Perhaps the most surprising thing when hearing medical professionals describe the city’s contact tracing program is that if someone is reported as a close contact of a COVID-19-positive person — but they themselves test negative — they’re still told to quarantine for at least two weeks.
“Someone can become positive for COVID at any point during that time period,” said Dr. Darpun Sachdev, a clinical prevention specialist with the Department of Public Health, who has been leading the contact tracing program. “We know that usually it happens between five and seven days, but it can be all the way up to 14 days.”
The city has a workforce of 118 people on its contact tracing team, although it has trained 276 people. On any given week, 60-some contact tracers are scheduled for four-hour shifts.
“We’re able to meet our demand right now, as of today. Everything can change tomorrow,” Sachdev said. “Fortunately, having a large workforce trained, we could activate them in the case of a surge.”
Across the country, access to low-barrier testing and rigorous contact tracing programs have been put forward as key tools in the public health toolbox to combat the spread of coronavirus: Testing to identify people who are positive for coronavirus, and contact tracing to quickly warn people who may have been in close proximity to a COVID-positive person to stop the virus from spreading further.
Sachdev, who in pre-pandemic days spent her time doing contact tracing for HIV and syphilis, said San Francisco’s COVID-19 contact tracing program started March 5, with the very first cases detected in the city. In those early days, when resources were extremely limited, they weren’t even able to offer tests to those first contacts. She said the program was further developed and really got underway by mid-April.
First come the case investigators, and then the contract tracers
In the era of COVID-19, the contact tracing program has been split into two teams: case investigators, who reach out to people who have tested positive, and contact tracers, who contact people who have been in close contact with a COVID-19-positive person.
“I feel the word ‘investigator’ might scare people,” Sachdev said. “But it’s interviewing a case, and providing them with education, and linking them to resources. That’s the basics of it.”
As part of the interview, conducted by phone, case investigators ask who someone with COVID-19 has been in recent contact with — beginning two days before the onset of symptoms, or when the person took the test, whichever is earlier. Those names and phone numbers are then handed to the contact tracers, who reach out to let people know they may have been exposed and need to quarantine for two weeks.
A COVID-positive person, on average, lists the names of three close contacts to the case investigators. But Sachdev said usually about half of the people reported are already known to them and are in the system.
“Historically, in other diseases, the role of the case investigator and contact tracer was fulfilled by the same person,” said Dr. Mike Reid, an assistant professor of medicine at UCSF, whose team has been supporting the Health Department’s contacting tracing program. “You get on the phone to a case, and the next thing you do is reach out to all of their contacts. But the sheer volume we’re seeing in the U.S. demands that you have different people fulfill these different roles.”
There are about 25 case investigators in San Francisco, made up of experienced Health Department personnel, Reid said.
But more contact tracers were required than the Health Department could spare, so they began to retrain city workers from other departments. By law, all city employees are disaster service workers who can be activated when the mayor declares a state of emergency, as Mayor London Breed did on Feb. 25.
“These are librarians, the city attorneys, the city assessors,” Sachdev said.
Mission District librarians pitch in
“I certainly never imagined I would be doing something like this,” said Jessica Jaramillo, a San Francisco Public Library district manager. She’s one of a number of librarians who have been temporarily reassigned to work as contact tracers. “I feel like I’m doing something with purpose, something important.”
“It’s also been a little bit emotional, because people are struggling to survive in so many different ways right now, and you are having a conversation with them that kind of lays that bare,” she said.
Ramon Hernandez, the branch manager of the San Francisco Public Library’s Mission Branch, has been reassigned as a contract tracer since last month.
“It feels good. We’re helping the community, and hopefully helping to contain the virus,” Hernandez said. “But there are definitely a lot of stories that are hard to hear — lots of people in bad situations, especially economically.”
Hernandez is bilingual and said most of the calls he makes are in Spanish.
The Mission District and Latinx population have been particularly hard hit by COVID-19. As of June 29, the Mission has had 576 cases, the highest of any neighborhood in the city. And the Latinx population, which makes up only 15 percent of the city’s population, comprises more than 50 percent of the city’s COVID-19 cases.
Sachdev said that more than half of the people who contract COVID-19 in San Francisco speak Spanish.
“I think that’s why in a lot of ways the library was a good fit, because the staff is multilingual,” Hernandez said. “We have Russian speakers, Cantonese, Mandarin, Spanish — pretty much the main languages spoken in San Francisco.”
“In the beginning, I thought people would get angry and hang up on me, and tell me to mind my own business,” Hernandez said. “But generally, people have been really friendly, open, and thankful.”
According to statistics from the Health Department, over the past two weeks, 82 percent of COVID-19 cases were successfully contacted by the case investigators, and 85 percent of their self-reported close contacts were reached by the contact tracers.
Locally, the Association of Bay Area Health Officials set a target of reaching 90 percent of cases, and 90 percent of contacts.
“For sure, it’s a super ambitious target,” Reid said “Will be able to maintain that if there’s a surge? I would argue that’s a metric we should hold our leadership accountable to: If we see those numbers go down, then that’s a message to the mayor that she needs to invest more in case investigators and contact tracers.”
Mary Ellen Massa, a bilingual children’s librarian at the Mission Branch, and who also recently started work as a contact tracer, said close contacts of someone with COVID-19 are asked to be tested as quickly as possible — either the same day, or the next day at the latest. While quarantining, those contacts are advised to stay home, but they can still interact with people in their household.
People in quarantine are asked to take a second test, between day 10 and 14 of quarantine, if the first test comes back negative.
If any of those tests return positive for COVID-19, the situation changes: They are no longer told to quarantine, but instead to self-isolate.
“They’re supposed to be in a room, and use a bathroom, and that’s about it — have minimal contact with people in their household,” Massa said.
The self-isolation period lasts a minimum 10 days from the onset of symptoms and doesn’t end until a patient has been symptom-free for three days.
“I think the biggest challenge is when there are multiple families living in one unit, and maybe they don’t have the space to quarantine,” Massa said. “Definitely it is hard to live in the city, it’s expensive. So, people do find ways — but it means they’re sharing a two-bedroom with two other families.”
In addition to letting contacts know they have been in close proximity to someone with COVID-19, Massa said contact tracers also connect people with resources while they quarantine, such as access to food, cleaning supplies, or connecting them with a social worker if social services are needed. If quarantining or self-isolating at home isn’t practical, hotel rooms can be made available free of charge.
“Many people are resistant to access that service until they realize it’s free, and it’s not an SRO hotel room — it’s a regular hotel room. Then people are more open to it,” Reid said. “It really makes sense, though. If you really want to curb transmission, you put the infectious persons away from the rest of the population.”
Sachdev said she didn’t know how many cases or contacts had taken the Health Department up on the offer for an isolation hotel room.
This week, the city launched its Right to Recover program, which offers up to four weeks of paid leave for workers or residents with COVID-19 who lack a local, state or federal safety net.
Santiago Lerma, a legislative aide for Supervisor Hillary Ronen, said the program does not currently offer assistance to people who are quarantining because they were listed as a close contact of someone with COVID-19. However, there are currently ongoing discussions to expand the legislation, he said.
As of last week, Sachdev estimated that at any given time there are roughly 600 people throughout the city in quarantine or self-isolation — but those numbers could soon be on the rise.
“We do anticipate the number of [new infections] to increase, and because people are becoming more social and going back to work, we would anticipate the number of contacts outside of households to also be increasing,” Sachdev said. “What we hope is people stay physically distant and masked, so then we have very few contacts outside of the household. That is the whole point of our ongoing recommendations.”
Health officials said they weren’t sure how many people had been abiding by the recommendations and successfully completing their quarantine and self-isolation periods.
“We have a lot of internal discussion around it,” Reid said. “It would be great to explore that, but we don’t have a way of accurately capturing that information.”
Technically, not complying with the recommendation would be a violation of the health order, which is a crime. But Sachdev said she hates to think of it in those terms.
“I don’t like thinking of health order violations,” she said. “I think we’re making strong recommendations. We would never say someone is violating the health order.”
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