The 62-year-old retired music teacher, legs outstretched with a red backpack at his feet, leans in as he speaks with a suspected coronavirus patient about their favorite hobby. Although the patient is somewhere in Lancaster County and Stover is sitting at a computer terminal in a nondescript office park, his body language is that of a friend engaging in small talk.
After a chuckle, he steers the conversation to the matter at hand: “I’m going to go through a few symptoms. You just tell me which ones you’ve experienced.”
Each conversation is a little different but this is what you can expect when you get the call that someone in your life has tested positive for COVID-19 and may have exposed you, as well.
“It’s not fun for anyone,” said Stover. “Part of our job is to tell them they’re not alone. They sometimes spend hours in a phone loop where nobody picks up; [the] contact tracer becomes a friend who’s looking out for them.”
Since Penn Medicine Lancaster General launched its contact tracing program this May, 36 investigators and tracers have followed leads provided by 1,197 coronavirus patients to 1,650 of their close contacts, some of whom eventually tested positive for the disease.
Contact tracing is hardly new. For centuries, from the bubonic plague to AIDS, public health officials traced the path of infectious disease with the goal of warding off further spread.
The average coronavirus patient will infect about two others, a ratio called the R-naught. When that figure dips below 1, it’s a sign the disease is waning. Right now, Pennsylvania’s R-naught is hovering at 0.98 due in part to contact tracers like Stover.
For months, Pennsylvania’s Department of Health struggled to ramp up contact tracing — much like its effort to expand testing — in advance of an expected second wave of infections this fall. As of last week, the state reported 1,205 contact tracers working statewide.
But that’s far below what’s needed.
Pennsylvania needs at least 3,840 tracers in order to meet the National Association of County and City Health Officials’ estimated workforce of 30 tracers per 100,000 residents to inform, warn and track those who’ve been exposed to the coronavirus.
Health Secretary Rachel Levine said the state is aware of the shortfall.
“We’re working our way toward those goals,” she said, noting that her agency’s internal goalpost is actually even greater — building to an estimated 4,500 contact tracers this fall.
And Pennsylvania is hardly alone in failing to meet the need. A recent survey by the Johns Hopkins Center for Health Security and NPR found a nationwide contact tracing workforce at just over 41,000 among the 45 states that provided numbers. Only five states and Washington, D.C., reported enough staffers or reservists to meet the need.
"Contact tracing seems to have stalled — or become less of a priority in many places," Crystal Watson, a senior scholar at Johns Hopkins, told NPR. "That is — in a lot of cases — understandable, given the case numbers that we're seeing, but I think it's still very important to have these workforces in place."
Part of the problem is funding.
While contact tracers don’t earn a lot of money — those at Lancaster General are paid between $16 and $20 per hour based on their level of experience — the costs accrue quickly. The state Department of Health’s emergency staffing request put the cost to hire 1,000 tracers and a few dozen support staff for five months at $22.9 million.
So far, such efforts have been funded via the federal CARES Act. Lancaster General, for example, received a $25 million contract for its COVID-19 response, including contact tracing.
But Congress and the Trump administration has yet to replenish the dwindling funds that would help expand contact tracing through the fall and winter.
That’s opened the door to a different kind of contact tracing.
Next month, Pennsylvania will launch a smartphone app that tracks where users go and warns them if they’ve spent at least 15 minutes within six feet of someone who tests positive for the disease.
The app, COVIDAlert Pa, is the result of a $1.9 million contract awarded to NearForm, an Irish software company, and is based on technology developed by Apple and Google. It uses the phone’s Bluetooth technology to track a user’s location and compare that against the location data of other users.
Of course, this app is entirely voluntary: It can only trace COVID-19 among those who agree to have their movements tracked.
“The more people who have the app,” Levine said, “the more effective it will be.”
Levine stressed that the app will not replace physical contact tracing but it will help bolster the system. And, much like the app’s human counterparts, the state has no plans to use it to force people to quarantine, she said.
“We do have the legal authority to mandate isolation and quarantine,” she said, “but what we’re finding is people will do the right thing. This app doesn’t have anything to do with that.”
COVIDAlert’s goal, instead, is to give users advance warning that they may have been exposed to the disease. With that knowledge, they can get tested and voluntarily isolate themselves to avoid spreading the disease. In principle, that’s exactly what human contact tracers are doing.
But the app has a significant advantage over human contact tracers: It doesn’t rely on the fallible memories of patients.
“If you went [to get] take-out and then to CVS, you may not know all the people you were within six feet of,” Levine said. “So when our contact tracers call you, you may not know who that person is.”
The technology on which the app is based, however, faces criticism both for gaps in its effectiveness and concerns about privacy.
“It really is too imprecise,” Cindy Cohn, executive director of the Electronic Frontier Foundation, told NBC. “You can’t tell if there was a wall between you and another person. You can’t tell if you’re on the same floor. If you’ve ever tried to connect to someone’s Bluetooth appliance, you can see that it really isn’t a substitute for the kind of thing a physical contact tracer is trying to get to.”
The app’s developers vowed not to share location data with government agencies and, at least in theory, its use of Bluetooth means that phone users are identified by a number rather than a name.
And that question of privacy is one that even physical contact tracers must grapple with.
Each hospital system’s contact tracing program is a little different but the principles are the same: Federal privacy laws protect the identity of a patient who shares information about who they were in contact with.
“When tracers call, they don’t have the information about who the initial person is,” said Alice Yoder, Penn Medicine Lancaster’s executive director of community health. “Their contacts will never know who gave the information.”
Generally speaking, a contact tracer will start by asking to verify the contact’s name, date of birth and address to ensure they’re speaking to the right person but they’ll never ask for a Social Security number or any financial information. Those with questions or seeking to verify the identity of a contact tracer can call the department at 1-877-PA-HEALTH.
In Lancaster, tracing generally begins with a case investigator like Jennifer Carter. A registered nurse, she began the year working mostly with schoolchildren. After coronavirus closed the schools, she moved to the contact tracing program, where she calls patients who’ve tested positive for coronavirus. Sometimes, she’s the one to break the news.
“The big thing for me is to be the friendly voice on the end of the call,” she said. “These are confusing times. I stress my role as a nurse, identify myself right away.”
Carter’s conversations tend to be a two-way street.
Often, she’s responsible for explaining the disease, its symptoms and treatment options as well as connecting the patient with community resources, since a COVID-19 diagnosis can disrupt employment, schooling and virtually every other aspect of daily life.
When the call turns to the question of who the patient may have been in close contact to, Carter said there can be some skepticism. But that’s not the majority.
“I can’t say I’ve hit a ton of resistance,” she said. “Where I have, we’ve met in the middle.”
Her most persuasive argument is an appeal to altruism: “We’re in this together.”
Actually figuring out who someone may have exposed to the coronavirus can be tricky. Since the people Carter’s calling had enough of a suspicion that they sought out a test, many already started thinking about their public interactions.
Even so, can you remember everything you did for the last week?
“I always think to myself, ‘Oh my goodness, figuring out where you’ve been can be pretty challenging’,” Carter said.
The case investigator begins with the most obvious risks: Who are your contacts within the home? From there, she works outward in concentric circles: work, school, social gatherings. Another trick: Carter asks the patient to look through their cell phone calendar and contacts, using the dates and names to jog their memory.
“I’m quite amazed what they can remember,” she said. “People are willing to help and may even bring on other family members to help them.”
Carter enters all of this information into a database, stripping any identifying data about the person who provided the contacts. That’s where a contact tracer like Stover comes in.
Like Carter, tracers are there to explain the disease to these contacts, the need for isolation and ask for other close contacts who they may have exposed. If the contact is already experiencing symptoms, he will escalate the call up to a nurse. Likewise, the hospital system has translators if the person speaks another language.
There’s no requirement that contacts or patients cooperate with tracers or that they self-isolate but Stover said most of them do.
“I always tell people this is about keeping you and everyone else safe,” he said. “It’s not like we put bracelets on them and track them.”
And the personal touch goes a long way.
Stover worked in the Peace Corps, traveled widely and speaks several languages. He’s organized AIDS awareness events and even found himself on the receiving end of contact tracing after one of his travels. He doesn’t share all of this with the people he speaks to but, whenever possible, he tries to connect with the person on the other end of the line.
“This is who I am,” he said. “I didn’t want to sit at home wringing my hands saying, ‘Oh the pandemic, oh the pandemic.’ I wanted to be involved.”
©2020 The Patriot-News, Distributed by Tribune Content Agency, LLC.
