Case Investigation and Contact Tracing

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Reports from the front lines of Public Health

Over recent weeks, you have likely heard media reports that expanded COVID-19 testing, case investigation and contact tracing are the main tools in combating COVID-19. These efforts are also necessary to safely launch Governor’s Inslee’s phased Safe Start re-opening of Washington’s economy. You probably have an understanding of what is involved in testing, and may know that drive-thru testing has been launched in Skagit (click here for details). But you may wonder: What exactly is case investigation and contact tracing? I called Skagit County Public Health’s Community Health Worker Graciela Ibarra and Public Health Nurse Ian Capron to hear what it’s like to be on the front lines of these efforts.

What is case investigation?

Skagit County Public Health staff contact people who test positive for COVID-19 to provide important guidance and complete detailed interviews. Guidance includes how to safely isolate at home after testing positive or developing symptoms, as well as ways to access resources. Interviewing is a methodical process in which answers are pieced together to create a detailed history of where the interviewee has traveled, eaten, slept, and bathed. These questions focus on other people who may have had close contact with the person interviewed and who are at risk for COIVD-19 infection.

Asking personal questions, especially with someone you just met over the phone, can be a delicate process. Ian notes that people’s responses are “on a continuum.” Graciela adds that people “usually understand this is needed to keep them and others safe.” They may be hesitant to share the names of family members or coworkers. “We reassure them no one has done anything wrong. No one is in trouble or being punished.”

As you have likely concluded, case investigation requires a special skill set – a mixture of calm understanding and a steady focus on the goal of reaching all at-risk contacts. Investigators have to make certain that interviewees are heard and respected while ensuring that people who were possibly infected are identified.

What is contact tracing?

In contact tracing, the same investigation process is repeated in reaching out to those contacts who may have become infected as well. The number of contacts can add up fast and reside throughout the community. However, Ian notes, “Since Stay Home Stay Healthy began and people started physical distancing, the new cases and contacts tend to be in clusters within families or in the community at job sites of essential services.” One success of distancing is this narrowing of where exposures are occurring.

How do case investigation and contact tracing work?

Ian sums it up best: “Case investigation and contact tracing are our bread and butter. It’s the most proactive thing Public Health can do about COVID-19.”

One clarification before we go further: the difference between isolation and quarantine. Isolation refers to when a person separates themselves from others following a positive lab test or when they have symptoms consistent with COVID-19. Quarantine is for people who have no symptoms but have been exposed to the virus and could develop the illness in the 14 days after being exposed. Some people may quarantine and later become ill while others may not.

In short, case investigation and contact tracing:

  • Identify the spread of COVID-19 within the community.
  • Prevent further spread of COVID-19 within the community through reduced contact from people infected with the virus.
  • Provide people who are confirmed to have COVID-19 with guidance on how to successfully isolate so they can keep loved ones, neighbors and other community members safe.
  • Provide people who have been exposed to the virus with guidance on how to quarantine so they can help others stay safe.
  • Linkage to health care which can result in early diagnosis and care to those who need it.

High points and challenges in the day of case investigators and contact tracers

As you might imagine, the workdays of investigators and tracers might have several high points matched by ongoing challenges. The highpoints are obvious – at the end of each shift, public health staff know they have pushed backed against COVID-19 and prevented transmissions of the virus. They hear thanks from the public for the hard work and for keeping people safe.

The challenges tend to involve pre-existing issues affecting interviewees, such as lower income, a lack of resources and prior health conditions. These issues cause disproportionate hardship from COVID-19. Graciela describes a household in which ten family members live together but have only one bathroom, making risk of infection high and isolation all but impossible. Fortunately, Public Health is leasing a motel where people can isolate while other family members can safely quarantine, shortening the amount of time people are exposed to their sick family member. Ian points out that this temporary housing option enables “families to do the best they can” when facing COVID-19.  

Other difficult situations involve quarantine in which some household members work in critical infrastructure and can continue to go to work as long as they don’t have symptoms. Other people in the household have jobs that aren’t in these essential service industries. They cannot work during quarantine, even if they show no signs of illness. The difference in financial impact between those who are working and those who can’t seems unfair and can result in friction. This disproportionate impact is not unlike what is happening in our county and country overall, where the social distancing necessary to save lives results in harsh economic losses to some and little financial impact to others. Needless to say, working right in the middle of such a polarizing issue can be very difficult for investigators and tracers.

Skagit success

Early on, Skagit County Public Health realized case investigation and contact tracing was where it needed to invest its time and effort. The investigation/tracer team expanded quickly by cross training a large number of staff to do this critical work. Ian describes his co-workers’ efforts as “unbelievable,” as they set aside the work they were used to doing and took on a new job for the betterment of the community. This team enables Skagit to do a rare thing in Washington State – contact tracing not only with people diagnosed with COVID-19, but also with close contacts who have also developed symptoms (also referred to as probable cases). More contact tracing strengthens our outreach and ability to prevent spread. Skagit County Public Health also upped its outreach to businesses. Some larger statewide and regional employers have expressed great thanks, noting they had not experienced outreach from public health agencies elsewhere. Working directly with employers is key to promoting on-the-job safety for local workers.

A contact tracer’s advice

When I asked for what guidance they may have for the community, Ian pointed out that some people who later are diagnosed with COVID-19 “thought they just had allergies or a cold. Don’t ignore any symptoms, especially if they get worse,” adding, “but call your doctor first before you go in.” Graciela advises, “Listen to your body. See what it’s telling you. But if you are diagnosed with the virus, don’t let the disease take control of you. Look at media that is positive instead of all the negativity. Let yourself heal.”

More contact tracing info

Want more contact tracing info? Check at the Centers for Disease Control and Prevention webpage at: https://www.cdc.gov/coronavirus/2019-ncov/php/open-america/contact-tracing.html


Important Message COVID-19

Recovered from COVID-19 – Important Message

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A very important message from the first Skagitonian diagnosed with coronavirus.

In life, we generally want to be first. Get that gold medal, be the valedictorian, hold the world record. Like most of us, Susanne had never been first before. Until March 10, 2020.

Susanne, 49, is a recent transplant to Skagit County, having moved here from Enumclaw in January. She decided to live fulltime in her 37-foot-long RV with her rescue dog. On March 10th, Susanne became the first person in Skagit County to be diagnosed with COVID-19.

She began feeling symptoms on Saturday, Feb. 22nd. It’s just allergies, she thought. She’d been through this every year and this time didn’t feel any different. This was weeks before Governor Jay Inslee announced the “Stay Home, Stay Healthy” order and things started shutting down. Weeks before most people began taking the pandemic seriously. Susanne continued to live her normal life, as we all did. Her story could be any one of ours.

As an avid square dancer, she drove south for a square dancing lesson, followed by a square dance. “I felt crappy enough that when I got halfway down to Lynnwood, I thought that if I have a fever when I get down there, I’m going home. If I don’t, I’ll toughen up,” she says. “I didn’t have a fever.”

“I was really sick the next day. The dog was really concerned about me. I didn’t want to get out of bed, I was getting dehydrated,” she says, crediting the dog with making sure she drank and ate. “But by Monday morning, I felt fine.”

On Tuesday, she went down to her 81-year-old mother’s house in Enumclaw and was cleaning stuff out. Luckily, her mom wasn’t there. On the way back, she ran errands, making stops at several stores, as we all used to do before the outbreak. She had contact with many people along the way.

“I had a long day and my allergies were really flaring,” she says. “At that point, I realized that I’m not going to manage to make dinner, so I stopped at a drive thru and picked something up.”

She was looking forward to a square dance coming up on Sadie Hawkins day, February 29th. As a lifelong allergy sufferer, she knew the feeling of her allergies working their way into her chest, causing pneumonia. She thought, with some rest, in a few days she’d be better.

“At this point, I’m like 99.9% sure that I’m not contagious. It’s just allergies,” she says. “There was no fever, all the drainage was clear. That’s an allergy, not an infection.”

However, she thought she better not go to the dance. Plus, “nobody wants to be around mucus girl!” she joked.

By March 2nd, she could hardly get out of bed. She certainly couldn’t make anything to eat. She didn’t even feel like making herself tea, so she picked up a few iced teas at a drive thru to keep herself hydrated. At 11:15pm, she got back to her RV site and checked her email. Sitting in her car, she read the news. One of her square dancing friends had been hospitalized and died. He had been diagnosed with COVID-19.

She knew she had to get tested. She drove to Overlake Hospital in Bellevue, arriving at 1:08 am, March 3rd, less than two hours after she found out about her friend.

“I drove south because they had people down there who had [COVID-19], so they would be prepared. And they were,” she says. Hospital staff immediately handed her a mask and placed her in a negative pressure room. While she waited to be seen, she turned on the TV.

“I don’t normally watch TV, but in like 5 minutes, I was concerned that I had been out in public and giving this to other people,” she says. “Just five minutes of TV and I was like … ‘Holy crap, no wonder people are freaking out.’ I shut it off.”

They took a chest x-ray and tested for non-COVID-19 respiratory viruses. The results came back quickly – all negative. The x-ray revealed what she already knew – bilateral pneumonia.

But still, she had no fever so she didn’t quite fit the COVID-19 testing criteria at that point in time.

“My symptoms weren’t what we were hearing,” she says. All of her square dancing friends who ended up testing positive had different symptoms, “and none of them were what you had to have to get a COVID-19 test. The one thing we had in common was that there was a time when we all were feeling better so we went out and did things. And then we crashed harder.”

Knowing she had been exposed and a friend had died from COVID-19, hospital staff decided to test her. She was told the results would be available in 24-48 hours. They gave her a box of masks to wear in public and sent her home.

Other friends were also tested on March 3rd and their results were in by March 6th. Of five friends tested, four came back positive, but Susanne was still waiting on her test. On Sunday, March 8th, she got a call from Skagit County Public Health, which had also been waiting to receive her test results. There had been problems processing her test. So Public Health arranged with Skagit Valley Hospital to have her retested early the next morning.

Approximately 24 hours after the retest, she got the call she was dreading. She had COVID-19. She spent the next hour and a half telling Public Health every place she’d been in the last 30 days. Fortunately, she lets her GPS run and it keeps track down to the minute.

Susanne spent the following two weeks in isolation. Once cleared by Public Health, she went out to enjoy some fresh air. From about 30 yards away, she had her first physical conversation with someone in weeks. She asked a man how he was doing, and his response left her astonished:

“Fine, not really doing anything because of this COVID-19. I think it’s a hoax. I don’t know anybody who had it or died from it,” Susanne recalled.

“Well, I’ve had friends die from it,” she responded. “And, hi! I just got out of isolation today!”

Later that day, while doing five-and-a-half weeks of laundry at the laundromat, she had a nearly identical conversation with a woman there.

“How are there still people who don’t think this is a thing?” she wonders. “They’re still denying it. That was kind of horrifying to me.”

She wants everyone to know that they can get this disease, even young people and those who do not have underlying health conditions that make them more susceptible to deadly complications.

“You’re not immune, you’re not special. You can still get it and you can still spread it,” she says.

She has hope for the future and is confident that with accurate, scientific information, the community will come through this.

“Life is never going to be quite the same. We’re going to be aware of things we weren’t aware of before,” she believes. “And that’s a good thing. Knowledge and growth are a good thing. “