As New York City’s coronavirus infection rate continues to rise, the city’s contact tracing program is bracing for an even bigger surge after the Thanksgiving holiday.
Despite repeated pleas from health officials to avoid travel, more than three million people traveled through U.S. airport checkpoints this past weekend, according to the Transportation Security Administration. Friday and Sunday marked the second and third times since the beginning of the pandemic when more than one million people were screened in a day.
The city’s Test and Trace Corps, along with the sheriff’s department, will be stationed at travel hubs across the city, including airports, bridges, and bus stations, to alert people to the city’s quarantine policy as they return. Travelers must quarantine for 14 days, unless they take a test on the fourth day of quarantine and get a negative result.
“Everything starts with testing,” said Dr. Ted Long, executive director of NYC’s COVID-19 Test & Trace Corps. “If they travel and come back or if they go to gatherings, they need to get tested. We need to see where the new cases are, who has contracted the virus, and then our contact tracers kick into gear and reach out to them.”
Tracking new cases is crucial to containing the spread of the virus, he said. But increased travel presents potential problems for the Test and Trace Corps, which is already dealing with a spike in cases. The city’s average seven-day infection rate on Tuesday remained above 3%, but areas like Staten Island have seen even higher rates, prompting Gov. Andrew Cuomo to enact new restrictions there and in Upper Manhattan. Once the clusters lead to community spread, tracing efforts become more difficult, if not impossible.
“When you have a disease that has such a large prevalence, contact tracing really isn't practical,” said Dr. Georges Benjamin, executive director of the American Public Health Association, the country’s oldest and largest public health organization.
In those instances, broader messaging makes more sense, said Dr. Benjamin, who’s worked more than 20 years in the public health field including as former secretary of the Maryland Department of Health and Mental Hygiene.
“You would put out some broad public announcement to basically say if you have these symptoms, if you've been around anybody who's tested positive or if you test positive, please let the people around you know,” he said. “The intent there is, you’re kind of letting the citizens help you with the contact tracing process.”
While there’s no infection rate threshold that experts can point to that would trigger switching strategies, there’s always a balancing act required in these decisions.
“You're always trying to trade off disease control to panicking the public and not ‘crying wolf,’” said Dr. Benjamin. “If people perceive that you’re ‘crying wolf,’ it will ultimately result in lower compliance.”
Officials also have to consider the capacity of their contact tracing teams alongside the prevalence of the outbreak.
At the onset of the pandemic, the National Association of County and City Health Officials estimated that at least 100,000 individuals would be needed to adequately do contact tracing. This number represents about 30 professionals for every 100,000 Americans. For New York City, that estimate comes to about 2,500 contact tracers.
Currently, the city employs about 4,000 contact tracers, according to Dr. Long.
“Across New York City, we're seeing, on the seven-day rolling average, on the order of 1,200-1,300 new cases a day,” he said. “With our team of seasoned contact tracers, we can easily handle well-over double that so we are equipped [to handle] whatever is going to come down the pipe to us.”
But the city’s still hiring more tracers, including in places like Staten Island.
And while that number might be enough on its face, according to certain guidelines, public health experts say the important part isn’t necessarily the number of tracers, but where the tracers are from.
“It's not a pure number [where we can say] ‘Okay, 4000,’ that means we’ve got it,” said Dr. Rachael Piltch-Loeb, associate research scientist at NYU School of Global Public Health. “It's about where those tracers are based and if they’re trusted by community members.”
When the Test and Trace Corps began its work in June, a little over half of New Yorkers completed their intakes, according to Dr. Long. And the program has continued to struggle with hiring Yiddish speakers, an important element in reaching Orthodox communities that saw a significant rise in infections over the past few months.
“We know that there just inherently is often a mistrust in government-employed people who want your information,” said Dr. Piltch-Loeb.
A national Pew Research Center survey in July found that 41% of respondents would be not at all or not too likely to speak with a public health official who might contact them about the coronavirus outbreak.
Since June, however, the city’s increased its intake completion rate to about 80%, according to Dr. Long.
“People have to trust us enough to be honest with us,” he said. “And I think because our program is run by New Yorkers who lived through the same horrors and tragedies of March and April — that's how we earn people's trust.”
The ability to not only reach someone over the phone but gain that trust highlights the importance of contact tracers coming from the communities they’re tracking.
“You’ve got to be prepared for that person having a complete meltdown,” said Dr. Benjamin, on the skills often required of contact tracers. “You're not just a recorder of information. You’ve got to have the psychological skills to talk with someone and, in essence, handle their acute grief when they hear they've been exposed to a disease.”
But at the end of the day, even with enough culturally-competent tracers, their work can only begin if everyone’s getting tested.
And as lines for testing are getting longer, that could prove challenging.
Though Dr. Long says that the city plans on continuing their contact tracing work no matter what threshold of infection is reached, at a certain point, people may feel the need to contact those around them if they do end up with a positive test result. It’s why experts emphasize the importance of educating everyone on the resources and protocols in place to protect people.
“What do you do if someone calls you and says, ‘It was great having you over for dinner and turkey, but you got something else while you're here or, at least, you got exposed to something while you’re here’?” said Dr. Benjamin. “And so people don't panic, we need to tell them what to do, where to go, and what the contact numbers are for the local health department. We’re going to have to plan for that.”