In a perfect world, with perfect testing and contact tracing, the state could bring COVID-19 to a halt in a matter of weeks.
There would be enough tests for all 3 million Arkansans. Everybody would be tested at once and get the results within 24 hours. Then, thousands of case investigators and contact tracers would spring into action to reach the infected and their “contacts,” meaning the people they’ve recently been around.
Anyone who tested positive would be told to isolate — even from family in the home. Anyone who came into contact with a COVID-positive person would be told to quarantine. All would comply and keep the virus to themselves.
Those things are not going to happen, either in Arkansas or the country as a whole. The coronavirus that causes COVID-19 is not slowing down. On Thursday, the state reported 1,548 cases, a new record for a single day. On Friday, it far exceeded that record with 1,870 new cases. On Nov. 8, there were 12,480 active cases of the virus in Arkansas. A month earlier, the active case count was 7,070. National trends look similarly grim.
The increasing number of cases makes it difficult for contact tracers to keep up. On top of the rising caseload, there are many other problems: delays in processing tests, missing contact information on lab reports, patients who refuse to speak to callers. Dr. Jose Romero, the secretary of the Arkansas Department of Health, told a reporter recently that tracers and case investigators don’t always get a warm reception when they place their calls.
“People will hang up, use obscenities,” Romero said. “It’s probably one step above telemarketing.” However, despite this poor treatment, he believes the state has enough contact tracers at the moment to keep up with the caseload.
The contact tracing process begins with the health department. The department has 221 case investigators, usually nurses, who handle the first calls to people who have tested positive. Case investigators inform them of the need to isolate, get their health histories, answer questions and advise them about how to use Sara Alert, an automated system that allows people to easily report symptoms to the health department.
Case investigators then pass these “index cases” along to contact tracers. Tracers collect the names of people the COVID-positive person has been near and then call those contacts. They instruct the contacts to quarantine and recommend testing if they are experiencing symptoms of COVID-19. (“Isolation” and “quarantine” mean different things to the health department. Quarantine is a 14-day period for people who were exposed to the virus but are not known to be positive. Isolation is a 10-day period for people who have tested positive, which factors in the time it took for the virus to be detected by a test.)
Arkansas had about 800 contract tracers at the end of October, most of whom worked for two vendors: 356 on contract with General Dynamics and 300 with the Arkansas Foundation for Medical Care. Another 124 tracers worked at the University of Arkansas for Medical Sciences Fay W. Boozman College of Public Health, and a special team of 16 were at the Northwest Regional Campus of UAMS.
Ransen Hansen, 35, is a contact tracer working with UAMS Northwest. Yes, he said in a recent interview, people sometimes hang up on him. But, Hansen said, “I try to call again and just explain, ‘We know this is frustrating, the cough and chills and symptoms. It’s really challenging. But we need to reach out to your family.’”
Hansen’s job is especially essential because he is one of the few tracers in the state who is fluent in Marshallese. Marshall Islanders in Arkansas, who mostly live in Springdale, have suffered disproportionately from COVID-19. Though Pacific Islanders account for less than 0.5% of the population of the state, they made up 2.1% of cases and 2.3% of deaths as of Nov. 6. Epidemiologists with the UAMS College of Public Health estimated in late August that the COVID-19 case rate among the Marshallese in Arkansas was 30 times that of whites and the death rate 48 times as high.
The outsize impact on the Marshallese community is due to several factors, public health experts say. Type 2 diabetes is extremely common, occurring in an estimated 41% of the Marshallese population in Arkansas, and the disease increases COVID-19 patients’ risk of becoming seriously ill. (The diabetes rate for the state as a whole is 14.8%, which is itself higher than the national average of 10%.) Marshallese households are often large, sometimes with multiple generations in the same home. Many Marshallese people are employed in poultry processing plants, which have been notorious sites of spread for the virus.
Some of those same factors also contribute to disproportionate COVID-19 rates within the Latino community in Northwest Arkansas. Latinos make up 7.8% of the population of Arkansas but 15.1% of its cases as of Nov. 6. (Only 4.8% of COVID-19 deaths were among Latinos, however.)
In July, a field team with the Centers for Disease Control and Prevention visited Washington and Benton counties to investigate these disparities in health outcomes. Their highly critical report blamed the state’s inconsistent messaging about COVID-19, a general distrust of authority, and a lack of information in Spanish and Marshallese for the high rates of infection. It urged the state to increase its numbers of bilingual contact tracers.
To address these needs, the state provided $7 million to the Northwest Arkansas Council, a local economic development agency, which turned to UAMS Northwest to beef up contact tracing, testing and community outreach around COVID-19 in the region. The money was drawn from $1.25 billion in federal funds that Arkansas received under the CARES Act, the massive relief package passed by Congress in March. The state has also used CARES Act funding to buy personal protective equipment (PPE), boost the pay of health care professionals, buy testing equipment, aid businesses, hire contact tracers and meet any number of other COVID-19-related needs.
Hansen was born in Enid, Oklahoma, to Marshallese parents, but he and his family moved back to the Marshall Islands in 1991. After graduating from college in 2008, he worked with the country’s Ministry of Health for a decade. Hansen returned to the U.S. in 2018 “to have a better life for my kids,” he said.
He settled in Arkansas because of its large Marshallese population and found a job with UAMS Northwest’s Diabetes Prevention Program. He began work as a bilingual contact tracer in August. As of late October, Hansen was one of three tracers on the team who spoke Marshallese.
The best way to contact people in his community, he said, is through social media.
Hansen said people in his community usually use Facebook Messenger when talking to family and friends. So, when he can’t reach someone by phone, he gets on his own Facebook page to track down contacts. (To avoid violating health privacy laws, he provides a number to call, rather than giving a reason for calling.)
When he talks to contacts, he’ll ask if it will be a burden to stay in quarantine, away from other people. Often, the answer is yes: If folks can’t work, they can’t get paid. Hansen said some poultry workers have told him they are not paid for time off should they need to take more than one quarantine period.
Contact tracers sometimes learn of families facing dire circumstances. Pearl McElfish, a vice chancellor at UAMS Northwest who is overseeing the team, said tracers learned a pregnant mother was living in a car to avoid exposure to family members who’d tested positive. Another woman said she couldn’t quarantine because she had a court date for a traffic ticket that she could not miss without penalty. When one contact was asked if there was enough food in the house to safely quarantine for two weeks, the person reported not having enough food to last the day.
But Hansen and the contact tracing team at UAMS Northwest have a way to help: The CARES Act funding provided to the Northwest Arkansas Council also pays for case managers and navigators who can provide cases and their contacts with support from 11 local nonprofits and churches.
The pregnant woman’s family was given shelter elsewhere, McElfish said. A navigator spoke with the traffic court about the missed court date. The person who had nothing to eat got a delivery from Ozark Regional Transit, which has delivered food to an estimated 711 people in 151 households since the UAMS Northwest tracers began work in September. By Oct. 10, case managers had connected 558 people with special services, such as helping with utility bills, providing PPE, writing letters to employers and assisting with deliveries from pharmacies.
Those services are more than just charity — they allow people to avoid breaking quarantine, which helps limit the spread of the virus. McElfish said navigators give a “very warm handoff” to connect contacts in need with nonprofits like the Arkansas Coalition of Marshallese and the Marshallese Education Initiative and follow up as best as they can to see if help was provided.
The UAMS Northwest team isn't the only group of contact tracers focused on a specific population. Those at the College of Public Health only handle cases related to colleges and universities. Often, the colleges tell the COPH tracers they have already asked some contacts to quarantine, which speeds the work along.
“Each [campus] has done a great job of trying to make sure all students and employees understand that they should report,” said COPH Associate Dean Ben Amick, who is in charge of the program. Amick said tracers make three attempts to reach case contacts. His goal is to reach 90% of contacts.
To encourage college students to acknowledge their (and others’) mortality and play it safe, the health department and the COPH launched a contest, which ended on Nov. 6: They asked students to submit short YouTube videos on what they’re doing to stop the spread of the virus on campus. The best video will win $5,000, the runner-up $2,500 and the honorable mention $1,000.
Across all four organizations, case investigators assigned 5,251 index cases to contact tracers in the week ending Oct. 31, according to weekly reports published by the health department. Tracers reached almost 85% of those cases. Based on conversations with the index cases, tracers collected 12,682 names of contacts that week. Of those, tracers reported making contact with 10,387, or about 82%.
But that same week, contact tracers were unable to reach 758 Arkansans who’d tested positive and another 2,131 of their contacts. That means community spread is far from being documented and contained.
Not all positive cases are assigned for contact tracing. Case investigators do not assign tracers new cases from hospitals, nursing homes or congregate settings, such as prisons, jails and human development centers. Index cases in which the person has died are also not passed along to tracers.
Sometimes, case investigators may also be unable to make initial contact with index cases. For the week ending Nov. 6, there were 2,789 out of 118,750 cases in the state still “under investigation,” or about 2.3%, according to a report from the health department. The department does not provide the number of positive cases who can’t be reached by investigators.
The health department also tracks the percentage of “unlinked” cases, or those in which no source of infection could be identified. The percentage has hovered around 35% since mid-July.
Dr. Namvar Zohoori, the health department’s chief science officer, called that fact “worrisome, but not surprising, as you get into community spread.” While there is a five-day cutoff for considering a case “unlinked” for the purpose of health department reporting, there is not a cutoff for case investigators to keep trying to find the source of an infection. If you can’t reach the source, Zohoori said, you can’t stop the spread.
This reporting is courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan news project dedicated to producing journalism that matters to Arkansans.