shelley Walker said, “At this time there are approximately 500 employees currently involved in case investigation, contact tracing and case and contact monitoring across the state. We could not put a specific figure on the amount of money spent on this; it would be staff time only.”
Walker said the county-run health departments with their own tracing efforts use the same database system as the state and the groups work together and share information.
Nashville resident Erin McAnally and her husband were diagnosed with COVID-19 in late March. Her description of talking to city contact tracers painted the picture of a rather informal conversation.
“We were asked very few questions and they seemed to jump to assumptions,” McAnally said. “My husband had been in Miami on business about 10 days before he got sick and as soon as we told them that, they said, “Oh that must be it.”
Top official defends program
Dr. Tim Jones, the chief medical officer for the state health department, said the staffing levels so far have been adequate to handle the case load, but there are plans in the works to hire more. Because some employees who were moved from other areas within the health department, or from other agencies, may soon have to return to their regular jobs, Jones said it could be necessary to hire more contact tracers.
Walker said the department could potentially use CARES Act funding for hiring more tracers if the number of cases demands it.
“I think the definition of adequate is, ‘Are we doing our job and succeeding,’ which means are we able to call all the people we need to call?” Jones said. “The day that we can’t call 10 people because we have too many cases, then we don’t have enough and we’re failing and we need to get more.”
There are 102 diseases other than COVID-19 for which the state does contact tracing, Jones said. He described contact tracing as a “core, fundamental public health effort” that’s been done for decades and yet, “six months ago, no one would have had the slightest idea what we’re talking about.”
“I would say on the first day of the outbreak,” Jones said when asked when it became clear that contact tracing would play a vital role in the state’s pandemic response. “Contact tracing is something we do all day every day. We use the same term and same techniques for sexually transmitted diseases, for HIV, for measles, for meningitis, basically for any disease where we have a case and there’s active risk to the people around that person.”
Jones said the department’s primary emphasis is on tracing who has come into contact with an especially vulnerable person. He used the example of a college student coming down with the virus and contact tracers urgently trying to contact the students who sat next to them in class as opposed to someone who may have sat far away in a larger auditorium.
Jones said it’s taken “a lot of time, energy and resources” to cross-train existing employees on contact tracing. He said tracers are dependent on a sick person’s honesty, good memory and willingness to cooperate.
“If someone doesn’t want their privacy invaded and they don’t answer the phone, or scream at me and say, ‘Get off my back, government person,’ there’s nothing more we can do. But at least my conscience is clear that I tried to help that person and I’ve done what I can do.” – Dr. Tim Jones
“We make every effort to reach each person we are aware has the virus, but if we call 10 times and leave messages and no one answers or returns the call, that’s not a failing of the contact tracing,” Jones said, adding the goal is to reach people absolutely as soon as possible after a positive test.
Jones disagreed with the concerns from some GOP leaders that contact tracing could be viewed as government overreach.
“I signed an oath to do everything that I can in my power to protect the health of people, patients or in this case it’s my population,” Jones said. “You could have said Democrat or Republican and flipped them and it wouldn’t make any difference to what I do. I would quit before someone told me I can or can’t do the right thing to a patient.
“If someone doesn’t want their privacy invaded and they don’t answer the phone, or scream at me and say, ‘Get off my back, government person,’ there’s nothing more we can do. But at least my conscience is clear that I tried to help that person and I’ve done what I can do.”