Reopening Oregon Depends on a Detective Squad Tracing Where Contagious People Have Been

Tracking the spread of COVID-19 is a lot like conducting a telephone poll.

Think back: Where were you at this time a week ago?

How many times did you leave the house that day? What businesses did you visit? Who did you talk to?

Now, imagine you just tested positive for the coronavirus. A stranger claiming to be from the Multnomah County Health Department calls.

He wants the names and phone numbers of everybody you've come in contact with since two days before you started feeling sick. He's got a million other questions. About whom you might have slept with, whom you came in contact with and where you were every hour of every day.

You just want to sleep.

David Cuevas is the man making that call.

Cuevas, 41, has the official title of case investigator for the communicable disease services section of the Multnomah County Health Department. In the larger scheme of things, he is the first link in a chain of steps that will determine whether the county can reopen successfully this summer.

His work can be difficult, interviewing someone who has tested positive for the coronavirus about where she has been, whom she had contact with, and how to get in touch with those people.

When Cuevas gets the information he needs, he then passes those facts along to a contact tracer. That person's job is to reach each of those contacts, tell them they might have been exposed to COVID-19, and urge them to stay home for two weeks.

Multnomah County must satisfy state officials it has the capacity to hire enough investigators to contact 95 percent of patients who test positive for the coronavirus within 24 hours, the threshold set by Gov. Kate Brown. Until then, it will stay shut. (Washington and Clackamas counties, which also remain closed, are in a similar position.)

Multnomah County, which has reported 1,000 COVID-19 cases and 56 deaths, is currently reaching about 60 percent of patients within that time. (Data for other counties isn't available, but in Washington, the statewide average is about 84 percent.)

On May 12, Dr. Anthony Fauci highlighted the importance of the work Cuevas and his colleagues perform. "Identification, isolation and contact tracing will determine whether you can continue to go forward as you try to reopen America," Fauci told a U.S. Senate hearing.

The Oregon state epidemiologist, Dr. Dean Sidelinger, echoes that point.

"By following [COVID-19] more closely, we're able to treat it like a brush fire," Sidelinger says. "We're stamping out the sparks and the smaller outbreaks and thereby preventing another forest fire."

In the past week, WW interviewed five members of the county's communicable disease team. They're all working long days and weekends, doing a job that's less like CSI: Miami and more like conducting a telephone poll. It's a deceptively complex job: To gather the information critical to slowing COVID-19, they must combine the relentlessness of a bloodhound with the cheery nature of a telemarketer in what can be a life-or-death situation.

Initial calls to people who have tested positive can take an hour or more, as the person on the other end of the line may be hostile, ill or under duress.

"I had a call where the guy was so sick, I said, 'You need to hang up and call 911,'" says Cuevas. "His wife drove him to the hospital instead."

Every morning, Sara McCall, a Multnomah County public health nurse, logs on to a state database called Orpheus. (In Greek mythology, the poet Orpheus strives—unsuccessfully—to rescue his late wife, Eurydice, from hell.)

Oregon law requires health care providers to report to the state when a patient arrives with a communicable disease. There are currently 112 such communicable diseases, ranging from anthrax poisoning to zika. Those reports go into the Orpheus system and are routed to the county where the patient lives.

With the name comes a record that usually contains a medical history and a phone number.

McCall, 38, knows that on any given day she will log in and find cases of hepatitis, salmonella, measles, Lyme disease or any of the other reportable diseases. In a normal year, the Multnomah County communicable disease team investigates about 2,500 disease reports. "Until recently, it was always something different," she says. "I'm not used to focusing on just one disease."

These days, Orpheus spits out the names of those who have tested positive for the coronavirus. It's crowded out all but the most pressing other investigations.

"In non-COVID times, I definitely felt a lot more excitement about work, because I've got no idea what is going to happen," McCall says. "For a while after COVID, I was concerned about logging in and finding out more people had died. Now I've gotten used to it."

Like Cuevas, McCall spends her days tracking COVID-19 as a case investigator, the first and most important step to tracking and stopping the virus's spread.

When the pandemic started, McCall worked as part of a team of eight case investigators and contact tracers. Now the team has expanded to 45 people. For Multnomah County to reopen, the health department needs to demonstrate to the state it's on track to employ 120.

She and her colleagues might each work four or five cases a day, although some have handled as many as a dozen. And since mid-March, that work has all been done from home.

McCall says she and her colleagues have little in common with the swashbuckling Hollywood virus investigators in such movies as Outbreak. (McCall says the 1995 blockbuster sparked her interest in communicable diseases when she watched it as a junior high student in North Bend, Ore., 25 years ago. She built a science project on community response to a lethal virus outbreak.)

"It's not as exciting as the movies make it seem," McCall says. "We're not actually testing people. We're on the phone all day."

McCall, who has degrees in health education and nursing and a master's in public health, studied motivational interviewing to help her gather information more effectively.

Investigators work with a list of questions developed by the federal Centers for Disease Control and Prevention that are pretty standard nationwide.

They record details about race, ethnicity, work status and location, and any underlying or related health conditions. They establish when the patient first noticed symptoms of COVID-19 and ask the person to think back two days before that. They want a detailed chronology, hour by hour if necessary, including all close contacts.

It's a lot of ground to cover. "The idea is, you empower the other person," McCall says. "It's less yes or no and more open-ended questions."

If people are reluctant to talk, McCall varies her approach.

"I will try to find connections or ask the same questions from different directions or prompt them with information from their medical record," she says.

Sometimes, nothing works.

"The interviews that tend not to go well are the ones that, from the beginning, the person makes it clear they don't want to talk," she says. That's rare, but when it happens, she moves on to the next case. (Investigators interview about 90 percent of patients who test positive, though only 60 percent within the state's new 24-hour goal.)

Few people are eager to get an unexpected phone call from the government. That's particularly true for those most likely to get COVID-19, who are disproportionately low income and people of color.

"It's fair for people to be a little suspicious," says Taylor Pinsent, 37, a Multnomah County epidemiologist who has been yanked back into case investigations during the pandemic. "People get called for all kinds of things: They get taken advantage of by scammers."

Pinsent says the first thing she does is identify herself and explain why she's calling. If people don't believe she is who she says she is, she gives them the main switchboard number at the county and asks them to call and ask for her.

In some states, COVID-19 skeptics have pushed back against contact tracing, saying it's an invasion of privacy and expensive. That hasn't been much of an issue in Multnomah County.

Most people are willing to talk, Pinsent says, because they've at least heard about COVID-19 and want to help. But emotions can run high.

"With COVID, I sense a lot more fear," Pinsent says. "People are afraid they are going to get really, really sick. I've have had people say, 'Are you going to call my employer?' I think there's always that fear, if we call the employer, they aren't going to have a job." (Typically, the investigator will ask patients to notify their employers themselves or will ask for permission to call.)

McCall's boss, Lisa Ferguson, manager of the county's communicable disease program, is in the process of hiring dozens of investigators per the governor's directive.

For case investigators, Ferguson wants people who are methodical and detail-oriented. They should also have the verbal and intellectual dexterity of a skilled salesperson. It helps to have a medical or scientific background.

"Many of our people are nurses," says Ferguson, 44, who worked in an orphanage in China before joining Multnomah County in 2016. "But we are essentially cold calling, so you have to be able to build a rapport and shift your conversation to fit the needs of the person."

Even though disease investigation requires the clinical extraction of precise information as quickly as possible, Pinsent says it also demands empathy and an ability to build a relationship, even if it's only fleeting.

On a recent call, she spoke to a person quarantined on their birthday. That was an opportunity to connect. "Man, it's a bummer that you are spending your birthday alone," she told the person.

Finding a connection is important: It's the spoonful of sugar that helps the medical information go down. "How many times can you tell somebody to make sure hey stay at home while ill and wash their hands?" Pinsent asks.

If all of that seems hard, it's just the beginning.

Once they get people talking, case investigators type responses into Orpheus.
They are trying to find out not only where the person might have contracted the virus and details of the person's illness but also names and phone numbers of all the people the ill person came in close contact with before and since becoming ill.

"We hand [contact names] to another team," Cuevas says. "They call those contacts and tell them they may have been exposed."

County contact tracers tell "contacts" they should stay home for 14 days. If the contacts have COVID-19 symptoms, they are put on what's called active monitoring. They must take their temperature twice a day and report their results to the county.

County epidemiologists, such as Russell Barlow, analyze the data the investigators gather, looking for hot spots and patterns that suggest outbreaks within social networks such as job sites or other group settings.

Case investigation and contact tracing is like solving a puzzle with the clock ticking. The investigators want to find out when and how somebody got sick and share information that will stop the disease from spreading. That's true with any communicable disease.

McCall recalls an instance two years ago when she and another investigator were tracking a salmonella outbreak.

"We both overheard the other say the same restaurant name. It was kind of like one of those movie moments," she recalls. "We went with the inspector to watch cooking techniques, take temperature checks, and look at how food was stored."

The inspection got the restaurant cleaned up, and McCall and her colleagues, using credit card receipts, were able to identify and contact other diners. They stopped the outbreak.

That kind of success is impossible with the coronavirus because it is everywhere.
COVID-19 is also more complicated than other diseases. For example, many people who test positive for the coronavirus never experience symptoms.

Second, the symptoms people do experience vary widely.

Some lose their sense of smell or taste; others get fevers; for some, it's gastrointestinal disturbances. And federal guidance on how long people need to be in contact with each other to spread the disease has shifted. The threshold used to be an hour; now it's 15 minutes.

"COVID-19 defies what we know about other coronaviruses, and that makes our work really complicated," says Barlow, the county epidemiologist.

People who have the virus are also confused. While gathering information, case investigators explain the disease and the precautions those who are infected should take.

"Sometimes, the calls can be frustrating when people are working sick," Cuevas says. "They might say, 'Well, I've had this cold for a while. I thought it was like allergies.' Or sometimes they'll say, 'It's just nothing or a false positive. I don't believe those tests.'"

That's where having a medical or scientific background can help.

Cuevas was a doctor in his native Mexico. He has worked in a variety of public health roles in Multnomah County. Before the pandemic, his specialty was tracking the spread of sexually transmitted diseases, which often takes him into the city's homeless encampments. He says that work taught him how to ask questions in an unthreatening way and to read people. "I definitely like the in-person work better," he says. "You get more information face to face."

For now, though, he works on the phone.

COVID-19 has hit Latinx populations particularly hard: Nearly a third of the state's confirmed cases are Latinx, although they constitute just 13.3 percent of the population.

As a native Spanish speaker, Cuevas handles many of those calls. He says being able to talk about Mexico—he's from Guadalajara—or touchstones in the Latinx culture helps him break the ice.

"The communities hardest hit by STDs and HIV are also the hardest hit by COVID," Cuevas says. "Many of them are considered essential workers, in places like food processing plants. It's a lot of industries that people don't see."
Cuevas says poverty and immigration status often come up when he asks questions.

"I have situations where families all get sick and they don't have money for food or rent so they still feel like have to go to work," he says. "A lot are undocumented so they can't file for unemployment."

The ultimate goal of the communicable disease team is to keep people from spreading the virus, which means getting them to restrict their own movement.

That's sometimes tricky.

"It's hard for somebody to understand they should stay home and not work when they feel fine," Cuevas says.

On May 15, President Trump announced Operation Warp Speed, a massive federal initiative aimed at fast-tracking a vaccine for COVID-19. In the best-case scenario, Dr. Fauci and other experts say, that vaccine won't come for more than a year.

In the meantime, Oregon is gradually reopening, with 28 counties having already met the governor's standards for at least partial reopening. Multnomah County says it has now exceeded the threshold for testing capacity to reopen, although it's still deficient in other areas—notably the number of contact tracers it's supposed to hire.

"Case investigation and contact tracing are among the most important and fundamental epidemiological tools that Oregon will be using to reduce the spread of COVID-19 as we move into the reopening of our state," Sidelinger tells WW. "The importance of doing this work and doing it well cannot be overstated."

On May 15, officials from Clackamas and Washington counties expressed concern about whether they could meet Gov. Brown's ambitious hiring goals.

But Ferguson says she's confident the county can meet the state guidelines for hiring additional contact tracers.

Johns Hopkins University, where the school of public health has made itself a national resource on COVID-19, has released a six-hour online training module for contact tracers. Ferguson says such resources will allow the county to increase its capacity and help achieve the goal of containing the spread of the virus.

For a society that has grown accustomed to fixing medical problems with pills and having everything we want when we want it, the COVID-19 pandemic has been both a wake-up call and a reminder that technology is not always the solution. Returning to normal will require a national contact tracing effort like the one underway in Multnomah County.

And it will require a quality often in short supply: self-discipline.

"Without contact tracing, we may need to go back to community or statewide mitigation efforts," Sidelinger says—that means more stay-home orders. "Those efforts have a much larger societal impact, and we'd like to avoid them. But this requires every Oregonian to be responsive if they are among those who get a call."

Normally, the county's communicable disease team works in the Gladys McCoy Building overlooking Union Station in Old Town. It's an open-plan office, where investigators can stick their heads up above their cubicles to share scraps of information. Like in any office, there are irritations. But there are also camaraderie and a sense of shared purpose as people make the same difficult phone calls, over and over.

But now, investigators and contact tracers are spread across the city, dialing from their couches and home offices, isolated from each other even as they plumb the despair of COVID-19 patients and their families.

Cuevas says the difference between COVID and other diseases he's investigated is the sheer volume of serious illness and death and the 24-7 nature of the disease.

"We are talking to people who are positive every single day," Cuevas says. "It's very hard to distance yourself from that. It sometimes never seems like my day finishes. It's very hard to step away from it. It's everywhere."

He says COVID-19 has affected him differently from any other disease he's tracked.

"I'm becoming very paranoid," Cuevas says. "I only shop every two weeks. I'm counting the days since I had an face-to-face interaction with somebody else."

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