Since the pandemic started, I have been
corresponding with our friend Chris Contillo, a public health nurse in New
Jersey and New York City for the last thirty years. Jan and I first met Chris
and her husband Bob when we were living in Takoma, Park, Maryland in 1979. She
nursed our son Chris to health when he caught the H1N1 virus in 2009.
Here in the UK, the government gives a daily press
conference at which it announces some new statistic or other (or not if the
statistic happens not to look too good), usually accompanied by a new daily
initiative. For all the information, it is often difficult to understand what
exactly is being done in practical terms, why and with what results. Chris has
been contact tracing in Bergen County since late March, when testing began. Bergen
is the largest of New Jersey’s 21
counties by population. Chris also writes regularly for nursing
magazines. She has direct experience of the practicalities of contact tracing in
her county’s health environment.
As background for my non-UK friends, our own
government had a national contact and tracing system in the early stages of the
pandemic, when the objective was to contain the virus. As cases increased, the
tracing system proved unequal to the task, and was abandoned until last
Thursday, when a new, larger, “test, trace, isolate” system started operation. In
the UK, a person with symptoms applies
for a test. If the result is positive, the infected person, and all members of
the household, are asked to self-isolate for 14 days. The infected person is
asked to identify, from two days before symptoms appeared up to seven days
afterwards, people with whom they were in close contact. Close contact is defined
as: a face-to-face conversation, physical, including sexual, contact and being
in the same household. The infected person also identifies anyone with whom she/he
has spent 15 minutes or more at a distance of less than 2 metres. All those
people are contacted, and whether infected, symptomatic, or not, asked to stay
at home for 14 days. There is currently no compulsion.
Unlike the Bergen County system, the UK operation
is national in each of the four nations (England, Scotland, Wales and Northern
Ireland). The UK tracers do not have local knowledge of the kind Chris
possesses. On the other hand, the US system is much more fragmented and
constrained by jurisdictional boundaries. In other words, how contact tracing
operates (and to some degree its effectiveness), is constrained by the health
care, governmental and legal structures of a country.
As of 31 May, there have been 160,445 cases in New
Jersey and 11,698 deaths. That’s 132 deaths per 100,000 people. At the same
date, the UK had 276,156 cases and 38,571 deaths: 58 per 100,000 people.
Chris Contillo: Tracing Contacts in Bergen County,
New Jersey
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| Bergen County, outlined, and the Tri-State area |
On Tuesday, March 10, I returned to my office from
a blood pressure clinic to find TV news satellite trucks blocking the street
and newscasters milling around trying to get statements. Bergen county had just
registered New Jersey’s first COVID-19 death hours earlier.
The number of deaths in New Jersey has been
exceeded only by New York. At one point, our county, population almost 1
million, accounted for half the cases in the entire state of New Jersey, which
as a population of 9 million. New York City did not become the epicentre of the
COVID-19 pandemic simply because it’s crowded. Residents of the Tri-state area (New
York, New Jersey and Connecticut) move around a lot. Bergen county is just
across the George Washington Bridge from Manhattan. Housing, from suburban
houses to high-rise apartments, costs a little less than in New York. Consequently,
our area has a large commuter population.
One cheerful middle-aged man told me that the day
before he developed “only a slight fever and cough”, he had delivered furniture
to his daughter in New York, gone to the supermarket, a deli, a chemist,
Starbucks, and had then joined a friend for lunch and golf. Later they had
dinner at a nice restaurant with their wives. I asked him if he had notified
his friends that he had a positive test result. He laughed and said “Oh, you
should try to get them on the phone. They’re really busy.”
Our communicable disease department usually deals
with maladies like salmonellosis, typhoid and strep. When we get a positive
test result, we contact the patient to see whom they might have exposed and how
they can limit further transmission. Our department is responsible for tracking
about 50 communicable diseases. We report cases to the state health department,
which in turn reports to the Centers for Disease Control. The CDC publishes “Morbidity
and Mortality Report Monthly” which has all the numbers from all 50 states. In
the USA, each health district, state, county, local, is independent and decides
how to carry out contact tracing in its area.
Patients who test positive for hepatitis A, for
example, might be told they cannot continue to work in a restaurant until they
submit negative stool specimens. A recent mumps outbreak in the local jail was
contained. We have legal powers to enforce regulations in such cases.
Enforcement is complicated by the Health Insurance Portability and
Accountability Act and privacy acts. Some people are very suspicious when I
call them and very reluctant to give me information. Many do not answer the
phone because they do not recognize my number.
I have had people ask me not to tell anyone they
have tested positive, or refuse to give me the last names of their room-mates.
A physician’s assistant without a fever, who had tested positive, told me she
was instructed to continue to work because there was no one else to take her
place.
My investigations began with a daily package of
investigation forms. The test results come from local doctor’s offices, the
federal drive-through site at our local community college, and multiple urgent
care centers. I have spoken to doctors who tested themselves and their staff,
and to a pediatrician who took the elevator down from his office to test a
coughing father sitting in a car double-parked on the street.
The sheer scale of the COVID-19 pandemic has made
enforcement much more challenging. For example, there have been outbreaks in
large warehouses. I might call somebody there, but they seemed not to know that
a co-worker had been sick. In many cases they don’t know their co-worker’s last
name, even of the person they have lunch or coffee with every day. In some cases,
I got the HR manager’s name and number so that she/he could tackle the problem.
We are responsible only for New Jersey. However, so
many of the people I contact actually work in New York. Ideally, we would be
contacting all the “close contacts” ourselves to make sure that they understand
the quarantine and self-isolation restrictions but this has not been practical
in all cases. I know that other investigators have ended up calling the New York
City Health Department about some healthcare workers if they didn’t believe
that they were notifying their HR departments correctly.
Because of the overwhelming nature of this current
outbreak, I would ask for the names of the close contacts — closer than 6 feet
for longer than 10 minutes over the period of the illness and the three days
before symptoms began — and then I would ask if they had notified these people
and what happened then. In almost every case, especially of people who got sick
after the lockdown had already begun, they were with their contacts all the
time, so of course, everyone knew who was sick. But what about people who were
at work when their symptoms started? Had their HR been contacted? Usually yes,
because, since they were out of work for a lengthy time, they would call to
find out what kind of health benefits they were entitled to.
Another problem we encountered was the language
barrier. Because we are so close to an urban area we have many languages. On
staff we have Spanish and Polish translators, but there were many languages
beside these. There is a legal issue about asking a family member translate for
a patient, which I had to do in many cases.
In some cases, the state has contacted me about my
investigations. One was the case of an elderly woman first admitted to the
hospital for pneumonia in December. What followed was several fever admissions
and discharges, and another pneumonia, but she wasn’t tested for COVID-19 until
March, because there was no testing before then. Her husband died at home of
COVID during this time. We could not determine whether or not this woman was an
early case of coronavirus. Another case was a young college woman who flew home
from Spain with a fever after meeting her Italian friends, all with fevers, to
attend a rock festival. She came down with a full body rash and was admitted to
a pediatric ICU. This was possibly an early case in a “child” of the
kawasaki-like illness that some young patients suffer.
I think that knowing the local area and its demographics
is enormously important. Public Health is less actual about patient care and
more about knowing how to serve the community. If you don’t know who you are
dealing with — what kind of businesses, religious centers, who to get on your
side to reach their people — you can’t be very effective.
Public health has always been an underfunded
specialty. The work of tracking trends and stopping the spread of illness isn’t
glamorous, nor are our tools: vaccines, education and disease reporting.
However, there’s nothing like a pandemic to demonstrate how important those
things can be.
Meanwhile, in western Mexico
Our source for Mexico, where 90,664 cases
and 9,930 deaths have been reported (almost certainly a substantial
under-counting), is much more anecdotal, from our son Chris. But it gives some
flavour of life on the ground. Chris, his girlfriend Carolina, and her two
young children, live in San Vicente, Nayarit state, close to the border with
the state of Jalisco. Chris and Carolina have made a few trips into Jalisco. On
one occasion, they took the children to dinner in a tapas restaurant. The
restaurant had a substantial area set aside for handwashing and hand sanitizers.
A poster informed customers that the staff had taken the state’s COVID-19
training course. Tables were spaced well apart and the staff wore face masks.
On the other hand, last week Chris and Carolina had dinner at a restaurant by
the marina. When he made the reservation, Chris was told that customers must
wear masks on arrival until they are seated at their table. As they began to
put on their masks, however, the maître d’ informed them that a health inspector
had visited the restaurant the previous day and had told the staff that
customers must be in possession of a mask, but do not need to wear it.
Last weekend, they took the children into
the Nayarit countryside for some exercise. They noticed a pleasant spot on the
banks of the Ameca river and agreed to stop there on their way home. When they
returned they found the area full of parked cars and picnicking families. This
is the hot season of the year. The river enables families to escape homes in
crowded towns that are often not well ventilated or easy to keep cool for the
refreshing cool of the Ameca’s waters. The crowd was sufficiently large that
some had set up tables and chairs in the river. A police car with a loudspeaker
arrived and informed the picnickers that if they did not leave, the National
Guard would be called. A great, not very distanced, rush to the parked cars
ensued. Nevertheless, this was evidence of some official efforts to enforce a
degree of distance.
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| Río Ameca |
In general, it seems that there are some
organized attempts to encourage safe practices, but enforcement is haphazard. For
example, police are stationed on the bridge that marks the boundary between
Nayarit and Jalisco, presumably to check whether journeys are essential.
However, when Carolina and Chris crossed the bridge the police made no effort
to stop them. However, tourism (the main economic activity of the area) has
ceased, many (including Carolina) are unemployed. Consequently, public
transport demand is reduced and bus services are less frequent. The President intends
to relax restrictions this month while deaths remain at a high level. I suspect
that more cases will ensue.
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| Middle class housing in San Vicente. Chris' home is to the left of the pickup truck |
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