South Carolina must dramatically ramp up its efforts to detect new cases of COVID-19 and stop its spread, experts say, an urgent need as the state begins to reopen on Monday.
As the number of new COVID-19 cases plateaus and state leaders relax restrictions that shuttered businesses and kept people at home, national health officials are calling for an army of new contact tracers to investigate and contain inevitable flareups of the disease before they become outbreaks.
States have published ambitious plans to hire thousands more of the so-called “disease detectives.” They will be trained to call people who just tested positive for COVID-19, interview them to learn who else they might have exposed to the virus, and then notify those “contacts” that they need to quarantine.
But such extensive plans are not yet in place here in South Carolina, where Gov. Henry McMaster on Friday announced he would lift his stay-at-home order and allow restaurants to reopen their patios for outdoor dining.
South Carolina’s public health agency has boosted its contact tracing staff to 230 from 20 and says it has more than enough capacity to investigate each of South Carolina’s 6,000 COVID-19 cases so far. The state Department of Health and Environmental Control says it is finalizing plans to beef up testing and hire more investigators. But it has not said how many tests and people it needs to reach to get — and keep — a grasp on the outbreak.
DHEC still has a long way to go, by several estimates. Testing for the respiratory disease remains limited, and a model produced by the National Association of County and City Health Officials estimates South Carolina will need about 1,500 contact tracers.
Others predict a need for even more as testing becomes more prevalent and there are more cases to investigate.
“Contact tracing is going to be the next big thing,” said Dr. Helmut Albrecht, an infectious disease physician for the University of South Carolina and Prisma Health. “(DHEC needs) to be put in a position where they can do that. We’ve just never managed to get our public health supported enough to allow them to do that.”
At least 19 states have put forward plans for testing and tracing that call for a massive increase in screening for the virus as citizens return to work, according to news reports and planning documents reviewed by The Post and Courier.
A full month ago, Massachusetts released a plan to hire 1,000 contact tracers. Texas wants to hire 4,000 and test 30,000 people a day. California is working toward hiring 10,000 tracers and conducting 25,000 tests a day.
Meanwhile, DHEC is putting the finishing touches on its own plan with the federal Centers for Disease Control and Prevention in Atlanta. In a Thursday interview, health officials would not yet say how much testing they plan to do nor how many tracers they expect to hire.
In the meantime, some S.C. cities are starting their own testing and tracing efforts.
South Carolina’s capital city will unveil its own program in the coming days, Columbia Mayor Steve Benjamin said. That likely will include a partnership with a cellphone app that can anonymously track users’ location data and notify them if they have been in close contact with another user who just tested positive, Benjamin said.
“We will be doing more testing, and contact tracing is at the core of a robust public health response,” Benjamin said. “In a perfect world, this would happen at the state level. But in the absence of that, it’s up to the locals to step up.”
The next phase
Contact tracing is not a new concept.
It has been used to track foodborne illnesses and HIV, and it has already proven effective at curbing the COVID-19 outbreaks in countries like China, South Korea, and New Zealand.
DHEC already employs 20 contact tracers year-round. They are experienced in tracking outbreaks of tuberculosis and sexually transmitted diseases, identifying where the disease came from and where it might spread next in order to stop it.
But combining contact tracing and aggressive testing is even more important now as Gov. McMaster looks to ease restrictions on businesses and public life, experts say.
The virus continues to spread across South Carolina, including from hosts who haven’t yet developed symptoms and don’t realize they are endangering others.
Future flareups of COVID-19 are inevitable as the state reopens, especially in rural areas, where cases are more likely to go undetected because health care is less available, Medical University of South Carolina President David Cole said this week.
He said aggressive surveillance would be key to containing those flareups and preventing outbreaks.
“We need to get this genie back into the bottle in a way that we can manage it … and it doesn’t kill our economy,” Cole said at a meeting of Accelerate SC, a group assembled by the governor to strategize the state’s long-term COVID-19 response.
DHEC has slowly increased testing, which has been limited by supply-chain problems as states and countries across the world seek the same materials on the open market. Including private laboratories, around 1,500 people a day are tested in South Carolina, a number that experts say must rise if the state is to get a handle on the prevalence of the disease and address outbreaks.
DHEC spokeswoman Laura Renwick said that supply shortage now "seems to be easing and we have been able to ramp up testing significantly within the last week."
DHEC has already gone to work boosting its contact tracing efforts, adding 210 more tracers to its team, chief of staff Jennifer Read told The Post and Courier on Thursday.
That’s a “good start,” said Dr. Patrick Cawley, CEO of MUSC Health. But Cawley said the state could need as many as 2,000.
“It’s just something you’ve got to do if you really want to get your arms around it,” Cawley said. “We need as a state to be doing more of this and to get a plan in place and just get started.”
Sixty of DHEC’s added contact tracers were new hires, including furloughed health care workers and volunteers. The rest were reassigned from other duties with DHEC. Most already have experience with patient confidentiality rules and interviewing people about their medical histories.
DHEC will look for similar candidates to hire more. At a meeting Tuesday, DHEC officials publicly brainstormed hiring social workers, public health students and furloughed state employees to do more tracing. DHEC said people are volunteering left and right to become tracers, and the agency has a rapid hiring process in place to accommodate them.
Cawley suggested several hundred MUSC workers who have been laid off could be hired as tracers. “And that’s just us,” he said.
DHEC leaders said some tracers will likely be hired specifically to connect with hard-to-reach communities of Native Americans and Hispanics, where government agencies asking personal questions aren’t trusted. New tracers could be trained with a standardized, online program.
The number of disease investigators the state ultimately needs will depend on how far the virus spreads, said Dr. Joan Duwve, DHEC’s new public health director. DHEC’s goal is to be able to adjust its staffing so a tracer can be assigned to every positive test. It expects to need more as tests become more widely available.
“I think we can get there,” Duwve said. “We are still talking about what this looks like.”
What it looks like elsewhere
Other states are much further along. They have released plans calling for far more testing and contact tracers than are currently under DHEC’s disposal.
Consider other states near South Carolina’s size.
Indiana’s stated goal is 6,300 tests a day. Missouri wants at least 5,700 a day. Louisiana, an early COVID-19 hotspot, wants up to 6,500 but has set a minimum goal of roughly 4,500.
Even North Dakota, home to fewer residents than Columbia’s metro area, is calling for 6,000 tests a day.
Some governments are also marshaling armies of tracers to track down anyone who might have been exposed to the virus. Illinois is working to hire 1,000 virus investigators. So is New York City.
Other states plan to undertake similarly sized hiring sprees, including Maryland and Wisconsin, which are near South Carolina in population, and Nebraska, which is far smaller.
Read, DHEC’s chief of staff, said one reason South Carolina appears to be behind is because other states were hit harder and earlier by COVID-19 and are working on a different timeline.
South Carolina’s public health leaders have likewise called for more testing, but they have not yet finalized their plans with the CDC. That is expected to come soon.
Dr. Linda Bell, the state’s top epidemiologist, said South Carolina would try to “markedly expand testing” so that someone with even mild symptoms could get screened.
DHEC declined to say how much testing capacity it would need to hit that goal.
Putting technology to work
Moving forward, South Carolina could rely on technology as well as manpower for contact tracing.
Like Columbia, the city of Charleston is looking into an app to facilitate contact tracing and monitoring, Mayor John Tecklenburg said Friday. MUSC is working on a project using technology developed by Apple and Google, spokeswoman Heather Woolwine said.
A handful of other states, like Utah and North Dakota, have already announced smartphone apps that track every person someone has been near, in case they later fall ill.
Since traditional disease investigations rely on a patient’s memory, the apps’ GPS tracking capabilities can help explain where people might have spread or contracted the virus.
Such apps have raised privacy concerns, but developers are working on firewalls that protect patients’ health data, officials say. An app would notify a person who might have been exposed to the virus, but it wouldn’t reveal the name of anyone who tested positive.
The Medical University of South Carolina has urged the state to take both approaches. It’s advocating for South Carolina to hire far more investigators and bolster them with technology, Cawley said.