Health care workers with the Carilion Clinic in Roanoke wear enhanced personal protective equipment inside the health system’s facilities (Photo courtesy of the Carilion Clinic).
As COVID-19 infections continue to surge across Virginia, the state’s Department of Health released new guidelines to prioritize contact tracing for cases most likely to fuel transmission.
Virginia Health Commissioner Dr. Norman Oliver announced the recommendations in a letter to health care providers on Monday, writing that “substantial levels” of community transmission “have forced many local health departments to prioritize contact tracing efforts for key elements of the population.”
In response, VDH is recommending that investigators focus their efforts on the most recently diagnosed cases, household contacts of those cases, and people living or working in congregate care facilities, such as nursing homes or prisons. The department also says tracing should be prioritized for people involved in identified outbreaks of COVID-19, as well as people who are more at risk for severe cases of the disease.
“This means that the local health department may not be contacting everyone with COVID-19 infection or close contact to someone with COVID-19 infection,” Oliver wrote in the letter. “Instead, VDH urges people to take proactive responsibility to isolate at home if they are infected and to identify and notify their close contacts.”
The new guidelines are a sobering reminder of surging caseloads in Virginia, which have reached higher levels than at any other point in the pandemic and continue to strain the state’s public health resources. Virginia recorded 3,817 new infections on Monday, adding to a total of 258,870 since the state’s first case in early March. The state is seeing record numbers of hospitalizations, according to data from the Virginia Hospital and Healthcare Association, with increases in each of its five geographic regions.
The statewide percentage of positive COVID-19 tests rose to 10.8 percent on Monday, which most epidemiologists say is indicative of extensive community spread. The World Health Organization recommends at least two weeks of percent positivity below 5 percent before governments consider reopening. In some health districts, including the Cumberland Plateau in Southwest Virginia, percent positivity is currently above 20 percent — higher than the state’s previous peak in late April.
In an interview with CNBC on Monday, Virginia Gov. Ralph Northam said he was considering additional restrictions to curb the spread of the virus. Northam last announced new measures in mid-November, implementing a 10 p.m. curfew for alcohol sales at restaurants and a prohibition on gatherings with more than 10 people. But indoor dining, fitness centers, and hair salons can still operate in Virginia under the state’s Phase Three reopening guidelines, along with many other non-essential businesses.
For some local health departments, the surge has meant hundreds of new cases every day, making it impossible for investigators to contact every infected patient and their close contacts. Health officials in Roanoke began to prioritize cases in November as new infections spiked across the southwestern part of the state. The Mount Rogers Health District, which stretches to the Tennessee state line, announced it was suspending some of its contact tracing outreach last week in an effort to keep up with high-priority cases.
“We want people to understand that with these high levels, we might not be able to call everybody,” said Elena Diskin, an epidemiology and COVID-19 containment program manager at VDH. The new guidelines, based largely on recommendations from the federal Centers for Disease Control and Prevention, are intended to help local health departments decide which cases to prioritize and encourage uniform decision-making across the state. But they’re also an effort to mitigate the spread of the disease as rising cases make it difficult — and sometimes impossible — to follow up with every new infection.
“It’s really trying to focus efforts on people who live in, work, or visit congregate living facilities or high-density workplaces or other settings with extensive transmission,” Diskin said. “Again, those high-yield scenarios where that public health effort is really going to be able to reduce transmission.”
Those determinations can be difficult to make based off the lab reports submitted to VDH, which contain little information about individual patients. Diskin said local health departments can adapt the guidelines to fit their needs, but it’s most likely that investigators will focus on reported outbreaks of the disease — situations more likely to lead to multiple exposures — or new cases that come into the department each day.
“It’s prioritizing in the sense of last in, first out,” she added. “If you have 100 new cases that day — or hundreds of new cases, you get to however many you can that day. And then the next day, you might have to start fresh instead of going back to the bottom of the previous day’s list.”
Conducting a full interview with someone who’s been infected with COVID-19 can take up to an hour, and most case investigators can typically speak to six or seven people a day, Diskin said. Interviewing close contacts of those cases typically takes 20 to 30 minutes, but nearly 14 percent are never reached by investigators, according to VDH data.
Typically, public health workers make three attempts to reach a contact before closing a case, but Diskin said some local health departments might pare back those efforts in order to reach out to more people.
VDH is asking infected patients to notify their own contacts to fill those gaps. On Monday, the department published a fact sheet with a sample script and guide to determining how to define a close contact. Diskin said the department has hired 2,674 new contact tracing employees since the start of the pandemic, but the influx of public health workers still hasn’t been enough to keep up with rising cases.
The problem isn’t unique to Virginia. Maryland, which is also seeing rising case numbers, recently removed parts of its contact tracing interview that provided more detailed information on whether infected patients had visited high-risk locations — including restaurants and places of worship — or attended a gathering with more than 10 people. Dr. Katherine Feldman, the director of the Maryland Department of Health’s contact tracing unit, said the questions were removed to shorten the length of time taken for each investigation.
“We trimmed that survey down so case investigators can conduct more interviews in the same amount of time,” she added. “With cases surging, we’ve had to dial back what we do to reach as many people as possible.”
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