As a result, public health departments haven't been able to accurately report the number of Idahoans with COVID-19, or to quickly find and notify others who may have been infected.
Public health officials hope that federal funds to help with COVID-19 response, and new personnel from the Idaho National Guard, can get them back on track.
Things have been bad since September in the South Central Public Health District, said investigator Mehli Marcellus. Staffers at the public health department based in Twin Falls deal with impossible case loads as coronavirus spreads in the Magic Valley. They deal with locals who are angry to see staff members wearing masks, or frustrated to get a phone call about their positive COVID-19 test result.
But the worst day for Marcellus was when she received a death notification for a man she'd spoken to just days before, she said.
Coronavirus case investigators can get to know the people they call, learning intimate details of their lives and routines to compile a list of close contacts who could have contracted the virus from the patient. For public health staff like Marcellus, every case and death in Idaho's coronavirus statistics is a person.
"It really took me off guard," Marcellus said. "It was difficult. I'd spoken to their whole family. So just to see that come in ... I was like, 'Oh, OK. I'm going home now.'"
Idaho's Coronavirus Cases Surge, Straining Health Districts
Idaho's long wave of coronavirus cases is not only straining underfunded, understaffed and overworked public health districts trying to survive a pandemic, it also hampers their ability to trace the virus's spread through communities across the state.Before the pandemic created an emergency, communities would have needed about 15 contact tracers per 100,000 residents to prevent transmission of things like HIV, sexually transmitted infections and tuberculosis, according to a position paper from the National Association of County and City Health Officials.
Idaho is tied for 35th in the U.S. when it comes to bolstering its contact-tracing workforce to aid in COVID-19, having added 4 percent more tracers, according to the website CovidActNow.org.
Central District Health — an area with more than 500,000 residents and six hospitals that are stretched thin by COVID-19 — had 30 people on its contact tracing staff as of Wednesday.
Six of Idaho's seven public health districts have a total of 142 employees on their contact tracing teams. ( Southwest District Health didn't respond Friday to a question about the size of its contact tracing team.) Idaho Department of Health and Welfare did not provide the total number of contact tracers in Idaho, but directed the Statesman to ask the health districts themselves.
Many of those employees help with contact tracing work part time, while juggling other job duties.
Central District Health plans to bring on six more in the next two weeks. South Central Public Health District has help from nursing students, and 10 Idaho National Guard members now working full-time, starting this week, spokesperson Brianna Bodily said. Panhandle Health District also has four Idaho National Guard members on the team now, and eight volunteers who help on a rotating basis, spokesperson Katherine Hoyer said.
When the pandemic began, officials at Central District Health didn't think they would need to ramp up contact tracing as much as they did, "because community restrictions would have to be put in place to protect our hospitals and to keep the virus from getting into our high risk groups such as those residing in long term care facilities," District Director Russ Duke explained via email.
Then, the summer surge arrived in July. There were more than 1,000 cases per week for four weeks "and the health systems didn't get overwhelmed," he said. "This meant that in order to keep up with the investigations, we needed a lot more staff. Finding people with the right skill sets became a challenge as we were competing with our neighboring health district and the Department of Health and Welfare for the same talent. We have also experienced a lot of turnover with the positions because they are temporary and people we hired moved on to permanent positions. High turnover strains the supervisor level staff in the disease response structure as they are having to spend much of their time on training rather than assisting with the investigations."
In addition to Gov. Brad Little mobilizing National Guard staff to help with COVID-19 response, Idaho's public health districts were granted "significant funding" to cover the cost of pandemic-related activities, said Bonnie Spencer, CDH chief operations officer.
Central District Health had access to nearly $2.6 million for that work, as of Halloween. In addition, CDH can tap $1.8 million of federal CARES Act money for COVID-19 expenses that aren't covered by other funding sources, she said.
The state has made up to $6.9 million of CARES Act funds available to the health districts.
The Idaho North Central Health District has six "partially reassigned staff" and six newly hired contact tracers on its contact tracing team, said spokesperson Tara Macke.
Macke said that "without CARES (Act) funding, we would not have had the budget to hire any new staff."
Central District Health has seen "upwards of 2,500 to 3,000 cases over the last several weeks, and they're a couple weeks behind with going through" those, said Brandon Atkins, spokesperson for Central District Health. "New resources are coming on board, and they are doing everything they can to keep up with it."
Atkins says the majority of people are cooperative. But the number "who are reticent or aren't as likely to cooperate is large enough that it's challenging to our staff ... and that is making it hard for our staff to do their jobs."
Central District Health and most other public health districts in Idaho issued news releases last month, telling the public the surge of coronavirus cases "have created backlogs and delays ... making it impossible to contact all new reported cases or those individual's close contact."
With no end in sight, the districts asked people to take public health into their own hands.
"Because of the backlogs, public health districts report a growing number of people are not getting a call from their offices and urge anyone who is awaiting a test result or who receives a positive test result to take their own proactive measures to protect themselves and those around them," the news release said.
Southwest District Health put a number on that backlog at its board meeting in mid-November.
Doug Doney, Southwest District Health general support services division administrator, told the board that 4,400 cases were reported in the prior 30 days. The department had been able to interview 2,300 of those people.
"We've obviously seen a huge increase in the numbers over the last few weeks," Doney said. "It's quite large, and it's not slowing down at this point. Just this last weekend, we had over 750 cases reported."
Why Does Contact Tracing Matter in Idaho?
Contact tracing is one of the key parts of a pandemic response. A failure to quickly communicate with COVID-19 patients slows everything down.Contact tracing wasn't invented to stop COVID-19. It goes back centuries in human civilization — used for cholera, tuberculosis and infectious diseases like syphilis.
"In the 1960s, when rates of syphilis soared again, physicians were required to report cases to health departments, which had the manpower to interview patients and follow up all contacts," three public health professors wrote in July for The Conversation. "Physicians had long exercised an ethical duty to warn sexual contacts, but as a health department practice, contact tracing fundamentally relied on the cooperation of patients. Confidentiality, therefore, became standard practice. Investigators would never confirm the name of the patient to a contact, even if it could only be one person, like a spouse."
That trust faltered during the early years of the AIDS epidemic, they wrote. Patients were reluctant to cooperate with contact tracing due to stigma and laws against homosexuality in the mid-1980s, they wrote.
But local epidemiologists worked with the public for years to successfully trace contacts and notify people of exposure, Atkins said.
"For years and years, as an epidemiologist, I (would) talk to people about their most intimate bodily functions," he said. "People enjoyed having someone who could help talk to them and help them understand what was going on. We're calling and trying to have better health outcomes."
Contact tracing teams ask about a person's contacts and alert people they might have infected. They answer questions that a COVID-19 patient might have. They help explain warning signs of complications. They help people brainstorm how to get groceries so they can properly isolate at home.
Their work also ensures that Idaho stays on top of where COVID-19 is spreading — and how quickly.
With contact tracing backlogged, Idaho's reported case numbers are lower than reality.
Here's why: If a person tests positive, that case will show up in the state's data because of a lab report. But what if their entire household is sick with COVID-19 symptoms? Unless every person in the home gets a COVID-19 test, those "probable" cases will not show up in the data until a contact tracer talks to Patient Zero — and only if the patient answers the phone and cooperates.
"That's one of the big fall-downs of not being able to keep up with contact tracing," Atkins said. "We're not going to see all the (probable cases) if we're not doing contact tracing."
Central District Health had logged 23,343 test-confirmed cases and 3,693 probable cases of COVID-19 in Ada County as of Thursday.
And when contact tracers can't keep up with phone calls, it means that Idaho's epidemiologists can't get a firm handle on where and how the virus is spreading.
Since the start of the pandemic, one of the main places people catch the virus is at home, from family members or housemates. But as the coronavirus rages through Idaho, more people are catching it out in the community and bringing it home, where they hatch mini-outbreaks.
Primary Health Medical Group has done nearly 60,000 tests for COVID-19 at its clinics in the Treasure Valley.
Clinical staff follow up with patients, and 35 percent to 45 percent "don't know where they got (the virus) from," Primary Health CEO Dr. David Peterman said in November. "When they do report contacts ... they report to us businesses, bars, restaurants, other gatherings and not just family gatherings."
Some patients are catching it at work, he said.
That means Idaho needs to take more measures to contain the virus out in public, which will in turn prevent outbreaks from families and small gatherings, he said.
"We're not saying family gatherings are OK," he said. "What we're saying is, this is a bigger problem. And family gatherings are a part of the problem. ... But where we are today, it's everywhere, and we're getting it everywhere, (so) we have to be careful and cautious everywhere."
Nine Months In, Idaho Woefully Short of Contact Tracers
During the COVID-19 pandemic, a community may need anywhere from dozens to thousands of contact tracers for every 100,000 residents, according to models using a tool for public health agencies.A controlled outbreak with patients who cooperate and use apps or email to check in daily? That takes fewer contact tracers to keep up with cases. A higher rate of spread among residents who continue to socialize and don't talk to contact tracers? That takes a lot more staff.
Based on that model's estimates, Twin Falls County may have needed more than 3,000 contact tracers in mid-November, to successfully keep up with the coronavirus cases in that county alone. The health district had 20 people on its contact tracing team — for that county and seven others.
The 15 investigators and five contact tracers at South Central were maxed out the week of Nov. 13, when the Statesman visited their offices.
They were recording 1,000 new cases and conducting 400 investigations a week for the eight counties covered by the South Central Public Health District. The number of new cases in the district was so high and sustained that investigators were pulled from calls just to help create new case files.
"We literally came in one day and we were fine, we were doing great," Marcellus said. "And then we came in the next and our cases were doubled. And then it just kept trending upwards."
Investigators like Marcellus usually spend about 45 minutes on the phone with each person, collecting information for a list of the patient's contacts who could have contracted the virus. Then, a contact-tracer will take that list and call the patient's close contacts, tracking who might have been exposed and should be told to quarantine or take a COVID-19 test.
But high case counts mean some positive cases might not receive a call from the health district for more than a week after their test result. And as investigators are forced to triage their investigations, some close contacts might not know they've been exposed to someone with coronavirus until it's too late to keep them from spreading the virus.
Right now, Idaho's overwhelmed contact-tracing teams are prioritizing cases among older people or school-aged children, in an attempt to slow outbreaks in places like nursing homes and schools.
The teams may be one or two weeks behind on other cases, such as employees of large businesses or food processing plants, which means they rely on company HR departments to be proactive and alert health officials. That also means employees have to rely on the trust and goodwill of their employers to give them paid time off to quarantine, without official proof that they have been exposed to coronavirus.
"If (we) haven't investigated the case they're a part of, we can't provide that letter to their employer confirming they are a close contact of someone who tested positive," said Brianna Bodily, the district's spokesperson said.
Dealing With Idahoans Who Don't Want to Hear About COVID-19
Public health districts aren't used to being in the public spotlight, Bodily pointed out. Staff members work "invisibly" with the assumption that it will help the community in the long run, she said."Well, now, we're still doing that, but with a lot of public frustration geared toward us," Bodily said.
That is a problem statewide.
Elke Shaw-Tulloch, administrator of the state's Public Health Division, told the Idaho Board of Health and Welfare about that in mid-November.
"People are over it. They're being rude, they're not answering the phone," she said.
With so many phone calls to make, investigators like Marcellus are instructed to try to simply end a call if the person on the other line is too hostile or won't answer questions about whom they might have exposed. Sometimes, people even give false information.
"You know, we do the best that we can to try and defuse the situation but at the end of the day, it's not worth our investigators getting berated for one call when they have thousands more that they could be making," Marcellus said.
The public still doesn't have an accurate idea of what case investigators and contact tracers actually do, Bodily said. Physically preventing people from leaving their houses or returning to work is never going to happen in Idaho, she said. Staff just want to tell them they need to quarantine or isolate — so that they don't accidentally spread the virus.
Case investigators and contact tracers are bound by the Health Insurance Portability and Accountability Act, or HIPAA. That limits what they can share with people about a patient. If a patient attended choir practice a few days before testing positive, for example, a case investigator would gather that information, so that contact tracers could notify other people who were at choir practice that they were exposed, so they can quarantine, pay attention to symptoms or get tested.
Meanwhile, public health workers are disheartened by the backlash against their efforts to keep their communities safe.
Residents and even elected officials and have turned against guidance such as wearing masks. For example, the majority of Republican state legislators were maskless in an organizational session held at the the Statehouse on Thursday. They have downplayed the seriousness of the virus and questioned whether hospitals and doctors are telling the truth about witnessing sickness and death firsthand.
"We're doing everything we can over here, everything," Bodily said. "Long hours, weekends, we're sacrificing our mental, emotional and physical health, to help everybody in our community. When we see people disregard the efforts that we're making, or simply throw them away, it makes it difficult to keep moving forward."
(c)2020 The Idaho Statesman (Boise, Idaho) Distributed by Tribune Content Agency, LLC.
