If you or a family member test positive for the coronavirus in Camden County, the official calling to ask about your symptoms and advise you to quarantine might be a health inspector, a school nurse or even a police detective.
Like health departments all over the state, the county has rushed to train other government workers to do contact tracing, scaling its workforce from six to 52.
Camden County’s growth is a nearly nine-fold increase. But the county averages around 100 new cases a day and tracking down all their close contacts is a time-consuming job that involves investigation and good interview skills.
That’s why county Health Officer Dr. Paschal Nwako was so glad to hear Gov. Phil Murphy’s announcement this month that the state would train and hire 1,000 new contact tracers to help out local health departments.
“We’ll take all the help we can get from anywhere,” Nwako said.
Experts say that until there is a vaccine, the key to limiting the spread of the disease is widespread testing and contact tracing, and Murphy announced plans to scale up both.
Contact tracing is a long-standing public health tool where tracers interview positive people about their close contacts who may have been exposed, and then advise those contacts to quarantine, get tested or monitor for symptoms, depending on the virus.
In the absence of a statewide plan to enlist new contact tracers, the state’s patchwork of 94 municipal and county health departments have found their own help from volunteers and repurposed public workers, essentially tripling the number of workers doing disease investigation in New Jersey to about 900, according to the Department of Health.
Murphy’s plan comes nearly a month after some states launched their own massive contact tracing plans, though many state efforts are still in the early stages like New Jersey.
The governor said the state will partner with Rutgers School of Public Health to train at least 1,000 members of a Community Contact Tracing Corps. Members will deploy as needed to help local health departments, ideally in their own neck of the woods.
In places that have been able to keep up on contact tracing like Camden County, the new workers can help ease the workload and replace the government workers who will need to go back their regular jobs as things reopen.
But in some of the hardest hit areas of the state — where health departments were so overwhelmed with cases that they had no choice but to tell positive patients to inform their close contacts themselves — an influx of contact tracers could be a game changer.
The problem is contact tracing doesn’t scale easily.
It was already time-consuming work before the pandemic, Nwako said. His investigators would be notified that someone had tested positive for HIV, hepatitis A or another virus, and they would reach out to that person to do an in-depth interview about who else they might have exposed.
Then each of those close contacts would have to be called and advised to quarantine, monitor for symptoms or get tested, depending on the virus. For coronavirus, close contacts are those who have been within six feet of the person for 10 minutes or more.
Now, tracers are trying to do the same detail-oriented work but for thousands more patients in a very short amount of time. And while there is some technology that can make it more efficient, contact tracing a lot of infections simply requires a lot of workers.
Nwako said having far more contact tracers earlier in the pandemic would have been better, but no one was prepared because the public health workforce has been decimated over the years.
“You should be scaling in peace times, not in war times,” he said. “Would it have been better to get more contact tracers in March? Yes.”
Murphy said implementing the expanded testing and contact tracing plans will cost hundreds of millions — and then clarified that might be the bill every six months.
Based on the hourly wage of $25 Murphy suggested and the maximum 35-hour workweek, it could cost as much $875,000 each week for 1,000 tracers.
“We are hoping for a big support from the federal government. We’ve got to do it anyway, we have no choice, but we were very much hoping for a big slug of federal money,” Murphy said when asked how the state would pay for the plan.
Murphy’s Chief Counsel Matt Platkin said the $484 billion “COVID 3.5” bill passed in April has funds earmarked for states to use on testing and contact tracing, but the money hasn’t come through yet.
How is New Jersey going to train and deploy all these tracers?
While training 1,000 new contact tracers may not be an easy job, finding people willing to do the work does not seem to be a problem. In the first week, over 32,000 signed up to be considered as prospective tracers, the state said.
The state’s plan starts with Rutgers School of Public Health, which is collaborating on comprehensive training for new tracers that can be used statewide. Perry Halkitis, the school’s dean, estimated the first new hires could be trained and ready within a few weeks.
According to the Department of Health, the first round of hires will likely be public health graduate students and alumni followed by students in nursing, social work and psychology and then members of the general public.
Halkitis said dozens of his graduate students are already volunteering as contact tracers around the state.
“It doesn’t feel like all of a sudden we’re turning the ship in a different direction. It actually feels like we’re making the ship go even faster,” he said of the state’s plan. “It’s an opportunity for the school to work with the state to train both students and a workforce around a practical skill set that then serves the public health of the population.”
Halkitis said that while the School of Public Health is training and helping to deploy these tracers, it will be creating a kind of prototype for how to do it, so it can be scaled up and eventually managed by a third party, like a staffing company or nonprofit.
“You’ve got a brain trust at Rutgers School of Public Health. We know how to do this. An employment agency hiring tracers doesn’t necessarily know how to do this,” he said. “So we’re going to manualize it and help them, and when the state needs more people — if it needs more people — we can say here are all our materials.”
Health Commissioner Judith Persichilli said the state is soliciting proposals from vendors, organizations, and institutions to “aid with recruitment, assessment, hiring, training and management of contact tracers.”
The state is hoping to hire a diverse and multilingual workforce who can work in the area in which they live. Halkitis said the training will be intensive and ongoing, covering everything from ethics and privacy issues to how to be sensitive during interviews and refer contacts to social services if necessary.
Murphy said his new plan will also increase consistency statewide by requiring local health departments to collaborate for a more regional, county-based approach and implement a new technological platform built specifically for managing coronavirus cases.
New Jersey is the first state to announce plans to roll out the CommCare platform created by Dimagi, but it is already up and running in San Francisco and Santa Clara counties in California and in a handful of cities, said Jonathan Jackson, the company’s co-founder and CEO.
Jackson said CommCare makes it easier to input and manage case information even for those who are new to contact tracing. Currently health departments are using the state’s communicable disease database system.
“A lot of the current systems that were built in states were just not enough to handle this kind of volume,” Jackson said.
Will this contact tracing plan be enough to stop the virus?
Persichilli said at a press briefing this month that the total number of tracers hired is not set in stone. It will be re-evaluated as the state works with Rutgers School of Public Health to stand up the new workforce.
“It is estimated that between 1,000 to as much as 5,000 may be needed,” she said.
Adriane Casalotti, chief of government and public affairs for the National Association for County and City Health Departments, said it is hard to compare states’ tracing plans because many are still being developed.
“Public health experts, including NACCHO, have advised that at least 30 contact tracers per 100,000 population will be needed in this next phase of the response,” Casalotti said.
New Jersey’s plan would bring the ratio here to just over 20 contact tracers per 100,000 residents. To get to that 30:100,000 ratio, New Jersey would need a total of 2,665 contact tracers.
A recent NPR survey found only eight states would meet or exceed the 30 tracers per 100,000 residents threshold: New York, Washington, D.C, Illinois, Michigan, Nebraska, North Dakota, Alaska and California.
California, like New Jersey, is relying on universities with public health know-how to train 10,000 new contact tracers. University of California San Francisco epidemiologist Dr. George Rutherford is leading the effort, which uses a virtual academy to retrain current public employees as contact tracers.
He said he believes case numbers, more than the state population, should determine the number of contact tracers needed, and that 1,000 hires sounds like a great place for New Jersey to start.
“That sounds like kind of the right number to me,” he said.
Rutherford said New Jersey’s plan to hire new workers not only helps more people earn a living but is also more long-sighted than relying on retrained public workers who will have to go back to their regular jobs.
“Public health departments have been stripped of staff for years and this is the price we’re paying, having to jury-rig something like this together,” he said.
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