The College Contact Tracers on the Offensive

Contact tracing isn't a new profession. But it is new for most colleges.

December 16, 2020
 
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Allison Lindsay didn’t dream of being a contact tracer. She came to the State University of New York at New Paltz as an athletic trainer in 2017. But when the college reopened in the midst of the pandemic, she suddenly had a new job.

“It’s always difficult not doing what you like to do and are trained to do,” she said. “[But] I personally have found it pretty fulfilling and also think it’s really important to contribute to the university’s effort to protect the students and the community.”

Contact tracing and disease intervention is not a new profession. The practice goes back hundreds of years. But this year, contact tracers’ numbers grew by the thousands. On college campuses, they are part of the new, rapidly deployed pandemic workforce.

A Historic Profession

As far back as the Middle Ages, a sick person’s family and friends might be warned about the disease and kept at home. But the formal origins of government contract tracing began in Europe in the late 19th century, said Graham Mooney, a professor of the history of medicine at Johns Hopkins University School of Medicine.

“People who had certain diseases, known as infectious or contagious diseases like smallpox, scarlet fever, cholera and so on, their disease had to be reported to local health authorities that had emerged as formal departments in the mid- to late 19th century,” he said. “Once you have that information that somebody has a disease, it’s a lot easier to begin to think about how you trace their contacts.”

National reporting legislation was a gateway into empowering health departments to take on other actions, like formal contact tracing, Mooney said. Before mandatory reporting, governments wouldn’t be informed that a person had an infectious disease until they died of it. In the U.S., states made their own rules about reporting, but by 1901 each one had some requirement to notify local health authorities of communicable disease cases.

Disease reporting and contact tracing gained new import from the 1920s into the 1940s as therapeutic interventions for sexually transmitted infections, like syphilis and gonorrhea, became widely available, Mooney said. Because of the sensitivity of contact tracing for those illnesses, health departments began to use some of the secrecy measures we see commonly today, such as discreet packaging for mail or anonymous forms and letters, to protect patient confidentiality. Many of those practices continued into the HIV/AIDS epidemic in the 1980s and 1990s.

“Public health leaders [in the 1940s] came up with strategies to interview, notify and contact people who had been potentially exposed to syphilis, and from then the practice really just grew over the decades and evolved to be now a function that we broadly practice in public health related to infectious disease outbreaks,” said David Harvey, executive director of the National Coalition of STD Directors.

Before COVID-19, there were only about 2,500 disease intervention specialists -- who perform contact tracing as part of a broader role -- funded by the U.S. federal government, Harvey said. When the pandemic exploded early this year, the STD and tuberculosis workforces were redeployed and upwards of 75,000 entry-level contact tracers were trained and hired to control the outbreak and connect people with testing and medical advice. Those numbers were not enough. Contact tracers have struggled nationally to keep up with the incredible community spread in the United States.

A New Role

On college campuses, contact tracers come from different places. Some, like Lindsay, were moved from other positions. Others are undergraduates or medical students. And others still had never worked at a college or university before but were hired for the new roles.

While contact tracing is part of the medical tradition, the knowledge and skills that tracers need to have are not exclusively medical in nature. For many, the ability to show empathy for a patient or contact, gain trust, build rapport and show support are equally important to knowledge of how the disease spreads.

Athletic trainers, who prevent, diagnose, examine and rehabilitate injuries and medical conditions in athletes, use similar skills in their interviews and relationships with students.

“In athletic training, we encounter injured athletes who can’t do what they love. It’s bad news, and in some cases it’s really bad news,” said Lindsay. “[In contact tracing], we just use the same skill set that we have to have a conversation with someone, respond with empathy, let them know that they’re supported and that they’re supported by people with real information for them, help them make choices and feel empowered to take the right steps going forward.”

Bryan Lurie, another athletic trainer working as a contact tracer at New Paltz, echoed the sentiment.

“It wasn’t a far leap for us to do this,” he said. “The kids that we normally deal with, these senior student athletes, they’ve lost a season of sport. Most of these kids aren’t going pro or anything like that. They’ve missed out on some big experiences.” Empathy and support are key.

About 85 percent of students that Lindsay and Lurie contact over the phone for tracing take it well and are open about who they’ve seen recently. The other 15 percent can be angry, opaque about their contacts or just really upset.

“That’s understandable,” said Lindsay. “People are apprehensive. ‘What does this mean? Am I going to get it? Am I going to get really sick? Did I spread it to a family member?’”

Sometimes students can change their stories, or be afraid of getting in trouble.

Bianca Godwins, a medical student and M.B.A. candidate at University of Alabama at Birmingham, also works in contact tracing as a project manager for UAB’s tracing project. Students in medical disciplines there work with the state to do contact tracing across Alabama, not just on campus.

“You have some [patients] that are super understanding and willing to speak with us and provide all this information. You have some that are extremely, extremely sick,” Godwins said. “We have those cases that literally don’t believe that COVID is real. They think that it’s a scam or that we’re scammers trying to contact them. Or it’s a conspiracy theory.”

“There’s a few stories, honestly, of contacting a patient or contacting the spouse of a patient and my investigators are getting cursed out,” she added.

Part of that can be the stigma associated with COVID-19, Godwins said. Although the coronavirus isn’t as stigmatized as sexually transmitted infections -- and doesn’t require divulging intimate or private information -- patients can still be distraught and ashamed.

Godwins found the human component to contact tracing so important, she developed a “soft skills” training for her team. Sometimes, even the way an investigator approaches the conversation can make a difference.

“Instead of asking, ‘Are you experiencing the fever, the chills, the loss of appetite or loss of taste?’ just go ahead and ask them, ‘How are you today? How are you feeling?’” she said. “This patient will now end up opening up a lot more than expected.”

One problem the UAB tracers, like others around the country, run into often is people not answering their phones. Sometimes the majority of a contact list may not pick up, meaning the tracers will send a letter requesting a call.

At SUNY New Paltz, Lindsay and Lurie use a Google Voice account to do their calls, which means that they are able to text students.

“Really critical is the ability to text,” Lindsay said. “I would say 20 percent of voice mail boxes are either full or not set up.”

When they can text, they get a call back within the hour nearly 100 percent of the time.

College contact tracers also have more resources than a typical government health department and may have an easier time getting in touch with people.

“We have a lot of support from residence life or for example the registrar to help us understand where these various people might have been on campus and who they might have been exposed to,” Lindsay said.

Often, students may not know the names and phone numbers of the people they were in contact with. (Contact tracers ask about anyone patients might have been within six feet of for 10 to 15 minutes, up to 48 hours before a test or symptoms.)

“A particular person on the third floor of this certain dorm, and that’s all they know,” said Lindsay. “We can look and see ‘OK, how many people are named that on the third floor of this dorm? Only one? Well, let’s try to reach them with the contact information provided to the university.’”

Before COVID-19, the number of disease intervention specialists was on the decline for about a decade, said Harvey, of the National Coalition of STD Directors. What will become of contact tracers, on college campuses and otherwise, when the pandemic subsides remains to be seen. Harvey and other advocates would like to see the permanent workforce grow. Lack of care and testing over the last few months means there might be an STD problem when the country re-emerges.

On college campuses, some contact tracers -- like Lindsay and Lurie -- will likely go back to their regular roles. Others, like Godwins, will carry their experiences through medical school and their careers.

“This particular job and this role has been one of the best blessings for me,” Godwins said. “I’m super honored to play such a part in tackling these COVID-19 cases.”

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