Contact Tracing Lags as Delta Spreads Faster Than Vermont Can Staff Up 

click to enlarge

• File: Sean Metcalf

Vermont's contact-tracing program is floundering — what's left of it, anyway. 

Contact tracers, whose role was crucial to limiting the spread of COVID-19 in earlier waves of infection, have been overwhelmed by surging caseloads caused by the Delta variant.

Delays in interviewing an infected person to learn who else may have been exposed used to be rare in Vermont. Now they're the norm, leaving state health officials and people exposed to the virus without the timely information needed to curtail outbreaks. 

For weeks, Gov. Phil Scott has resisted calls for a more aggressive state response to the Delta wave, saying it does not justify a state of emergency. "We are better protected than any other state from Delta," he said last week, emphasizing Vermont's high vaccination rate and few hospitalizations. The state, he's said, is on a path toward being able to manage COVID-19 like other seasonal respiratory viruses. 

In some parts of the country with low vaccination rates, hospital resources have been pushed to the brink. That hasn't been the case in Vermont, though COVID-19 has killed 22 people in the past 33 days. Yet during this post-vaccine wave, the state's mitigation efforts have been uncharacteristically wobbly.

The pressure couldn't have come at a worse time, with K-12 schools reopening in an environment of higher transmission, hastily issued guidance and a diminished Vermont Department of Health.

Last year, the health department trained an army of contact tracers from its own ranks, state agencies and the Vermont National Guard. The team expanded and contracted with the virus' ebb and flow. At one point, nearly 200 contact tracers were available to pitch in. 

In May, as COVID-19 cases were plummeting, Vermont outsourced most of the work to a Virginia-based firm, AM Trace, for $50 per tracer per hour, up to $10 million. Pandemic-weary state employees finally went back to their regular duties, many of which had been pushed aside by the state of emergency. 

The caseload didn't remain minuscule for long. Since the Delta surge began in July, the contact-tracing program has been playing catch-up. 

Delta has caused more new cases than officials foresaw when they contracted with AM Trace, Deputy Health Commissioner Kelly Dougherty said in an interview. The company has been trying to increase its ranks but, like many businesses, is having difficulty hiring, she said.

In response to an interview request, AM Trace provided a general statement through a public relations firm that said its teams "work seven days a week to reach as many individuals and their close contacts as soon as possible."

Many states dismantled their contact-tracing programs over the summer, only to scramble to rebuild them as Delta arrived, Kaiser Health News reported last month. Unlike for many other states, however, the strain on Vermont's system is a largely new phenomenon. 

For much of the pandemic, Vermont contact tracers reached infected people within 24 hours of their positive test result more than 90 percent of the time, according to health department data. When a large surge last fall put renewed demands on the team, the figure dropped to 74 percent for a couple weeks — still above a federal benchmark of 65 percent, Seven Days reported at the time. 

With Delta, the rate has fallen off a cliff. Between August 1 and 28, contact tracers reached only 37 percent of people who tested positive within 24 hours of their diagnosis. It took even longer to notify close contacts.

"Now, it can be several days before people are reached," Dougherty said. 

In mid-August, the state decided to reassign employees from across the health department back to contact tracing.

Contact tracing is relentless, intense work, and some employees "are not very happy" about returning to it, Dougherty acknowledged. The department was already dealing with burnout from a grueling 15-month state of emergency and frustration among many employees that leaders aren't taking more aggressive steps to contain the virus. More than 90 signed a recent letter pushing for additional action, and tensions were high at a recent internal staff meeting, VTDigger.org reported last week. 

Initially, the department reassigned 15 staff members to conduct contact tracing part time. Last week, another 11 were reassigned, Dougherty said. The department is also recruiting four contact tracers from the Agency of Transportation and a few from the Department of Corrections. 

Contact tracing has evolved since the vaccine rollout. For one, there are more contacts to trace, given that people are socializing more than during lockdowns. The health department said the average number of close contacts per infection is about five, up from closer to three, and is expected to continue to increase. 

But the state is identifying fewer people who were likely exposed. Only about half the people who were infected between August 8 and 21, the most recent period for which published data are available, provided the tracers with their close contacts. That's the lowest level to date. 

The health department isn't sure why fewer people are providing their contacts. "It could be associated with 'COVID-19 fatigue' among people and how they are thinking about their day to day contacts and activities, the relative rates of time in having these contact discussions, or other reasons," spokesperson Ben Truman wrote in an email. 

Many people who are identified as close contacts, however, are no longer asked to change their behavior. Current state and federal guidelines say that close contacts who are fully vaccinated and don't have symptoms need not quarantine, even though vaccinated people can still get infected by and transmit the virus. That means a vaccinated schoolteacher who is identified as a close contact may continue to instruct unvaccinated young children.

Contact tracing nonetheless remains important. Not everyone is vaccinated, including all children under 12, and the process yields valuable information about breakthrough cases, infection clusters and outbreaks. Plus, many vaccinated people still want to know of their possible exposure so they can get tested or elect to quarantine.

The task of explaining the increasingly nuanced guidance is now falling, in part, to school officials. Last month, the Agency of Education notified districts that they would need to conduct contact tracing for their schools, as they did last year. School nurses often make the calls. 

As classes began, some districts discovered that the health department is not able to assist them as quickly as it did last school year.

The process, according to the department, is designed to work like this: Once school officials learn that someone was at school during their infectious period, they should assemble a list of contacts from the school setting. Then they review it with the health department to assess the overall risk. Finally, schools notify close contacts.

Just days after classes began at Twinfield Union School in Marshfield, school leaders learned of several student infections stemming from a daycare. But when they submitted their list of potential close contacts to the state, the health department said it needed up to 24 hours to review it.

Last year, the consult would have happened immediately, Caledonia Central Supervisory Union superintendent Mark Tucker said. Without that prompt response, the district decided to take action itself, sending home K-6 grade students as a precaution. 

If the health department isn't staffed to "provide the immediate, one-on-one contact we need, we'll go ahead and make our own decisions, and we'll always err on the side of being safe," Tucker said.

In Montpelier Roxbury Public Schools, superintendent Libby Bonesteel also had to make decisions on the fly when positive cases emerged during the first week of school.

One of the positive students had ridden a bus with teammates, Bonesteel explained on Tuesday at a press conference where she called for a statewide mask mandate. The district decided that only unvaccinated teammates who sat within six feet of the student needed to quarantine.

The health department eventually told the district that everyone on the bus should have quarantined. That conversation was five days after the fact, according to Bonesteel.

"We need immediate responses," she said.

School districts have new points of contact at the health department this year, and some "kinks" are still being worked out, said Becca McCray, president of the Vermont State School Nurses' Association. She, like Tucker, expressed confidence in schools' ability to take on contact-tracing duties.

"It makes sense to have it be done in the school, because we know the families; we are the ones that can get the situation under control quickly," she said. 

But school contacts are only one piece of a contact-tracing case. Kelly Landwehr, the president-elect of the school nurses' association, said her district in Addison County recorded three cases last week. When the district notified families, some clamored for more details, fearful that perhaps their child interacted with an infected classmate outside of school. Landwehr isn't in a position to provide those answers. 

"The health department is busy, so they're not getting to these cases as quickly as we are," she said. "So it might be several days before the family even hears from the health department, outside of the school contact tracing."

The delay in contact tracing is indicative of what has struck some school officials as inadequate coordination by the state for a fully in-person school year. 

The Agency of Education notified districts in early August that the state would offer regular COVID-19 testing to both staff and students. The expanded version of the program offered only to staff last year is seen as a valuable tool for catching infections before they become outbreaks. 

The rollout has been rocky. 

The procedure has changed and takes more time because it includes young children. It's also being introduced without the advice of a since-disbanded state task force that included school nurses and superintendents who helped shape schools' COVID-19 response last year. 

As a result, McCray and Landwehr said, many details of the surveillance testing program are still being ironed out. Schools need to collect consent forms for all their students, but the forms were only drafted in English, McCray said. It takes time to translate them to the many languages spoken by families in the Burlington School District, where she works. 

"I think we're all definitely feeling the lack of [the] thoughtfulness that was put into last year's process," Landwehr said. 

As of last week, five school districts and two independent technical centers weren't signed up for the surveillance testing program at all. 

Many of those that did sign up haven't yet been able to implement it. Schools in the Caledonia Central Supervisory Union won't start until at least mid-month, Tucker said. 

Landwehr, who doubles as her district's COVID-19 coordinator, would have liked to roll out the testing regime on day one. With so little planning and so few resources, she concluded that it wasn't possible. She hopes to start in October.

State officials said last week that the school surveillance testing programs, once up and running, will detect asymptomatic students whose infections would otherwise get missed.

Those cases, too, will need to be contact traced.