‘Patchwork’ Public Health System Complicates COVID-19 Contact Tracing, Community Notification

It’s a challenge to coordinate the gathering and dissemination of vital information

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By Lilo H. Stainton

The coronavirus is once again circulating rapidly in communities across New Jersey. State officials have reported thousands of new cases daily and shared data that shows how some situations — like youth sports and private parties — appear to have an outsize role in the spread.

But it is not clear if New Jerseyans are getting the information they need to keep themselves — and others — safe.

Much of the data is posted on the state’s COVID-19 website and Gov. Phil Murphy now intends to hold three media briefings weekly, instead of the twice-weekly events he convened during the summer and fall. The state also works with county and local health departments to alert the public when potential coronavirus clusters are identified. And schools have a protocol for contacting parents when outbreaks are discovered in a district.

But the public notification system is complex and coordination can be a challenge, according to those involved. The work generally depends on a network of government and public health officials who have been on the front lines of the state’s coronavirus battle since March, and the growing surge of new cases adds to the weight of their responsibilities.

“The state is a microcosm of the nation. We have this patchwork public health system. We don’t have a coordinated public health system,” said epidemiologist Stephanie Silvera, a professor of public health at Montclair State University.

Most of the time, it works well enough, Silvera said. “The problem is, when you have a global pandemic that really requires a coordinated response, the systems we have really do get put under pressure quickly,” she added.

For weeks, New Jersey officials have pointed to the rapid rise in new cases and hospitalizations as evidence that the state has entered a “second wave” of the pandemic, first diagnosed here in March. Since then, more than 270,000 cases of COVID-19 have been reported, including at least 16,500 fatalities confirmed or likely to have been caused by the disease.

Cases began to spike up again in October

After the initial onslaught of the virus, which peaked in April here, the rate of community spread — and new cases, hospitalizations and deaths — declined significantly over the summer. But the pattern changed in October, when transmission began to spike up again as people moved indoors (where spread is more likely) and appeared to ease up on pandemic precautions. At times last week, the number of new cases in New Jersey was nearly 10 times the daily diagnoses reported in late August.

According to information provided to the state Department of Health’s Communicable Disease Service by local health departments — which are responsible for calling individuals who test positive to inform them about the risks and tracing their potential contacts to contain the spread — much of the transmission appears to involve youth sports and associated events as well as gatherings in private homes.

DOH Commissioner Judy Persichilli shared charts Thursday that showed, of the 164 outbreaks that occurred between late March and Nov. 1 and could be definitively traced: 17% were connected to sports teams; 14% involved public safety, food and agriculture businesses, including restaurants; 13% were linked to private gatherings; 12% involved day care facilities, and 10% came from other work-related situations. It is not clear exactly how many cases are linked to these clusters.

“Often, the Department does not get additional reports on cases from the local health department after the initial report of an outbreak. The outbreaks drive the public health action taken, not necessarily the number of cases associated with it,” DOH communications officer Dawn Thomas said.

When examining a subset of that data — the 51 outbreaks reported in October alone — Persichilli said the DOH found that 33% involved sports teams; 11% were connected to government offices; and public safety jobs, day care and other workplace scenarios contributed another 10% each. The data would be more complete if New Jerseyans were more willing to participate when called by contact tracers, she noted, something that remains a challenge in nearly two-thirds of the cases investigated.

 “This information is vital to protecting the health of others and containing the spread of the virus,” Persichilli said Thursday.

Viral transmission is difficult to track

DOH officials have repeatedly stressed that, even with public participation, it is often difficult to track down the source or location of viral transmission. “We know if someone tests positive. But even to that person, it may not be clear when or how they were exposed,” Thomas said.

New Jersey’s public health system predates the coronavirus, with contact tracing and public notification processes designed to keep citizens safe from outbreaks like hepatitis, measles and the flu. The Communicable Disease Service depends on reports from health care providers and public health officials. When outbreaks involve multiple locations, the state makes a public announcement. When the threat is more isolated, it is up to the county or local health department to inform the public.

Thomas said the public notification process also varies by disease and is determined by the experts involved; measles, being highly contagious and easy to transmit, requires robust public outreach, as does a situation involving a food handler with hepatitis A, who may have infected others, for example. There is no state regulation dictating how this process works, she said, but the DOH often consults with local officials regarding public outreach, she said.

“It’s a little bit of a black box if you’re not inside of it,” Montclair State’s Silvera said of the multifaceted system.

But when it comes to the coronavirus, the scope of the pandemic has created challenges for the multiple state, county and local public health entities involved in protecting communities from viral spread, according to those involved; these agencies must also balance privacy issues and other concerns. New Jersey has essentially doubled its existing contact tracing capacity since March but as case loads rise, the workload expands, which could result in delays alerting community members of a potential danger.

‘What’s new is the level of contact tracing’

“This isn’t new in the field of public health to do contact tracing. What’s new is the level of contact tracing that’s required,” Silvera explained. “The capacity has to match the number of cases.”

The DOH has contracted with a staffing firm to recruit new contact tracers and tapped Rutgers University’s School of Public Health to train them in an effort to ensure each county has at least 30 tracers for each 100,000 residents. Four counties have reached this threshold — Cumberland, Passaic, Salem and Warren — but several, including Bergen and Morris, remain at nearly half this rate, according to state figures.

But with community spread so rampant, and daily infections and hospitalization numbers rising so quickly, contact tracing itself offers limited protection, experts acknowledged. In recent days, Murphy and Persichilli have underscored the critical importance of basic infection-control measures, like wearing masks, washing hands and maintaining social distance.

“We’re unfortunately pretty well beyond containment and we’re going to be moving back to mitigation and trying to reduce the impact” of COVID-19, Silvera said.

Header:  Photo by CDC on Unsplash