As state ramps up contact tracing, some local health directors feel out of the loop
Cathy Bethel has lived in Muhlenberg County for more than 30 years.
The “hometown, family atmosphere” in this western Kentucky county of about 30,000 makes her job as director of the Muhlenberg County Health Department all the more intimate and rewarding, she said. Her personal cell phone number is listed on the department’s after-hours voicemail. When she ventures in public, she factors in a certain cushion of time, anticipating she’ll be stopped and chatted up.
“It’s nothing for me to go to the store when we don’t have COVID-19 and for a million people to stop me and say, ‘Hey, how are you doing?’” Bethel said this week by phone. “When I go in somewhere, these people know me.”
So, when Kentucky’s outbreak of the new coronavirus started blooming in early March, necessitating aggressive contact tracing — locating all people someone with confirmed coronavirus had contact with — her small department, like many across the state, had a leg up investigating webs of the virus spawning in their own communities. Mostly rural, western Kentucky counties boast the highest COVID-19 infection rates per capita.
An outbreak at Green River Correctional Complex in Central City ratcheted up her county’s total number of cases to more than 460. About 70 are cases in the community, and Bethel has a team of four of five, including her, currently doing the tracing. Another four trained epidemiologists are waiting in the wings if there’s a case spike.
“All of them aren’t doing tracing yet because we’re managing it,” she said.
Soon, though, her county and eight others in the Pennyrile District are slated to get more than 20 additional contact tracers and communicable disease investigators, through a series of private sector contracts the state expects to award next week.
Contact tracing is considered a key factor in helping to limit the spread of the disease. With the state slated to begin opening next week, Gov. Andy Beshear’s administration is trying feverishly to increase the state’s capacity.
Once businesses do reopen, state and local officials expect the contagious disease to spread, and measures like contact tracing will be used to try and contain it. The new normal, as Beshear calls it, will likely involve the knowledge that at any moment someone can receive a phone call telling them to quarantine for 14 days because they came in contact with the virus. Last week, the state put out a request for proposals so it can hire close to 600 new contact tracers and investigators — the people who will be making those calls.
But some public health directors, while grateful for the extra help and pleased with Beshear’s actions up to this point, are skeptical.
Seeing as contact tracing will be the first line of defense to keep new infection rates at bay, and it’s work that public health departments almost exclusively have overseen up until this point, some don’t understand why the state hasn’t involved them at all in the planning process. It’s a slight that, when colored by Kentucky’s long history of underfunding its public health departments , stings maybe more than it should, some said.
Kentucky Health Department Association President Allison Adams learned the state was hiring hundreds of new contact tracers when the rest of the public did, when Beshear announced it in a daily news conference last week.
Beshear on Tuesday said these new hires will “answer to or collaborate with local health departments,” since “they know how to do it, [and] they do a phenomenal job. We’re going to rely on them to lead the individuals helping out in their district.”
But exactly how fluid that coordination will be, or who will spearhead it, is unclear, since a plan hasn’t been announced, more than half a dozen public health directors interviewed for this story said.
Much of the state’s response to the virus, first diagnosed in early March, has been slapdash by nature, since a pandemic of this scale hasn’t been seen in at least a hundred years. But for those in public health, it’s mostly just another day at the office, especially when it comes to contact tracing: “It’s our jam. This is what we do,” Adams said.
“I want to be an optimist and think, OK, the health departments have this. We want the support, we want the flexibility” with new contact tracers, “but we don’t know what the state has in mind,” said Adams, who also serves as the Buffalo Trace District Health Department director in Maysville.
Her district in Mason and Robertson counties has had a total of six confirmed cases and all have recovered. According to the RFP, which closed to bids Friday afternoon, her district, along with Bath, Menifee, Montgomery, Rowan, Elliot, Bracken, Fleming, and Lewis counties are supposed to get a dozen new contact tracers, three communicable disease investigators and five coordinators.
Adams doesn’t know whether they will be hired locally, who will train them, or how their training will fit with proven health department methods.
The RFP doesn’t detail specifics of how closely new contact tracers will work with local public health departments, just that “staff will be [Department of Public Health] assets to be deployed locally and with local coordination” and that new tracers will work “alongside” local health departments.
Hiring of all the new contact tracers should happen in five days, “if possible,” the RFP says, followed by a week of training — a timeline that leaves virtually no room for error or delay.
By that point it’ll be late May, and many Kentucky businesses will have already been open for two weeks. On May 22, restaurants will open at partial capacity — Beshear had said previously that wouldn’t happen until June — and on May 25, people can get together in groups of 10 or fewer.
The governor has said local public health departments will handle contact tracing for the first two weeks or so after the economy reopens, before new hires start. But once they’re in place, public health directors don’t know how the two efforts will be braided.
“How can we build our existing work into a bigger picture,” Adams said, when “we don’t know what that should look like?”
‘Not the first outbreak we’ve worked’
Contact tracing is a retroactive piecing together, usually by phone and beginning with a person who tests positive, of everyone that came into direct contact with an infected person, both to notify them of possible transmission and to make sure, if they were at high risk, that they preemptively quarantine for 14 days to halt any chances of further spread.
It also involves monitoring those quarantined people, checking their symptoms daily, and ensuring they stick to their stay-at-home order before they’re allowed to safely reenter society.
Though the practice has been discussed more publicly by state and federal leaders in the last few months than probably ever before, it’s a centuries-old public health tool used to stem the spread of communicable disease, like tuberculosis, hepatitis, foodborne illnesses and HIV and other sexually-transmitted diseases.
“Contact investigation of communicable disease is the cornerstone of public health,” Hopkins County Public Health Director Denise Beach said. And COVID-19 “is not the first outbreak we’ve worked.”
It’s also a practice enhanced by knowledge of a place and its people, especially in rural areas, everyone interviewed for this story said.
Adams, in Eastern Kentucky, agreed: “If you hire a Lexingtonian to work the hollers of Wolfe County, it’s not going to work,” she said.
People tend to reveal more information when they know who you are, or at least where you’re from, Bethel said. And when you’re asking questions about recent decisions people have made, who they’ve been around, it helps to have some semblance of who’s asking the questions, she said. Recently someone Bethel knew in Muhlenberg County tested positive, and rather than wait for public health staff to call, they called Bethel’s cell, asking what to do.
Sara Jo Best can relate. As director of the Lincoln Trail District Public Health Department for Hardin, LaRue, Marion, Meade, Nelson and Washington counties, “I absolutely recognize the importance of local representation,” she said. “Being a trusted member of the community, that’s something that’s very real and alive in Kentucky.”
The 134-page contact tracing RFP says, “staff are not required to live in Kentucky.”
Rumors and frets about a call-center contact tracing model have also been circulating among public health directors. The RFP says the Department for Public Health “will also consider call center solutions, to provide additional active monitoring for isolated or quarantined individuals.”
Another section reads, “it is not the intention of the Commonwealth to award a call center” a contract, rather “the intention is to have individuals available to help field statewide calls as necessary.”
Even for Muhlenberg County residents who aren’t familiar with the health department, Bethel thinks people are more likely to answer their phone when they see “Muhlenberg County Health Department” on the caller ID.
While it may seem over the top, she said, “I think if you didn’t hire someone who was from here, and they were working from a remote location, I don’t think my people would answer the phone.”
‘We are not starting at zero capacity’
Some local public health directors, worrying their residents wouldn’t even call the state coronavirus hotline, set up their own local hotline.
In Graves County, which has 145 positive cases, county public health director Noel Coplen said, “back early on in March, we set up our own call center locally, just so if somebody didn’t want to call someone they didn’t know in Frankfort, they could call here, ask questions and tell us their concerns.”
Generally, Coplen said, “doing the same thing the same way all across the state I don’t think ever works. What works in Louisville and Lexington might not work here. Even what works well in Graves County might not work in Calloway County,” he said.
What’s more, “contact tracing isn’t always neat and clean,” Best from the Lincoln Trail District Health Department said. Often filling in those gaps, “does take a local connection.”
Multiple times, directors interviewed for this story said they’ve had to track people down in person — a feat made easier when they’re familiar with a community and its establishments.
Best is an at-large officer for the Kentucky Health Departments Association, representing 13 other district health departments. All of them are “thankful” to Beshear “for the ability to bring in additional temporary assistance,” she said. “But what we really hope is that it’s under the leadership of the local health departments and integrated into our existing staff.”
On Tuesday, after the RFP had already been put out for bid, Beshear held his first telephonic meeting with public health directors, at their request, since the outbreak started.
He was receptive and supportive of their efforts, as he has been publicly, directors said. But they still didn’t come away with new insight into what the plan is.
“Please understand, we are not starting at zero capacity, [and] we want to be able to use our existing staff as much as we can,” Best said. “They’re trained and ready and have those local connections.”
What directors want is for new hires to “complement” already in place contact tracing infrastructure, she said, “rather than reinventing what we’ve been skilled at doing for many years.”
