It was the early days of the pandemic and Jessica wanted to do something, anything, to help. So she jumped at the chance to be a case investigator for San Diego County’s contact tracing program.
The county was following the lead of health departments around the world in establishing systems to identify people who had been exposed to COVID-19 and notify them as part of the overall effort to prevent outbreaks. Jessica (KPBS is not using her real name to protect her livelihood) had no experience in such work but was willing to learn.
“It was a pretty steep learning curve, we were thrown into the mix within just a few days of training,” she said. “But after a few days of pretty rigorous training, I would say that I caught on pretty quickly.”
The county spent millions on the program, eventually hiring upwards of 1,000 people. But within months it became clear that it wasn’t enough. In July 2020 during the initial surge, just 11% of people with COVID-19 were being contacted by a case investigator within 24 hours — far short of the county’s goal of 70%.
RELATED: San Diego County's Contact Tracing Struggles Explained
Now, more than 18 months after the start of the pandemic, experts are looking back on the program to examine how it could have been changed to be more effective. Contact tracers would not agree to be interviewed for this story, but county spokesman Michael Workman insisted in emailed responses to questions that the program is worthwhile.
“The county is able to reach and interview about 50% of the cases and close contacts,” he said. “There are several indicators that are tracked across California counties which indicate that San Diego is experiencing better ... contact tracing outcomes and with case rates, death rates and hospitalization and vaccination rates.”
Health experts widely agree that contact tracing programs should continue to play a role in fighting COVID-19 and future pandemics, but one local epidemiologist said the county will need a more robust approach if COVID-19 surges again, or if another pandemic emerges.
“Contact tracing is the most useful for putting out flare ups rather than dealing with a wildfire.”Rebecca Fielding-Miller, epidemiologist at UC San Diego
“Contact tracing is the most useful for putting out flare ups rather than dealing with a wildfire,” said Rebecca Fielding-Miller, an epidemiologist at UC San Diego. “So in the very beginning, it was really important to catch those flare ups as quickly as we could, but testing was so hard to get ... Then when we got into the peak of the virus, we could not tamp down that wildfire with contact tracing.”
Still, Fielding-Miller said, any program that helps stem the spread, even in small measures, has value.
“At least some people did not go to Thanksgiving when they were told they were exposed to COVID,” she said. “But on a broader public health level, trying to use individual phone calls in that massive spread is like using a hand screwdriver instead of a really powerful tool.”
RELATED: Why Is San Diego Struggling To Keep Up With COVID Contact Tracing?
Jessica feels her work has made a difference. But the job has taken a significant toll on her mental health as the pandemic became more and more politicized after the COVID-19 vaccine became available early this year. People who earlier in the pandemic might have simply been dismissive of her now will scream at her and tell her she can’t control them, and that COVID-19 is a myth.
“So it can feel like a Sisyphean task at times when there are folks who just don't want that information or potentially are going out into the community after perhaps they've tested positive or have been exposed, knowing that they are potentially exposing other people to this virus,” Jessica said. “Knowing that there are some people who don't stop to think about how that can be affecting other people in their own community, it's a heartbreaker.”
A revolving door
As vaccination rates increased and case counts decreased in the spring and early summer, the county cut back its contact tracing staff. The number of contact tracers went from 203 in June 2021 to 101 in July 2021, while the COVID-19 disease response investigation team went from 924 to 738.
“In June, a weekly incremental demobilization process was occurring resulting in the ending of assignments for the temporary staff,” said Workman, the county’s spokesman. “Staff were given two week’s notice before their assignments came to a close.”
But that cutback was short-lived. As the delta variant surged, the county tried to hire back the contact tracers who’d been laid off.
“When the delta surge started its upward trend in the summer, the county put a pause on the demobilization process for several weeks watching to see how steep the surge would go,” said Workman. “As the delta surge continued upward across California and in San Diego County, the county began to remobilize staff who were demobilized in recent months.”
By the beginning of September, the county was back to 163 contact tracers.
Big spending on FedEx
One thing that surprised Jessica was the county’s heavy use of FedEx. When a case didn’t have an email address, she would send the person a letter via FedEx telling them to isolate and quarantine.
“It's shocking to many of us working on this project that those letters are sent out through FedEx, which I believe is like maybe $11 or $12 a letter, to get it to them as quickly as possible, when we have the post office that could be doing the same service,” she said. “A lot of us are confused as to why a government agency is not also using another government agency to do this work, especially knowing the dire straits that the post office is in currently.”
Workman confirmed that from March 2020 through the end of July 2021, there were 45,057 letters sent out via FedEx at a total cost of more than $535,000.
RELATED: Here's Where COVID-19 Outbreaks Have Happened In San Diego County
“Each case and contact receives an isolation or quarantine letter. Most cases like to receive these by email. FedEx is used for those who prefer the delivery in paper or used for those for whom contact is not made after several attempts by phone or if a wrong phone number is received,” Workman said. “The benefit of FedEx is a more timely and trackable delivery.”
“The county did consider using (the U.S. Post Office) but given the nature of the seven day a week operations, need for timely and trackable delivery of information, FedEx was the choice for delivery,” he added.
However, other large California counties, including Los Angeles and San Francisco, didn’t use FedEx at all. Still, Workman defends the practice, saying it “highlighted the seriousness of this pandemic.”
More funding, more support next time
Fielding-Miller, the epidemiologist, said contact tracing can be successful. But it needs to be supplemented with other methods for controlling the virus spread, including stay at home orders and even paying people to stay home.
She predicts cases will surge again over the holiday season, but then in 2022, as COVID-19 becomes endemic, not a pandemic, contact tracing will prove especially useful.
“If we get to a place where COVID-19 is endemic, then think of the wildfire analogy, we will be keeping an eye out for hotspots, and the quicker we can stop a hotspot, the better everyone will be,” Fielding-Miller said.
Meanwhile, for Jessica the heartbreak continues.
“I just had someone call me yesterday asking me if the county could help in any way because she was going to miss 10 days of work and her employer was not providing any kind of sick pay for her,” she said.
