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Playing catch-up with the curve

Montana's COVID-19 surge is delaying some county health departments' contact tracing efforts, decreasing the strategy's utility and forcing adjustments

In Montana’s largest county, Yellowstone, the public health officer said his workers are facing a backlog of more than 760 new COVID-19 cases waiting for contact tracing and case investigation. 

Nearly 300 miles away, Roosevelt County’s public health officer says her office receives calls from people who have recently tested positive, but haven’t yet been contacted by a public health worker. 

And in Lewis and Clark County, public health officials say they have scaled back their contract tracing efforts because of the surge in cases, in some cases relying on residents who have tested positive to spread the word to close contacts themselves. Due to the county’s strained resources, Lewis and Clark health officials have even asked state lawmakers to assign their own designated staffer to conduct Capitol-specific contact tracing when legislators meet in session starting in January. 

As COVID-19 continues to sweep through Montana, public health workers are struggling to keep up with the sheer volume of demand for contact tracing, which health officials say is one of the most basic tools they have for tracking and combating pandemics. 

As a result, people who may have been in contact with a confirmed case, and so may be contagious, may continue their normal activities and interactions when they should be quarantining. Or the source of a case, like a school, could go unidentified longer, leading to further spread of the virus. 

Despite the challenges, public health officials say contact tracing  should still be prioritized as much as possible, even if that means doing it less thoroughly. 

“We will absolutely continue to do case investigation [and] contact tracing, but unfortunately, we just are not able to work fast enough,” said Lewis and Clark County Health Officer Drenda Niemann. “And our resources continue to be really strained. And on top of that, we’re all tired. We do [contact tracing] even when we’re not in the middle of a pandemic. We do case investigation, contact tracing for whooping cough in a school … We’re just doing it on a scale that is so much greater than any of us were ever equipped for at the beginning of this year, and still really not equipped for.”

In an attempt to respond to the spiking scale of demand for contact tracing, the state has partnered with the University of Montana to offer free training and certification for volunteer contact tracers. So far, 170 volunteers have been certified, and another 300 are currently enrolled in the course.  

On Friday, the state reported 1,013 new COVID-19 cases, bringing the state’s total active cases to 15,901, with 652 deaths attributed to the virus. By March, a University of Washington model predicts, Montana could see 1,110 Montana deaths linked to COVID-19 — a death toll that could be held to 871 with universal mask use, or increase to 1,290 if current statewide restrictions are eased. 

In Lewis and Clark County, Niemann said her 72 contact tracers are prioritizing household contacts of people who have tested positive and people who work with or have come in contact with a member of a particularly vulnerable population. 

Health officials anticipate that case numbers will continue to grow as people gather for the Thanksgiving holiday this week. The Centers for Disease Control and Prevention has recommended that people stay home for the holiday and celebrate only with household residents. 

Niemann and Yellowstone County Health Officer John Felton both said they’re not optimistic that most people will follow that guidance, which will create additional workloads for contact tracers and health care workers in hospitals and clinics.

“I know that people are really hungry for connection,” Niemann said. “And people are struggling to find creative ways to celebrate the holidays differently this year, which means that we will see cases come because of the gatherings that will happen over Thanksgiving.”

The fall surge in cases has already led hospitals to warn of exhausted capacity, overworked medical personnel and potentially reduced levels of care. On Tuesday, Gov. Steve Bullock said in a press release that 110 temporary medical workers arrived last weekend to work at many of the state’s largest hospitals through the end of the year, with another 90 expected to begin working this week. 

In Roosevelt County, where four new and 98 active cases as of Friday amount to a fraction of Yellowstone County’s caseload, county Health Department Director Patty Presser said she and the one public health nurse on her staff would have struggled to keep up with their case investigations had the state’s Disaster and Emergency Services division not taken over to relieve the pressure after she recently lost two other public health nurses. She also said AmeriCorps workers are helping answer phone calls from residents inquiring about test results or asking why they haven’t been contacted about their positive test. 

Some people contacted by public health workers likely won’t cooperate with tracing and investigation efforts, Felton said. About 25 percent of Yellowstone County residents who have tested positive for COVID-19 haven’t cooperated with contact tracing efforts, he added. Some have refused to cooperate, while others have simply not responded to inquiries, he said.

Ideally, a contact tracer would contact a new case within two days of a positive test result, Felton said. In some cases, Yellowstone County contact tracers have decided to forgo contact tracing entirely after a case has gone too long without being addressed. 

While contact tracing is an important pandemic-fighting tool, it’s not the only one, Felton said. The public also has to take steps like limiting gatherings, obeying quarantine orders and wearing masks. 

“There is no magic answer that makes it go away,” he said. “It takes all of those, and each one helps a little bit.”

Felton said public health workers in Yellowstone County will continue to work through their backlog. In addition, the county has made improvements like implementing a web-based portal designed to help contact tracers speed up the work. The new system is expected to reduce the time required for a case investigation from 90 minutes to 45 minutes. 

While they may not get to every case quickly enough to help flatten the curve, or garner 100 percent cooperation, he said, continued contact tracing leads to valuable information nonetheless. 

“It’s still important to try and identify those highest risk categories and put them at the top of the list for case investigation [and] contact tracing,” he said. “The other thing is, there’s still value, to the extent that it can be done, in figuring out where our cases are coming from.”


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