How Hawaii Botched Contact Tracing And What It Will Take To Fix It
Updated: 8/11/2020, 10:05 a.m.
The state Department of Health’s contact tracing has failed to keep up with the burgeoning numbers of COVID-19 cases and key state senators are calling the department’s bluff on officials' claims that they are managing with the workers they have and are hiring.
Contact tracers are charged with identifying and communicating with people who are close contacts with those testing positive. A close contact is someone who had at least a 15 minute, face-to-face interaction with a confirmed infected person. Normally, contact tracers continue to follow up with these close contacts throughout a 14-day period when they could develop COVID-19 symptoms.
For over a month, state Epidemiologist Sarah Park and Health Director Bruce Anderson have said in press conferences and before the Senate COVID-19 response committee that the department employs over 100 contact tracers and touted the training of up to 450 others.
However, several senators paid a surprise visit to the department last week and described a bleak scene among contact tracers.
“It just seemed like they were bootstrapping that whole operation,” said Windward Oahu Sen. Jarrett Keohokalole.
“I just don’t think that the department has ever built any kind of capacity over the several months,” said state Sen. Donavan Dela Cruz, who represents Central Oahu.
“They were overloaded with over 100 cases each,” said Sen. Donna Mercado Kim, whose district includes Moanalua and parts of Kalihi. “They were not able to get through all of the cases, not to speak of following up with the contact tracing.”
Keohokalole, Dela Cruz and Mercado Kim are members of the Senate COVID-19 committee that dropped in on the department after failing to get full answers from health officials about contact tracing.
Mercado Kim learned that a contact tracer is not necessarily doing the work full time. Finding close contacts of those who tested positive may be just a part of a worker’s job duties.
Instead of the 105 contact tracers that Park and Anderson last said they had, there are far fewer people fully dedicated to contact tracing.
“The only specific contact tracers we saw were the five National Guard and then there was one specialist,” Mercado Kim recounted.
“She was actually training a contact tracer in the little cubbyhole that they were at. And that was it. And that person said she had 31 cases in addition to training.”
At the beginning of July, Anderson reported having 179 contact tracers, but that number has declined even as cases have surged over recent weeks. Anderson said the department is using an app that helps contact tracers follow as many as 20 cases at a time. The success of that program is not clear since the department has not released information on how well the app has performed.
Mercado Kim said six epidemiologist specialists who said they work cases from beginning to end -- meaning they were expected to contact confirmed infected people and then their close contacts.
“One of the specialists actually showed us the list of our cases and that they were prioritizing. They're prioritizing the elderly and those who are high risk. And everybody else couldn't be contacted because they just couldn't do it,” she said. “They said they're working from 7 a.m. to 6 at night.”
Yesterday, the Hawaii Government Employees Association that represents contact tracers filed a grievance for workers who perform COVID-19 contact tracing, field swabbing and outreach response.
"Our members have been working incredibly hard to keep up with contact tracing but it has become an impossible task," the union said in a statement. "Had the DOH brought on additional staff more quickly, this steady surge in cases may have been mitigated. This grievance represents the tip of the iceberg of a much larger public health problem."
Calling for Park's resignation
The state’s lack of robust contact tracing is one reason Lt. Gov. Josh Green, an emergency room physician, called for Park to step down.
“Dr. Park has other priorities and a different philosophy. Her philosophy is very smart as far as social distancing and decreasing large gatherings. She's very firm on the high risk behaviors in state,” he said.
But while blaming public behavior for the surging cases and downplaying the importance of contact tracing, Park at times appeared to be throwing in the towel when it comes to contact tracing, noting that colleagues in other states have abandoned contact tracing.
“I know what we're capable of and what we're not capable of socially, as far as preventing spread," Green said. "She doesn't have that kind of commitment to a program that is necessary to trace and test everyone.”
The senators and Green want the health department to set up a contact tracing hub at the Hawaii Convention Center to house the contact tracers.
Lack of room to put the contact tracers is one reason Park has cited for why the department has not hired more people. She also pointed to the need for computers and telephones.
“Space has been a big issue for us . . . as well as further equipment,” she told senators during a hearing last Thursday.
“Our grants from the Centers for Disease Control and Prevention do not actually allow us to rent space," she said. "They do not allow us to renovate space, basically don't allow us to do anything for space. They give us money to be able to hire people. They allow us to use our funds to obtain certain amount of equipment, but they do not allow us to use ... any of those funds to identify and secure any space anywhere. And so that's been extremely stressful, extremely problematic.”
The health department received a $50 million grant from the CDC, which Green said should be more than enough to scale up the contact tracing program. He said using the convention center should not be an issue.
The state scaled up its capacity to process unemployment benefits, another continuing area of concern during the pandemic, by creating space at the convention center and bringing on staff and volunteers.
Green has submitted a plan to the health department leadership to have a contact tracing facility at the convention center up and running within a week.
Park also identified a lack of people to further train newly hired contact tracers on use of the department’s computer system. But critics say that need should have been part of the initial training.
Money has not been an issue -- department has the federal funds to hire, but it's the department's policy to employ contact tracers only as needed that has senators up in arms. Rather than anticipate the need for many more contact tracers when the state began its ill-fated reopening that's brought about the latest surge, the department continued to hire at a slow pace.
It has proved to be too little too late as the number of new daily cases surge into the hundreds and existing contact tracers say they are overwhelmed.
Contact tracers need experience
Tim Brown, an infectious disease expert at the East-West Center, pointed to major pitfalls in the department’s approach to contact tracing.
“If you have trained these people, but they require additional training to work with the state systems and so on, that additional training should have been part of the training,” he said.
“They need practicum training, they need actual training in the field. Contact tracing is not something that everybody takes to -- it requires a certain amount of ability to interview people. It requires the ability to be authoritative. It requires the ability to be empathic. It requires the ability to get information out of people that many people do not want to give. That's a skill that takes time to build.”
When New York City began widespread contact tracing, the results were disastrous. While the 3,000 contact tracers were able to reach about 64% of the almost 20,000 people who tested positive between June 1 and July 25, less than half -- 42%-- of infected people provided the tracers even just one contact they may have exposed.
Hawaii's health department does not release that level of detail in its public data, so Brown said there’s no telling how many people the state is actually reaching and how many close contacts are even being identified.
Green said each infected person has about 10 to 20 close contacts, but Anderson has refuted that number and said it was probably much lower, although he could not provide an average number.
Mercado Kim said during her visit to the department, an epidemiologist specialists told her one easy case takes about two hours.
“When they get that one case, say you’re the one that’s infected, they ask you, ‘who did you come in contact with?’ and if you live in a household that has numerous people, and then you went to work, or the gym or somewhere-- they could end up with 20 people now that they have to contact.”
Anderson said each contact tracer can handle up to 25 contacts at a time.
That means if DOH had its reported 105 contact tracers, the department could monitor up to 2,625 people at once-- that would supposedly include keeping up both the confirmed cases and their close contacts.
There are currently 2,052 active COVID-19 cases statewide-- so even if each active case only had one additional close contact, the 105 tracers would be completely overwhelmed.
Anderson and Park have not specified at what point the department would stop contact tracing, as many states that became overwhelmed with cases have done. They have said that could happen here, while acknowledging it is not ideal.
Brown said contact tracing is a key component in controlling large outbreaks and it becomes even more important as infections are driven down to ensure the state does not see further spikes.
“Don't give up on contact tracing,” he said.
“We need to redouble our efforts on contract tracers, make sure we've got a cadre of trained contact tracers who are ready to jump into it at a day’s notice . . . I think this spike caught everybody unawares. But sadly, I've almost got to say it was almost predictable because of the poor public messaging that's been done here. People do not understand that if a party of 10 people gets together, and you're talking about five couples from five different households, that’s a COVID party.”
When HPR asked Gov. David Ige if the state had fumbled its communication by targeting an older audience when the surge has largely impacted younger people and communities of color including Pacific Islanders, the governor acknowledged there was work to be done now that the demographics of who is contracting the virus has shifted.
So far, there has been no obvious change in the state's messaging.
When HPR asked for an interview with Park or Director Anderson, a spokesperson said due to their extreme workload, they will now only respond to media questions during scheduled news briefings.