Testing and tracing are needed to stop COVID. Why Tarrant County is struggling with both
Nearly every indicator the Tarrant County Public Health Department uses to gauge the severity of the coronavirus outbreak is pointing upward: Hospitalizations of COVID-19 patients have more than tripled since June 1. Positive cases have nearly tripled, and COVID-like illnesses have also jumped. Even the test positivity rate, which was supposed to fall as more people got tested, has quadrupled over the last few weeks, from 5% to almost 20%.
And as everything trends up, Tarrant County’s ability to contain the coronavirus has fallen. The effectiveness of both testing and contact tracing, two key tools necessary to bring about a return to normalcy during the pandemic, have struggled to match the growth of the virus over the last several weeks.
Since June, Tarrant County Public Health’s drive-through COVID-19 test sites have been “completely booked out,” with as many as 1,500 people trying to schedule a test per day. And DFW residents have said they’ve run into similar issues with private providers, staying up until midnight to try and secure an appointment and waiting over 10 days to receive their test results from backed up labs.
The step that is supposed to happen after testing is case investigation and contact tracing. But bereft of enough staff and resources Tarrant County has not consistently alerted the contacts of people who have tested positive for COVID-19, much less investigated enough of the positive cases — between 500 to 800 per day in recent weeks — to know exactly how or where people have contracted the virus.
The lack of information has made it difficult for Tarrant County Judge B. Glen Whitley to know where the bulk of new cases have come from. “We haven’t been able to find that out yet,” said Whitley, who added that more information could allow him to better convince people to wear masks or curb potentially irresponsible behavior. “That’s why I think the contact tracing is still important.”
Tarrant County is not alone in its setback. The entire state has been reeling from testing shortages and has fallen short of the contact tracing goal set by Gov. Greg Abbott, an estimate that may have been insufficient to begin with. So as Texas counts upwards of 9,000 new coronavirus cases per day, the spread of the virus has grown too large for containment measures to work efficiently. It raises the question of whether Texas committed enough resources to be ready for the return to normalcy many state and local politicians wanted.
“I don’t think we had to stay under lockdown for longer if we had put in the preparation to be able to open,” said Ben Neuman, a virologist and professor at Texas A&M-Tekarkana. “It was a balancing act. It was trying to balance concerns for different groups. And coronavirus doesn’t balance.”
Why testing and tracing were key for Texas to reopen
The public health world essentially uses a combination of two main strategies for battling disease: mitigation and containment. Mitigation tactics range from hand washing to social distancing to business closures to total shutdowns, and they are largely incumbent on responsible public behavior. Containment is, more or less, a “four-cornered quest,” said Veer Vithalani, an ER doctor who is the medical director of MedStar and leads the Tarrant Medical Operations Center. “Test, isolate, trace, quarantine.” And according to the CDC, containment should be used to prevent an outbreak before it occurs, or to snuff out a disease that has been suppressed through mitigation.
Texas, like the rest of the country, had to emphasize mitigation in March and April. It was not equipped with adequate testing infrastructure, PPE or contact tracing staff at the time, and community spread had been detected. The stay-at-home order, a very strict mitigation strategy, was supposed to suppress the disease long enough for Texas to build up its PPE, testing and contact tracing arsenals. Then, Texas could dial back the stay-at-home order and place a greater emphasis on containment.
“That is absolutely what was expected: that the mitigation strategy would slow the spigot and we would contain it through containment strategies. And that’s what we were doing,” said Tarrant County Public Health Director Vinny Taneja. “But as the spigot got opened up, (as) we rolled back on some of the mitigation strategies, the volume has increased quite a bit.”
And the containment strategies of testing and tracing were not equipped to handle the volume that came with the rollback.
Waiting 10 days for test results
In Abbott’s late April reopening report, he listed testing and contact tracing as priorities for stopping the spread of disease while things returned to normal. For the strategy to be effective, Abbott’s plan entailed Texas conducting 30,000 tests per day and employing 4,000 contact tracers by June 1.
The state began to more consistently meet its testing goal in late June. Despite more tests being conducted, Tarrant County residents say they’re still having a hard time finding available appointments or facing long waits and miscommunication over their results when they do — just like in March, when the few people who could get tested waited nearly a week for results. The problem is affecting both Tarrant County’s Public Health sites and commercial or hospital labs, where 99% of confirmed cases are run, according to Tarrant County’s COVID-19 dashboard.
Last week, Kaylie Dupre started to have trouble breathing, and had a mild fever and a cough. A day before she had found out someone at her daughter’s preschool had tested positive for COVID-19. Both she and 3-year-old daughter, Kennedy, also have underlying conditions that put them at higher risk for developing severe complications from the virus. So she decided they should get tested.
Her husband stayed up until midnight hoping to be the first for the next day’s openings, and she also tried through Tarrant County Public Health’s screening portal, CVS and other private providers. They had no luck. On July 1, she finally found an appointment at the CareNow Urgent Care clinic in Saginaw.
Dupre said the clinic was upfront, and told her that at the time of her appointment it may not have a test available. Luckily, it did. But six days passed and she still hadn’t received her results. Frustrated, she found out online that she could find her results through LabCorp’s online portal. When she logged in on July 7, she learned she had tested negative for COVID-19 — and that her results had been ready three days before on July 4.
“I actually called them to say, ‘Hey, where are these results?’ And they apologized, and said that they were so backed up, that they haven’t called me yet,” said Dupre, who had to call for her daughter’s results.
Berndt Parker said he received a similar response after waiting 11 days to get his COVID-19 test results back from Quest Diagnostics following a visit to a CareNow clinic in Denton.
He was told it would take three to five business days, and checked Quest Diagnostics’ patient portal every day hoping to see his results. In the meantime, he still felt awful, with a fever, loss of appetite and stomach issues. But other doctors he called wouldn’t see him until he had a negative result.
Eventually, his dad helped track them down, calling both Quest and CareNow to get some answers. By the time Parker received his negative result Tuesday, he was feeling well enough to get to return to work in a few days.
“It was rough because I couldn’t go see a doctor to get medicine for flu or whatever I did have, so I was just laying in bed all week,” Parker said. “I was tired and it sucked.”
In statements, both Quest Diagnostics and LabCorp pointed to a rise in demand and constraints on equipment as reasons for slower results. The average turnaround time is now between four to six days for patients who are not hospitalized or part of priority groups. CareNow said it was adding daily lab partners and increasing daily shipments of tests to meet demand. The company notes on its website that results may take two to 10 days, and encourages people to create accounts through the labs’ portals. But Dupre said she hadn’t been told to do so.
“It did leave me frustrated, angry. It’s very discouraging,” Dupre said. “Two to seven days is way too long, in my opinion, to wait for results that could potentially be deadly for some people.”
Why Texas may need thousands more contact tracers
As for contact tracing, the goal of 4,000 tracers statewide was not reached. By the June 1 deadline, Texas had about 2,900 contact tracers, split among the Department of State Health Services, various local public health departments and a private Frisco-based company hired by the state. That number fell to 2,800 by the end of June as coronavirus cases surged, according to the Texas Tribune (DSHS did not respond to the Star-Telegram’s questions about contact tracing staffing).
The result of an insufficiently-sized contact tracing staff is particularly visible in Tarrant County. The public health department had about 12 contact tracers on staff in March, Taneja said. By shuffling around resources it was able to increase to about 40 staffers, and it also received help from a few dozen public health graduate students from the UNT Health Science Center. After a hiring spree of 50 people in mid-June and the departure of many HSC students because of graduation, Taneja estimated Tarrant County has 100 people working on case investigations and contact tracing (Dallas County, with a population about 25% greater than Tarrant County, had about 330 contact tracers, including volunteers, as of late May).
The National Association of County Health Officials recommends that in a non-emergency situation, a public health department should have a staff of 15 contact tracing-related positions per 100,000 population, with the potential for staffing more when outbreaks occur. That means at the outset of the pandemic the organization would have recommended Tarrant County have three times more staff than it does now, a total of about 300 investigators, contact tracers and supervisors.
At this stage of the pandemic, the recommended number is much higher. Researchers at George Washington University, working with the National Association of County Health Officials, have kept a running estimate of how many contact tracers each state and county should employ based on coronavirus case counts. As of Wednesday, they estimated Texas would have needed 39,000 contact tracers, investigators and supervisors to be able to trace every case from the last two weeks. Tarrant County, they estimated, would have needed 2,600 — or 26 times more than the public health department has.
High as these estimates are, other states have created or planned much more robust contact tracing staffs than Texas. New York started a program in April to employ between 6,000 and 17,000 contact tracers, depending on the demand. And California set a goal of hiring 20,000 tracers.
The reason why such a large number is needed is because contact tracing is an enormous undertaking. For contact tracing to be effective, said Diana Cervantes, a professor of biostatistics and epidemiology at UNT Health Science Center, about 80% of someone’s contacts must be reached. An April Harvard study indicated the average number of close contacts of someone who has tested positive for coronavirus and has social distanced was 10; for someone who has not social distanced it was almost 20. The contact tracing process is easier said than done even with a large staff: Language and cultural barriers, political beliefs and the simple fact that many people won’t answer phone calls from unknown numbers make it a challenge.
In May, when Tarrant County’s cases typically reached around 100 per day, Taneja said the health department could investigate and do contact tracing for most of them. However, he also said that the last time he checked on the data was about two weeks ago when Tarrant County had about 11,000 cases. And from those 11,000 cases, he said, they had documented 9,000 of those people’s contacts — fewer than one contact per person.
But Taneja noted that about one-third of Tarrant County’s earlier coronavirus cases were occurring in enclosed facilities where it was not necessary to document contacts, such as elder-care facilities and jails. The cases in June and July have not only increased fivefold compared to May, but a smaller proportion have occurred at enclosed facilities, leaving the department behind on investigating and tracing. “We’re not getting to all the contacts at this point because we’re struggling to get through the cases at all,” he said. “But the effort is ongoing.”
The slow test results haven’t helped, either. That’s because the longer it takes for a test result to come back, the less effective contact tracing is. “If you’re only able to get to cases and their contacts well after an individual has tested positive,” said Elaine Symanski, professor at the Center for Precision Environmental Health at Baylor College of Medicine, “you’ve lost your window of opportunity.”
How Texas can get the outbreak under control
So how does Texas get back on top of its testing and tracing strategy? “If you were fighting a battle and you weren’t doing well you would try to commit more resources. That seems like the goal,” said Neuman, the professor at Texas A&M-Tekarkana.
At this week’s county commissioners meeting, Whitley brought up the need for more contact tracers while addressing Taneja. “We gotta bring that number (of cases) down and if we set up call centers I don’t care what we have to do. Bring it to this court,” Whitley said. “We need to be doing some contact tracing to try to get at the cause of some of these things.” For testing, Whitley discussed the need to extend hours of county testing sites and open them more consistently on weekends. He also wants to improve data collection by having the state mandate private labs report negative test results to the county, in addition to positive results.
But Texas and Tarrant County are too far behind the outbreak for an infusion of testing and increased staffing of contact tracers to get things under control, according to several public health experts. Reaching even half the recommended amount of contact tracers is a near impossibility at this point, and testing capacity will take time to build. “When you have this wide of a spread in your community and across the country what you really need to apply is mitigation strategies, which we got a good start on in March,” Taneja said.
That’s why Texas closed bars, mandated the wearing of masks in public places and limited gatherings to no more than 10 people. Despite calls from local counties and cities to restore their power to use the stricter mitigation strategy of a stay-at-home order, Abbott has not agreed to their requests. Whether these lighter mitigation efforts can suppress Texas’s outbreak will not be known for a while. For people wondering how to best behave as Texas struggles with testing and tracing, public health experts recommend that everyone act like they have been around somebody who has COVID-19, which means staying home when possible, practicing social distancing and wearing a mask in public.
In television interviews Thursday night, Abbott said when COVID-19 treatments eventually come out, those “will provide a sense of relief.” But until then, he stressed that if Texans want the economy to remain open, they have to wear a mask. “If we do not begin to adopt the practice of wearing masks and if COVID-19 continues to increase, hospitalizations continue to increase and deaths continue to increase, it will force us to lead to the ultimate solution that I do not want to do — and that would be to close Texas back down,” Abbott told KRIV-TV in Houston.
Neuman has said since Texas chose to reopen in May that near-100% adherence to mask-wearing would lower the spread of disease even with more businesses open. He still believes it can after this surge, although a decline in cases may not appear for at least two weeks. “Will it be a slow turnaround or sudden? The stronger the restrictions the quicker the turnaround can be,” he said.
And to avoid another surge after that time period, it will be essential for Texas to scale up its contact tracing and testing. Stephen Parker, who tracked down CareNow and Quest Diagnostics to find out why his son Berndt’s results were delayed, wonders why Texas isn’t better prepared already.
“There’s a huge operational capacity issue that nobody is addressing,” Parker said. “They’ve had three months to prepare for this, and I’m not sure why many are saying now it’s spiked and we weren’t ready. That excuse to me is lame.”
This story was originally published July 10, 2020 at 8:27 AM.
