As the Nation Begins Virus Tracing, It Could Learn From This N.J. City

By 

THE NEW YORK TIMES

May 21, 2020

Dr. Paul Persaud, Paterson’s top health official, holds weekly meetings with the city’s contact tracers. 

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PATERSON, N.J. — The Uber driver had lost his sense of smell and taste but otherwise felt fine. He kept driving passengers in this small, industrial city until last week, when he took a test for the coronavirus.

By Friday, Jean Mugulusi of the Paterson Health Department was on the phone with him, breaking the news that he had tested positive and asking for a list of his recent passengers. He gave her eight phone numbers.

“You came into contact with somebody who tested positive,” Ms. Mugulusi told one of those passengers, a young man who worked in a factory.

“I need you to self-isolate,” she said.

“Can you tell me who?” the man responded. Because of privacy laws, she could not, she told him, but he needed to self-isolate.

Ms. Mugulusi was doing contact tracing, a once obscure public health measure that has suddenly taken center stage in the fight against the coronavirus and the push to reopen regions for business.

States and cities around the country have begun with varying degrees of success to ramp up efforts to put contact tracing in place on a large scale. Last week, Gov. Philip D. Murphy of New Jersey said that his state would hire up to several thousand contact tracers to assist the 800 now working for local and county health departments.

In New York, Gov. Andrew M. Cuomo of New York has announced that the state will build an army of up to 17,000 contact tracers. A political tangle between agencies has complicated efforts to expand tracing in New York City, the epicenter of the pandemic in the United States, but Mayor Bill de Blasio said on Sunday that he hoped to have 1,000 tracers in place by June.

Twenty miles to the west of New York City, Paterson, a poor, largely nonwhite city of about 150,000, has been tracing the virus at a level that could be the envy of larger cities. The team has been able to successfully investigate and trace about 90 percent of the more than 5,900 positive virus cases in Paterson, said the city’s top health officer, Dr. Paul Persaud.

As of Saturday, 306 Paterson residents have died, giving the city a death rate of 5.1 percent among those who have tested positive, compared to 7 percent statewide.

Perry N. Halkitis, the dean of the Rutgers School of Public Health, said that it was impossible to know how much contact tracing has helped control the spread of the virus. But contact tracing, he noted, “is one of the few tools that we actually have in the absence of a vaccine.”

When the first cases began to appear in Paterson in mid-March, the Board of Health added two dozen employees who had been trained in communicable disease investigation last year to join their regular team of two disease detectives.

Since then, the full team, which the board calls its Covid-19 strike force, has grown to nearly 50 of the 60 board employees. Joining a dozen public health nurses are clerical staff, translators and health inspectors. The board’s accountant, Bob Ardis, tallies total cases and deaths and asks the police to drop by homes where positive cases don’t pick up the phone.

“We are almost like an extra arm of the Board of Health here,” said Lt. Detective Louis Spagnola, the group’s police liaison.

Calls do not always go smoothly. On Saturday, Ms. Mugulusi called a 26-year-old man to let him know he had been exposed. “Yeah, I know, my mom tested positive,” he told her, with street noise in the background.

“If you are aware, then you know you should be in quarantine,” Ms. Mugulusi told him. “So what are you doing on the street?” He hung up on her. She said the police will now visit him to see if he is staying home.

Many of the residents whom Lenore Bertolero, a head public health nurse in Paterson, calls to tell that they have been exposed to the virus also already know they’ve been exposed.

There were the son and daughter-in-law, recalled Ms. Bertolero, who had recently visited their parents. The mother was in the hospital with the virus, and the father had already died.

There was the wife she called who tested positive after caring for her sick husband, who was quarantining in a room. Now the wife was also sick, and upset that she had to care for the children alone.

There was the brother she called to warn that his sister had tested positive. He already knew — she lived upstairs.

“Sometimes they will text each other back and forth, and say ‘Oh, the nurse needs to talk to you, too,’” Ms. Bertolero said. “You kind of get involved in their lives.”

The contact-tracing team mostly works from their homes, making calls and entering their interview results into the state’s communicable disease reporting system. Once a week, they put on their masks and come to the city’s small public health headquarters to confer about the crush of cases.

During last week’s meeting, Andre Sayegh, the city’s mayor, handed out a sheet showing a line curve that tracked the city’s progress: From a high of about 260 daily positives on April 15, the city is now at about 50 to 70 cases per day, a level not seen since March.

“This is a testament to what you have been doing,” the mayor, who had Covid-19 himself, told the team. “You kept me and many others alive.”

Last week, Ata Rahman, a new tracer, dropped by the office of Kate Bond, the department’s lead nurse, to ask what he should do about a patient who told him that she had experienced symptoms since January, months before she tested positive.

Ms. Bond reassigned the case to a senior infectious disease nurse, who re-interviewed the woman and found out that she wasn’t quite sure when the symptoms began. They tracked back through her calendars and memories to see whom they should call to warn of possible exposure, even if it was months ago.

Several health workers said contact tracing is an art as much as a science. The first step is to develop rapport with the person being interviewed, so they feel comfortable giving details about their health and lives.

In a city with a large immigrant population like Paterson, language skills are important, as is familiarity with the community.

Much of an interview can be spent providing health advice to families about how to isolate in small, crowded homes and when to seek medical attention.

Because of the statewide stay-at-home order, most new virus patients in Paterson have only been in close contact with family, extended family and sometimes co-workers. That will change once restrictions are eased, making contact tracing even harder.

After gathering the list of contacts, the case investigator then hands most cases off to a support staff of 20 other workers, who call each contact, tell them they have been exposed and ask them to self-quarantine for two weeks from the date of exposure.

The monitors do daily check-ins with all the contacts and the original patient during quarantine to see how they are feeling and monitor their compliance.

Paterson’s tracing efforts have been aided by New Jersey’s electronic communicable disease tracking system, which has been serving as the master database for all cases and contacts. That system pings Ms. Bond’s phone throughout the day with new cases.

A $95,000 state grant last year to train several dozen health workers in communicable disease investigation also helped, Dr. Persaud said. At the time, his main concern was that the city could have been swamped by a food-borne illness, because it is home to several large catering halls.

But the program also has limitations. The team only calls contacts who live in Paterson. They aren’t sure other localities will follow up on cases. Only symptomatic patients have been tested until recently. And test results sometimes take days to show up in the system, giving the virus a big head start.

Statewide, Dr. Halkitis said, coronavirus contact tracing has been haphazard and inconsistent.

“You have places like Paterson that have really revved up; Newark, which has begun training; and local health departments that haven’t really begun,” he said. In the absence of a coordinated federal response, he said, the state’s new Community Contact Tracing Corps will attempt to standardize training and protocols so fewer cases fall through the cracks.

In Paterson, the work has gone on through nights and weekends, and the tracers said it can be tedious and emotionally grueling.

The goal may be to get information from each patient, but just as vital, the tracers said, is to develop enough trust so that their advice is followed.

“Usually, I start the call by saying, ‘I see you had a Covid test, can you tell me why you went?’” Ms. Bertolero said. “One woman said to me, ‘Because my brother died.’ I just had to stop for a bit and tell her how sorry I was.”

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