Every day, Tolulope Oyetunde wakes up to a list of Philadelphians newly exposed to COVID-19.
Sometimes it’s just a few names. Other days, the names fill pages. She is one of 122 Philadelphia contact tracers, tasked with identifying people who had recent close contact with COVID-19-positive people and informing those contacts they were exposed to a potentially fatal illness.
“I’ve had people hang up on me," the 26-year-old said. "I’ve had people who were in denial. I’ve had people who were just angry.”
When COVID-19 first struck the region, it overwhelmed county health department efforts to track cases. Since then, both the counties and states have sought to build robust tracing units to contain the spread by letting people know they could infect others if they don’t isolate themselves.
Now case counts in Pennsylvania and New Jersey are growing faster than they have in months, matching national trends toward a long-feared resurgence.
“Contact tracing is the most important thing we can do to get this under control,” said Michael LeVasseur, an epidemiologist at Drexel University.
A contact tracer reaches out to people who have been infected, or anyone who may have spent at least 10 to 15 minutes within six feet of an infected person over the two days before either a positive test result or the onset of symptoms. The system relies on the memory and candor of the infected person, and the number of contacts varies widely, especially for younger patients attending school or playing sports.
“As soon as you’re in that group setting, your contacts go up,” said Jeanne Casner, who as Chester County director of health oversees 68 contact tracers responsible for Chester and Delaware Counties.
Pennsylvania has 1,287 tracers, compared with New Jersey’s reported 1,899. Experts have estimated Pennsylvania could need 2,000 to 4,000 tracers.
The most important metric of success is whether tracers can connect with all new positive cases and their contacts within 24 hours of the infection being reported, said Edward Salsberg, a researcher with George Washington University who helped design a method to determine how many contact tracers a region might need.
Pennsylvania is in the process of hiring 1,000 more tracers, Department of Health spokesperson Maggi Mumma said, and will seek to add volunteers, as well.
A resistant public
Slow test results continue to hamper tracing efforts even seven months into the pandemic. Philadelphia health officials report that 5% to 7% of all positive cases in the last month couldn’t be effectively traced because it took too long to get test results.
The bigger issue: People don’t answer their phones. From Sept. 20 to 26, almost half of all Pennsylvania’s confirmed COVID-19 positive cases — more than 3,000 — couldn’t be reached, and their contacts couldn’t be identified, Mumma said. In New Jersey, about 29% of positive cases could not be successfully contacted, according to state data. Tracing efforts in both states are further stymied by contacts who are identified but can’t be reached, or refuse to provide information to tracers.
There are also people who answer but won’t help. In Philadelphia, about 8% of 7,088 positive cases in the last month refused to share contacts. In Camden County, health officials said, as many as 69% of infected people in recent weeks refused. A failure to identify and communicate with people exposed to the virus seriously undermines health officials' ability to corral the virus.
“It is concerning,” said Rianna DeLuca, a communicable disease investigator for Camden County. “We want people to be more forthcoming. We want to speak to those people, we want to inform them, educate them.”
Experts say some people, including immigrants, are afraid of sharing information with the government, even though their answers to tracers stay confidential. Some are ashamed of admitting how they got infected.
“We’re human, and we want to get together,” said LeVasseur, who experienced similar reluctance to share personal information while doing contact tracing with HIV patients. “It’s understandable." Still, he said, health workers are trained to be compassionate, not judgmental. "No one is going to yell at you.”
Building trust — quickly
A contact tracer is part detective and part social worker. In Camden County, a number of contact tracers are former investigators from the county Prosecutor’s Office, county spokesperson Dan Keashen said.
If the infected person can’t provide a way to reach the people they had contact with, tracers search databases for phone numbers or email addresses, and make multiple attempts to reach people if the first one fails.
“There are days when it’s a lot, you get very minimal breaks,” Oyetunde said. “We have to move really quickly because we don’t want anyone who’s been exposed or who’s had COVID out or spreading it to everyone.”
Once a tracer has reached someone, breaking through suspicion and stigma requires a soft touch.
“You have to call quickly, build trust, understand the experience as a Philadelphian experiencing COVID right now,” said Sara Grossman, Philadelphia’s contact tracing manager.
When an infected person is reticent to share contacts, tracers try to gather as much information as possible, said Casner of Chester County. Even getting a count of how many close contacts the COVID-19 carrier had can help.
Philadelphia’s contact tracing team includes people with clinical and public health backgrounds, as well as some from the service industry, like baristas, she said. And they were hired with an eye to the city’s diversity. Among the city’s tracers are speakers of Arabic, Mandarin, Hindi, Punjabi, and a host of European languages. Oyetunde, a native of Nigeria, speaks Yoruba, though she has not yet had occasion to use it in her job.
Contact tracers check in on patients throughout the course of their illness, helping them find testing, medical care, and social services, including identifying hotels where someone can isolate. There can be surprising intimacy between people who otherwise would be strangers.
“When you’re on the phone and you’re talking to someone who has COVID and they’re worried about ... giving it to their child, that sticks with you," said Oyetunde, who finished a master’s degree in public health at University of Pennsylvania this year and began the tracing job in May.
A coming surge
Even as experts say a fall surge is likely as cold weather drives people indoors, they also say masks, social distancing, and contact tracing still could prevent a repeat of last spring’s serious illnesses and deaths — without another severe lockdown.
“This is really not about government trying to keep track of you but really to protect your family, friends, loved ones who may come down with this,” Salsberg said. “Contact tracing is really an alternative to sort of really shutting down society.”
Oyetunde primarily manages seven contact tracers but does tracing herself, depending on the team’s workload. She has seen firsthand how contact tracing can work. Her first case was a Spanish-speaking household where people who tested positive shared a home with an elderly grandmother. She advised the family through a translator over the course of 14 days how to isolate the older woman and kept her from becoming infected.
She finds support in a virtual community of colleagues dispersed across the city, tracking the virus from their living rooms and bedrooms.
“Something we also have to remember is we can’t burn out,” she said. “We’re in this for a longer run.”