She is one of about 20 employees of the Washtenaw County Public Health Department currently involved in contact-tracing, which is the process of reaching out to individual coronavirus patients to stymie the chain of infection.
“It’s part investigator and part teacher,” said Zilke, who normally serves as the department’s immunization nurse coordinator.
The job of contact tracer includes helping coronavirus patients figure out specific strategies to keep from infecting others; keeping tabs on household members and other close contacts to see if they get sick, and following the trail of more potential victims if and when those contacts test positive.
“It can be like a target with circles around it that get bigger and bigger” as the virus works its way through a community, Zilke said.
Contact tracing is nothing new to county health departments, which have long performed case investigations of infectious-disease outbreaks from mumps to HIV to E. coli.
But the coronavirus crisis has taken a little-known function of public health and turned it into one of the most important tasks of Michigan local governments for the foreseeable future.
“No question, it’s huge,” Mark Hackel, chief executive of Macomb County, said about the importance of contact tracing. "We’re definitely going to have to have people dedicated to this for quite some time.”
A core part of the plan to reopen Michigan’s economy involves widespread testing for COVID-19, isolation of those who test positive, contact tracing to see who else they might have infected and quarantine of those contacts.
“Most leading public-health authorities agree contact tracing is critical to keeping things at a low level until a vaccine is available,” said Emily Martin, a University of Michigan epidemiologist who has been working with Gov. Gretchen Whitmer’s office.
But, Martin added, “this is not something that routinely was being done on a very large scale. So we need to get all these new systems up to the level where they need to be."
And that’s putting stress on county officials, who having been frantically scaling up their contact-tracing personnel and now need to sustain that for the long term.
In Washtenaw County, for instance, the health department has had about five nurses who have worked on contact tracing in recent years.
When the COVID-19 crisis hit, nurses such as Zilke who were working in other areas were called in, as well as other staffers such as sanitation inspectors, health educators and nurse supervisors, said Susan Ringler Cerniglia, who heads the Washtenaw County Health Department.
“We have a small pool of people for whom this is the normal job,” Ringler Cerniglia said. “But we have a much bigger pool of folks doing it now. And there are serious questions about how we sustain that.”
The same is true in other counties.
Before the coronavirus crisis hit, the Kent County Health Department’s infectious-disease unit had fewer than 10 people and contact tracing was only part of their responsibilities, said Adam London, head of the Kent County Health Department. In recent weeks, he’s brought in staffers from other units as well as medical students and graduate students in health science programs to help with contact tracing.
“We’re getting between 250 and 150 new cases each week, which is a lot," he said. “We’re just absolutely at capacity and overwhelmed with doing case investigations."
Right now, the priority is determining who a coronavirus patient may have infected, so those persons can be quarantined and monitored for symptoms, London said. “We don’t have the capacity to do a deep dive” into finding out how the patient him- or herself was exposed.
Likewise, Macomb County had a handful of people who worked on contact tracing before March. Now it’s almost 60 people trained for the task, including county employees from other departments.
“That’s a remarkable number for a county our size,” Hackel said. But “we could really use 75, maybe 100 people to really get a full handle on the contact tracing here.”
Why contact tracing is important
The standard playbook of infectious-disease control is figuring out who is sick, isolating those patients and keeping a close eye on others who might have been infected.“If you have a specific hot spot, you have to act very quickly,” U.S. Sen. Gary Peters said. “You have to contain that spread to that one area and make sure it’s not spreading from that hot spot to other areas, because then you just create a whole bunch of hot spots that keep spreading and pretty soon the hot spots take over a big swath.”
That didn’t happen at the beginning of the coronavirus crisis in the United States: A nationwide shortage of coronavirus tests meant there was no way to thoroughly investigate the initial hot spots and figure out who had the virus and who didn’t. That allowed the virus to spread uncontrolled through southeast Michigan.
At this point, there are still hundreds of new cases being diagnosed each day in Michigan. But a stay-at-home order implemented March 24 has slowed the rate of new cases and has made the transmission routes much more apparent.
In the past few weeks, most new cases have involved people who live in congregate living settings such as long-term care or correctional facilities, or essential workers, especially health-care employees working with COVID-19 patients.
It’s also made the work of contact tracing much easier.
In creating a list of people who were potentially infected, Zilke asks her coronavirus patients to list face-to-face interactions within 48 hours of the onset of symptoms, and specifically interactions that lasted at least 10 minutes and where the encounter was within six feet and without masks.
“Lately, the number of people that they’ve been in contact with is very low, and it’s usually their household,” Zilke said.
“In the beginning, it was everybody under the sun,” she added. "We still had the universities in session, so we had students at Eastern and Michigan where we would interview them, and they had gone to classes and then they went to the bar and the list of contacts was never-ending.
“We anticipate that’s going to happen again” as the economy reopens, she said. “Once things start to open up, people are going to have more contacts so that’s actually going to be more work for us. So we think this is going to get worse before it gets better.”
Scaling up
County officials say they’ve been able to piece together a temporary workforce of contact tracers for now, but it consists of people who already have other responsibilities.A big concern is that “we’re going to be doing this kind of work for probably the better part of the next year or so,” London said. “Maintaining a sustainable team of people who can do case investigations and contact tracing is going to be an enormous challenge.
“All the people that we’ve trained to do this work, they have regular jobs that need to be done as well,” he said. “Everything has stopped for the time being. But pretty soon we’re going to get back to inspecting restaurants, and testing drinking-water supplies, and doing sexually transmitted disease testing and counseling, and health education, and everything else.”
There’s also the likelihood that the demand for contact-tracing will increase as the economy reopens. Most experts predict that could result in a new surge of cases -- and those cases will become more complicated for contact-tracers as people increase their social interactions.
Ringler Cernaglia agreed the “intensity of contact tracing and the volume of it is likely to pick up” as the economy reopens, and Washtenaw County’s coronavirus response team is trying figure out how to staff a team of contact tracers for the next year or two.
Decisions need to be made about what services to reopen and which can be put off for now, she said. “We’re also looking at where we can bring in other staff: Are there some volunteers who can come in? We’re looking to recruit some grad students and bringing in more interns than we normally would.”
Macomb County also is hoping to recruit some graduate students to help with contact tracing, but otherwise will use existing staff, Hackel said.
“The good news is that we’ve got a lot of people now trained in how to do contact tracing,” so even when those employees move back to their regular tasks, they can be pulled back into contact-tracing if and when a surge occurs, he said. “If there’s a need for more personnel, we will figure that out the best that we can.”
One potential source of help could come from the Michigan Department of Health and Human Services, which has recruited 3,500 volunteers who have taken online training to be contact tracers.
The state hopes to end up with between 2,000 and 3,000 volunteers available to help with contact tracing, said Lynn Sutfin, MDHHS spokesowoman.
However, the project has been temporarily stalled by controversy over a no-bid contract to manage the volunteers.
Great Lakes Community Engagement and Every Action VAN were hired by MDHHS to oversee the contact tracers, but the firms’ ties to Democratic campaigns prompted criticism and Gov. Gretchen Whitmer canceled the contracts to “take out any speculation" of political favoritism.
As a result, “the project hasn’t begun yet as we are awaiting a new contract,” Sutfin said. “The volunteers will be assigned people to call and this will all be done remotely, so from their homes. They will not be going out door-to-door or need to report to a specific health department.”
County officials say they don’t know much about the state initiative. But “something like that would be helpful to us,” London said.
Meanwhile, Peters and U.S. Sen. Debbie Stabenow are among those pushing for federal funding for contact tracers, saying that the next coronavirus recovery package should include $7.6 billion “to expand the number of disease investigation specialists and contact tracers.
More than just a phone call
Zilke has about 40 open cases right now, which she says is typical among her Washtenaw County colleagues who are doing contact tracing.Most days, it’s a mix of calling newly diagnosed patients, tracking down people who were potentially infected and follow-up calls with people recovering from coronavirus.
“When someone is in isolation, we check in regularly until they’re asymptomatic for least three days,” Zilke said. “And some of these people are sick for a really long time."
That initial call with someone who tested positive for coronavirus, “it’s really a conversation -- when did you get sick? What were your symptoms?” she said. “Who were you with in the 48 hours before you got sick? Who have you been with since you’ve gotten sick?"
“Most people want to be very helpful, and give us all the information we need" about close contacts, Zilke said.
Still, the conversations can be difficult, she said. In some cases, “we’re talking to people who are really sick or talking to people who’ve had a family member that passed away."
Several aspects of the coronavirus crisis make it unique when it comes to contact tracing.
One, of course, is the sheer numbers combined with the length of the outbreak. “It’s what we normally do to prevent disease in the community, but on a much larger scale,” Zilke said. “It’s huge.”
Another is that coronavirus is so contagious and potentially virulent that it’s imperative to isolate patients so they don’t infect others. And ensuring that physical isolation isn’t always easy.
For instance, an outbreak of coronavirus in Grand Rapids’ homeless population raised the issue of how to isolate people who don’t have a home, said London, the Kent County public health chief.
“They have to go somewhere,” he said. “So we worked in partnership with Guiding Light Mission to acquire their mission as our isolation center. That allowed us to provide a safe place where they can recover with dignity, and once they’ve recovered, they can return to the (regular) shelter.”
Another challenge is when a coronavirus patients lives in close quarters with somebody who is "very vulnerable,” Ringler Cerniglia said.
Coronavirus patients recovering at home are encouraged to isolate in a bedroom and, when possible, use a separate bathroom from other household members; the goal is not to have any face-to-face interactions with other household members or share any living space. But in many households, that’s just not possible, and if there’s another family member at high risk, “we might actually be providing the housing” for the isolation period, Ringler Cerniglia said.
More common is a scenario in which a coronavirus patient is a primary caretaker for children or an elderly relative.
“It can quickly get complicated if we’re telling someone that they need to isolate and stay home,” Ringer Cerniglia said. “So we’re going to do the best we can to make sure their needs are met. We’re not just going to provide instructions and let it go. So in many cases, our nurses and contact tracers end up filling almost a case-management role to get folks to what’s needed, if it’s food delivery or whatever.”
Yet another tricky aspect of coronavirus is that patients can be contagious for several days before they are symptomic, Martin said.
“That lag time has proven to be really difficult," Martin said. “By the time test results show a problem, you may have infected others and then secondary infections already can be happening during this window."
The fact has some people questioning how much contact tracing can stem the spread of coronavirus.
“We now believe there were many cases already in Michigan before the first one was reported,” said Mark Cheatham, who heads the Mid-Michigan District Health Department, which serves Clinton, Gratiot and Montcalm counties. "We missed them. They were not identified and reported to public health. I’m afraid that will keep happening.
“I think the root cause of this is the asymptomatic spreaders -- 25% or more of cases happen because of asymptomatic people,” Cheatham said. “That means that no matter how careful you are, if you are around people, you’ll eventually have contact with someone who is contagious.”
Zilke acknowledges that fighting the spread of coronavirus is “complicated. There are so many pieces to it.”
But “if nobody was doing what we’re doing, then people might not know” when they were exposed and possibly contagious, she said about contact tracing. “They wouldn’t know to quarantine themselves so they don’t spread it.”
There’s no way of getting around the importance of contact tracing, Martin said.
“Safely going back to work requires that we can respond to outbreaks quickly, and this is going to require fully staffed contract tracing efforts,” she said. “We need a major investment in public health infrastructure to get there quickly.”
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