Every day, St. Louis County Health Department employee Haley Alder calls strangers on a government-issued cellphone and asks them where they’ve been and whom they know. It’s all to find out who has the virus and who could be in danger of getting sick.
As the coronavirus continues to spread across the St. Louis region, health officials say one of the keys to controlling the spread is finding out who has been exposed to the virus. That’s where Alder and dozens of other contact tracers come in.
“We might be speaking with someone who is upset or frustrated or angry, or we might be speaking with someone who is sad and grieving because they just lost their husband. We get all ranges of emotions,” Alder said.
She and her colleagues are essentially disease detectives. They start with a positive case and work backward to identify those who may also have been infected. Health workers say contact tracing is a time-tested technique that gets results. But their efforts are hampered by the public’s lack of trust in health officials and widespread rumors the virus is a hoax.
An important tool
“You’re intervening before there is an opportunity for additional transmission,” said Spring Schmidt, co-director of the St. Louis County Department of Public Health.
“We try to hit the case investigation in the first 24 hours,” she said. “We get it so we prioritize the people who have tested the most recently, because that is our best opportunity to control transmission to find other people who are exposed and get them quarantined.”
The county has nearly 150 contact tracers. The St. Louis Health Department has about 30 contact tracers. Many positions are temporary or part time, and turnover is high.
On a given day in the county, workers make dozens of calls to those who have tested positive for the virus to identify their recent close contacts. For most health departments, that means people they’ve been within six feet of for 15 minutes or more.
Then, contact tracers call those people, ask them about their symptoms, advise them to seek a coronavirus test and tell them to isolate themselves for 14 days. The idea is to stop the disease in its tracks.
A tall order
Multiple pieces need to fall into place for contact tracing to be effective. First, health workers need to identify and get in touch with patients who have the virus as fast as possible. That can be impossible when some tests results can take days or weeks to come back from a lab.
“In some cases, it was greater than 10 to 14 days,” said Dr. Fred Echols, acting St. Louis health director. “By that point, individuals are no longer infectious.”
After two weeks, many people can’t remember who they saw or what they did during the time they were contagious, he said.
Contact tracing is also dependent on people answering the phone and telling the truth — a tall order when many have been shamed for contracting the virus, Alder said.
“A lot of people will just straight up hang up or not answer at all,” she said. “Some people will kind of question my authority on the matter or tell me that it’s all a hoax and unnecessary and debate the science and the evidence.”
Finally, people need to actually stay home if they’re potentially infectious. That’s advice some people won’t or can’t follow, Schmidt said.
The coronavirus has disproportionately affected poor people and people of color, said Dr. Mati Hlatshwayo-Davis, an infectious disease specialist at Washington University. Many are working essential jobs for minimum pay and don't have sick leave.
If officials are asking for a two-week quarantine, they need to make it easier to stay home, she said. That’s why it's important to ask the people they call what they need, be it help getting food, housing or utilities assistance.
Trust is required
Building trust quickly is key to effective tracing, Schmidt said. People need to trust that they’re not in trouble or being judged and that their health information won’t be shared.
“We try to establish to make sure people understand what it is we’re here to do,” she said. “This isn’t a punishment, we are really are here to help.”
Some may not trust or appreciate a stranger calling them to tell them what to do, Hlatshwayo-Davis said.
“Think of the history with this. Someone from a government agency who may not be of the same sex, racial or ethnic background as you telling you something about your health all of a sudden,” she said.
Contact tracers need to be clear about what they need to know and how that information keeps patients and their loved ones safe, Hlatshwayo-Davis said. Working with community organizations, churches and neighborhood leaders could help instill some of that trust, she said.
Haley Alder, the contact tracer, knows that while the county requires people to isolate themselves for two weeks if they’ve been in prolonged contact with someone whose tested positive for the virus, she can’t force anyone to share their information or listen to what she says.
If people refuse to talk to her or stay home, she gives them the best advice she can. She calls it coronavirus harm reduction.
“You know we don’t condone you going out in public, but if you do, wear a mask, wash your hands, stay six feet away from people,” she said.
After all, she has dozens more people to call once she hangs up.
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