New York faces enormous challenges in its attempts to implement one of the largest contact tracing schemes in the US, as the city prepares to reopen after nearly two months of coronavirus lockdown.
The New York governor, Andrew Cuomo, has said the state is recruiting an “army of people to trace each person who tested positive” for an “unprecedented, nation-leading contact tracing programme”. The New York city mayor, Bill de Blasio, announced a new test and trace corps, which he said would “lead the way in creating testing and tracing on a level we’ve never seen before in this city or this country”.
Contact tracing is considered to be a key pillar of safely lifting stay-at-home orders, and involves asking Covid-19 patients to recall everyone they have had close contact with while they may have been infectious, and asking those people to quarantine themselves to help prevent the virus from spreading. In countries such as South Korea and Germany, early contact tracing has been credited with successfully minimising outbreaks.
But as New York authorities roll out their plans to hire and train thousands of contact tracers, experts warn of the difficulties of pulling it off in thecity of 8.6 million in which the pandemic that has killed more than 20,000 people.
And De Blasio, who is hiring his own team of 5,000 contact tracers – separate from the 6,400 to 17,000 being recruited by New York state – is facing mounting questions over its organisation.
Dr Tom Frieden, the former director of the Centers for Disease Control and Prevention (CDC) and the former commissioner of the New York City health department, said: “There are enormous challenges in New York City – ranging from the extent of the outbreak here, which is still very large, to the mobility of population in metro areas.
“This is the biggest health emergency in more than a century and New York City has had a heartbreaking number of deaths.”
Frieden, who is now president and CEO of Resolve to Save Lives, which is working on the state’s contact tracing effort, said other challenges include population density, reliance on public transport, and the amount of travel into the city.
“All the things that we love about New York City … make it more susceptible and more challenging to do contact tracing.”
Large crowded housing, including in nursing homes, correctional facilities and homeless shelters, is also an issue, he said.
New York state said contact tracing was already under way, while New York City said it plans to have hired 1,000 tracers by 1 June. Neither city nor state have said how much their programmes will cost. Other US states developing tracing programmes include neighbouring New Jersey and Connecticut, as well as Massachusetts and California.
New York City said although previous experience in public health is preferred for tracers, new recruits will be supported and trained by experienced “disease detectives”. Tracers, they said, will do most of their work on the phone.
Frieden said contact tracing is “not an easy job” and requires an understanding of patient confidentiality, medical terms, principles of exposure, infection and symptoms as well as interpersonal skills and cultural sensitivity.
The mayor has come under fire for putting NYC Health and Hospitals (H+H), the city’s public healthcare system, in charge of contact tracing rather than the department of health and mental hygiene (DOHMH), which has historically done it – including for diseases like tuberculosis and HIV.
A group of New York politicians, including senator Gustavo Rivera, have called on De Blasio to reverse the decision. Such was the concern that the city council speaker, Corey Johnson, who said the plan “raises a lot of alarm bells”, held a hearing on Friday to investigate.
Frieden said the move was “a big mistake”. Adding: “Moving it to an agency that has no experience with it, no legal mandate to do it, no institutional memory of how to do it, will make something that’s very difficult even harder.”
Avery Cohen, a spokeswoman for the mayor, said it was done to “prioritise continuity, speed and the ability to break down bureaucratic barriers” by “housing testing, tracing and isolation under a single, streamlined entity”.
New York state, which is working with the former New York mayor and businessman Michael Bloomberg and Johns Hopkins Bloomberg School of Public Health, has specified that every region must have at least 30 tracers for every 100,000 residents in order to reopen.
It said all tracer applicants will take an online introductory Covid-19 contact tracing course, devised by Johns Hopkins University and available free on Coursera, for which they will have to score at least 85.
The contact tracing process will begin in labs, which will report Covid-19 cases to contact tracers, who will then interview the positive patient to identify everyone they may have had contact with over the past two weeks. The tracer notifies and interviews each contact, tells them to quarantine for two weeks, and monitors them by text to see if they are showing symptoms.
Dr Kelly Henning, who leads Bloomberg Philanthropies’ public health programme, which is assisting in the hiring process, said the initial interview with the person who has tested positive is key.
“We recognise that it won’t be 100% [effective] but the goal is to get as many contacts identified and pulled into the system as quickly as possible to break those chains of transmission.”
And if people refuse to cooperate? Henning said with a good rapport, ongoing contact and education, she has found “compliance is very high”.
Dr Sung-il Cho, a professor of epidemiology at Seoul National University, who is on the consultation committees of Korea Centres for Disease Control and Prevention and Seoul city’s coronavirus responses, said: “In the Korean legal system, the police give great help tracking credit card usage, transportation paths, mobile communication signals and CCTV analysis, just as any criminal investigation.”
But in the US, digital tracing technology such as the initiative by Apple and Google has prompted data privacy fears. On Thursday, five Democrats introduced a bill to protect the health data of consumers using contact tracing technology.
Katharina Kopp, deputy director of the Center for Digital Democracy, said: “History has taught us that the deployment of technologies is often driven by forces that tend to risk privacy, undermine fairness and equity, and place our civil rights at risk.”
At Friday’s hearing, Dr Mitch Katz, president and chief executive officer of Health and Hospitals, said they are working on an app, but that “we are absolutely committed that none of the data that is collected will be shared.”
When asked about quarantine enforcement, he said: “We believe that carrots are much better than sticks.”
Bloomberg has said the public health non-profit Vital Strategies, funded by Bloomberg Philanthropies, is developing three smartphone apps for New York state. But Henning said initially the focus would be on using human contact tracers and that all information would be kept “fully private”.
She said: “The idea of using humans is the tried and true public health strategy so we have confidence that that will be a successful model – assuming we have the right number of contact tracers and they’re well-trained and well-supervised.”
Amid record unemployment, there has been no shortage of applications. New York City said it had had more than 10,000 people apply and the state has had over 30,000.
The online course, which takes five hours to complete and is open to anyone, had 150,000 enrolments in its first week.
Student Shernidane Romelus applied to both the state and city to be a contact tracer. The 24-year-old is now waiting to hear back.
“It’s safe. It’s also a way to help, so I feel like it’s a good job for people to do at home and then still earning some money,” she said.
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