Now that the number of COVID-19 hospitalizations appears to be in decline, New Jersey officials are starting to game-plan how to ease restrictions and start reopening commerce. Gov. Phil Murphy is expected to outline the broad parameters of a plan for that today.
Until a vaccine is developed, however, the strategy has been reduced to a mantra: test, trace, isolate. Health experts believe that is the only way to keep the virus boxed in and prevent a second surge.
As testing for the coronavirus increases, the effort to trace the contacts of those who have tested positive is seen by public health experts as the next vital step in trying to control the pandemic and move beyond the stay-at-home reality of now. An army of pandemic detectives will have to be recruited, trained and deployed in short order.
Murphy who readily admits the state is far away from a “responsible reopening,” has been unwavering on one point: Science will dictate how soon New Jersey can return to any semblance of normalcy. A closer look suggests it will also require a good deal of math, elbow grease and money. And perhaps even a different way of thinking.
“We don’t have the whole architecture, by any means, fitted out,” Murphy said last week. “We’ve got to be in a completely different place in the next four to six weeks.”
That place requires some math. New Jersey does not yet have an accurate picture of the scope of the infections. A dramatic increase in testing is necessary just to obtain a statistically significant sample size. Health officials are trying to figure out what that is. Until then, it’s a bit of a guessing game.
Contact tracing is the decades old, shoe-leather tactic of epidemiology. Absent universal testing, it will help fill the void. In order to tamp down future outbreaks, health officials will have to move swiftly, interviewing every person who tests positive, find out who they have been in recent contact with, interview them and isolate them. As testing capacity increases, they would test them as well.
Murphy said the state’s contact tracing strategy is in its “very early stages,” but “we all recognize that robust contact tracing in addition to that testing protocol is vital to any serious reopening efforts.”
Needed: from 1,000 to 7,000 contract tracers
State Health Commissioner Judith Persichilli last week announced she has started to assemble a task force to produce a plan for testing and contact tracing. On Thursday, she revealed how challenging contact tracing will be. She said New Jersey will need to deploy anywhere from 1,000 to 7,000 contact tracers, depending on the mathematical model officials choose. On Saturday, Persichilli said she had spoken to a health official from Germany, which is “very aggressive” in contact tracing and uses 25 tracers per 100,000 people. That model would require about 2,000 tracers for New Jersey.
Even the lowest of those three numbers is far beyond the resources of the state’s 99 local health departments, which thus far are conducting contact tracing as they can afford and see fit. Murphy said Saturday that furloughed local and state employees could provide an additional source for tracers.
The stark reality is that local health departments don’t have the resources or personnel they once did.
“Our public health system, over the past couple decades, has seen major decreases in funding and major losses in personnel. And so, you’re going to have to rebuild that,” said Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation. (He is also Murphy’s representative on a regional, seven-state COVID-19 task force.)
And in a state that reveres home rule — the doctrine that cedes power to local governments — that presents a distinctly New Jersey conundrum.
Asked last Tuesday what role the state health department would play in contact tracing, a spokeswoman there said, “Local health departments are the leads in contact tracing for residents of their towns.” Asked how that’s going, she repeated, “Contact tracing is done on the local level. You would need to speak with local health departments to get a handle on their efforts.”
Two days later, Persichilli announced the formation of the task force, which she said is now trying to determine the appropriate number of tracers needed, along with a plan to recruit and train them. This may suggest the state is contemplating a larger role in implementing and coordinating contact tracing.
“It has to be orchestrated centrally, quite frankly,” said Perry N. Halkitis, dean of Rutgers School of Public Health. The process has to be consistent throughout the state to make sure it’s done properly and the data are consistent. “There has be one strong central Department of Health … New York state actually has a very strong health department … We need a stronger and more centralized one ourselves.”
A native of Queens, New York, and a professor at New York University for two decades, Perry recalls being taken aback when he first came to Rutgers three years ago and discovered the state’s adherence to home rule: “New Jersey was like a set of Greek city states …. with all these little fiefdoms and with their own public health units,” he said. “But crises bring great opportunity,” he is quick to add. “This is an opportunity to change the way we do business in New Jersey and lead public health with one centralized voice and approach, and marry efforts of the centralized DOH with us, the state’s leading public health school.”
And he has suggested this idea to many public health officials, including Persichilli: “I think we are getting there. COVID forces the issue. I think we realize that one coherent approach to testing and tracing will not just magically happen … there has to be oversight and coordination at the state level … It can no longer be business as usual; the world has changed with COVID-19.”
Seed money from Bloomberg: just a start
Last Wednesday, New York Gov. Andrew Cuomo and former New York City Mayor Michael Bloomberg made a nationwide splash when they announced they were launching a contact-tracing campaign for New York, New Jersey and Connecticut. Bloomberg Philanthropies will pony up $10.5 million and partner with Johns Hopkins University, which would execute the recruitment, training and deployment of 3,500 contact tracers. The hope is it would become a national model. New Jersey officials said it is too early to know how they fit into this plan.
Some more math is required here. If you were to hire 3,5000 tracers, and pay them $20 per hour, Bloomberg’s money would be gone in a month. Bloomberg’s investment, it appears, could provide a potent jump-start, but it is nowhere near what will be needed for a comprehensive regional contract-tracing program.
According to a report released last week by researchers at the Johns Hopkins Center for Health Security, the nation needs a new workforce of 100,000 contact tracers. At that scale, the effort would require $3.6 billion, researchers projected. They called for an infusion of emergency funding from Congress.
Their estimates are based on what has worked in other countries. In the Wuhan, China region where the outbreak started, 9,000 contact tracers were rapidly deployed to curb the spread in the city of 11 million. But Thomas Frieden, former chairman of the Centers for Disease Control and Prevention (CDC), says the U.S. will need three times the Johns Hopkins estimate, and thus three times the money.
“We’re gonna need the feds in a big way,” Murphy said, repeating his own daily mantra. “We’re gonna have to be very nimble, but we’re not there yet.”
U.S. Sen. Chris Coons (D-Del.), last week proposed a bill that would fund 750,000 national service positions over a three-year response and recovery period, which would include 300,000 public health workers for contact tracing. In the meantime, the CDC has reached out to the U.S. Census Bureau, as well as the Peace Corps and AmeriCorps, to see if they can provide some manpower.
Murphy said he was told by Vice President Michael Pence last week that a team of 10 to 12 CDC employees would be dispatched to New Jersey, as well as other states, to assist in contact tracing. “That’s a good step,” Murphy said. But “we’re going to need a lot more than that.”
And not even that seems certain.
“As part of the administration’s plan, CDC will be working with states to assess their needs for resources. At this point, there is not a team identified for NJ, but if that changes, we will reach out,” said CDC spokesman Benjamin Haynes.
States not waiting for federal action
Some states are not waiting for Washington to act.
Massachusetts was the first state to launch an ambitious tracing program, investing $44 million to hire 900 contact tracers. In its first week, which ended April 18, the state unleashed about 300 contact investigators, who reached 765 residents who had tested positive. Those 765 people identified more than 1,000 close contacts — someone they spent more than 15 minutes within six feet of during the three days before their positive test — and 626 second-tier contacts; a person is considered a second-tier contact if they have come in contact with a contact. Massachusetts officials also said they have lined up nearly 2,000 volunteers prepared to assist with contact tracing.
In Rhode Island, 100 members of the National Guard have teamed up with 140 health department employees. California Gov. Gavin Newsom announced last week he is building an army of 10,000 contact tracers. San Francisco, the first city in the country to issue shelter-in-place orders, has launched its own program, cobbling together and training a team of about 100 city librarians, staff from the city attorney’s office and medical students, among others.
Out of privacy concerns, the city’s tracing program does not involve any smartphone tracking app, like the one Apple and Google have created, which uses Bluetooth signals to identify contacts. Such technology was used effectively in Taiwan, South Korea and Singapore, where privacy and civil liberties are not as coveted as they are in the U.S. What New Jersey decides on the use of digital technology to assist in contact tracing has yet to be seen.
Challenge in poorer neighborhoods
RWJF CEO Besser points out another aspect of contact tracing that will require more thought: The task will be dramatically more challenging in underprivileged urban neighborhoods.
First, the state will need to recruit people from diverse communities to do contact tracing. “There will be an issue of trust. You are asking people to share very personal information — Where have you been? Who have you been with? — Some of these people will be recent immigrants without documentation. … They will need to be assured their participation won’t affect their immigration status. … These types of things will have to be worked out.”
Self-isolation is not possible for some populations. When a contact tracer calls and tells them they have been in contact with someone who is infected, and they must self-quarantine, that may be impossible. “People live in homes with multiple generations and often older people with increased risk,” he said. “Government is going to have to ensure everybody is provided a safe place to isolate.”
For the past six weeks, Stanley H. Weiss, an epidemiology professor at the Rutgers School of Public Health, has been collaborating with the City of Paterson to address these and many more issues related to COVID-19. They hope to devise and implement a contact-tracing strategy that can be replicated in other cities — from recruitment to training to reporting technology.
“We’re trying to hit a moving target. We’re still learning about this disease at the same time we’re trying to deal with it,” said Edward Boze, Paterson’s chief innovation officer. “It’s gonna take a collaboration of government, academics and private industry to deal with this crisis. We’re very excited about partnering with Rutgers. We are also looking to partner with a private company that can provide us with some of the technological applications that will help us in this crisis.”
While establishing the basics of the program are “complicated and daunting,” Weiss said. “It’s only part of what needs to be done.” Weiss, like Besser, recognizes the additional challenges for a city like Paterson.
First, Weiss notes, there is a higher rate of infection in our inner cities for many reasons, including financial insecurity for a great number of people and the inability to isolate. Moreover, many inner-city jobs require person-to-person contact. The cashiers, the home health aides, the bus drivers, the grocery store clerks — “They can’t work from home. They still need to go to work. They don’t have a cushion,” Weiss said, “and they frequently have limited access to health care.”
Controlling the coronavirus in the state’s inner cities will be the biggest challenge going forward. For people to cooperate in all this, they will need to have confidence that they’re going to be helped, Weiss said. “You tell someone to quarantine, you need to make sure you get them food and water and stay in touch with them. … How are they going to survive? What happens when a parent gets sick in the house? Who’s going to take care of the kids? … We’ve developed all these drive-through testing sites. Well, not everyone has a car.”
Contact tracing in places like Paterson will require even more assistance from beleaguered social service providers, who will have to become integrally networked into the contact-tracing operation, Weiss said. These are things that will have to be thought through beyond the usual basic elements of contact tracing.
“If you stigmatize people and isolate them without helping them, you’re going to rapidly be in trouble.”