Once Meg Barclay tested positive for COVID-19, she knew she’d be getting a call from a contact tracing investigator at the Maine Center for Disease Control and Prevention.

To make things easier, the Camden resident began to make a list of the places she had been and the people with whom she had come into contact in the days before her first symptoms.

“I was all over the place,” said Barclay, 60, who owns a local architecture firm with her husband. “This is why we wear masks. I didn’t have a clue.”

Barclay’s initial symptoms appeared on March 10 – a few days before the state started applying the first stay-at-home measures. In the days prior, she had been to a restaurant, participated in a committee meeting at Town Hall, went to her karate class at the local YMCA and attended a play in the basement of the Farnsworth Museum – all places that would be closed a short time later. She went back a little further and the list included: the dentist, two job sites, a veterinary clinic visit for her dog and shopping at no fewer than six different stores.

“I’ve been thinking of this as people go out more,” Barclay said. “You just don’t realize how many contacts you have.”

In the absence of a vaccine or viable, widespread treatment for coronavirus, the most effective tool for combating its spread as stay-at-home orders are lifted is contact tracing.

But what does that mean and how will it be used? And more importantly, will people embrace it?

Contact tracing has long been a tool in public health to monitor and limit disease spread. It’s been used for outbreaks of tuberculosis, smallpox, syphilis and, more recently, to mitigate the spread of the Ebola virus in West Africa in 2014.

Identifying someone who has tested positive is crucial because it allows for them to be isolated until they are no longer infectious. Just as important, though, is identifying people who may have interacted with someone who tested positive so they can quarantine long enough to determine whether they contracted the virus. Even small disruptions in the transmission train make a huge difference.

One of the reasons countries such as China, South Korea and Germany have fared better than the U.S. with their coronavirus outbreaks is vigorous contact tracing.

Still, the practice – which at its core involves voluntarily sharing information with a government agency – is not an easy sell to some in this country, even in the middle of a pandemic, and even when doing so is proven to benefit the greater good.

Sara Robinson, director of the Maine CDC’s infectious disease epidemiology program, said for the most part, people have been forthcoming and receptive when they get a call from one of the agency’s contact tracers.

“Contact tracing is a common enough term now and when we explain the importance of what we’re doing, people understand,” she said.

Last week, state officials announced that they have begun hiring as many as 125 contact tracers and will also begin training 50 volunteers to assist. That would add to the existing team of about 30 at the Maine CDC, although the increase in staff will be done in phases.

Barclay, who is now considered a recovered case, said her experience with a contact tracer was pleasant. By the time she tested positive in early May – she wasn’t in the top tier for testing – she had mostly recovered and had been isolating the whole time.

Still, she worried about those people she encountered just before she got sick. Who might have given it to her? And who did she pass it to?

“It would have been horrible to think I was responsible for someone getting sick, or worse,” she said.

Downtown Camden on Thursday. When Meg Barclay tested positive for COVID-19, she knew a contact tracing investigator at the Maine Center for Disease Control & Prevention would be contacting her. Barclay made a list of the places she had been and the people with whom she had come into contact in the days before her first symptoms. “I was all over the place,” said Barclay, 60. Brianna Soukup/Staff Photographer

‘PART DETECTIVE, PART THERAPIST’

This month, the Bloomberg School of Public Health and Johns Hopkins University in Baltimore began offering a free online course on contract tracing, which this reporter completed.

The instructor, Emily Gurley, an infectious disease epidemiologist, described the job as “part detective, part therapist.”

Here’s how a typical case works:

Once someone tests positive for COVID-19, their doctor will advise them on what steps to take next. Since there is no treatment, it often involves monitoring symptoms and reporting anything serious, such as extended shortness of breath or chest pains that might require hospitalization. The first task is to ensure that each person has support – access to medical care and social services, if needed. They will then be asked to isolate until 10 days after their symptoms subside.

“If we want to interrupt or stop transmission, we have to find people who are infected and limit their contact,” Gurley said during the course.

Contact tracers then will ask the person to think about their activity in the days leading up to the onset of symptoms, as well as after, if they didn’t already isolate. They might use calendars, social media apps, even receipts to help build a comprehensive list.

Tracers then attempt to calculate a person’s incubation period, or the time between infection and the first symptoms. This can be anywhere from two to 14 days with COVID-19, but the average is four or five days. Then, they will want to estimate the infectious period, which starts two days before symptoms present and runs for at least 10 days, unless symptoms don’t improve, in which case it can be longer.

Once a tracer identifies those periods, they can begin to locate the people who might have interacted with the confirmed case during the infectious. These are called contacts, or people who may have been exposed to the virus.

A contact doesn’t mean everyone you pass in a grocery store. For contact tracing purposes, contacts are broken into three categories: Physical contact, close contact (defined as less than 6 feet away from someone and for more than 10 minutes), or proximate contact (defined as more than 6 feet away but in the same enclosed room for an extended period of an hour or more).

These contacts may not all contract the virus – many won’t – but the key is that the ones who do may not know it right away and could spread it. This is where the process gets tricky, though. Asking people who have been exposed to the virus but may never get it to quarantine for 14 days is a challenge.

“We’ve seen the extremes of it,” said Robinson, at the Maine CDC. “People who are very concerned and want to voluntarily stay home and others who are concerned about missing work or overreacting.”

Last week, during the announcement that Maine would be adding more contact tracers, Maine Department of Health and Human Services Commissioner Jeanne Lambrew said the state would work with local community action programs to ensure needs are met for those who are asked to isolate or quarantine.

Robinson said one of the biggest questions that has come up so far is: If I test negative, can I end my quarantine?

“We have to tell them, ‘No, that’s not how it works,’” she said.

A contract tracer will build a list of contacts for each case and will ask for names and phone numbers, if available. This is another possible hurdle: Will people voluntarily give names and numbers, even in service of public health?

All information gathered by contact tracers is kept confidential. Gurley gave an example in the online course that, if a man lists a girlfriend as a possible contact but he also has a wife, it’s not the contact tracer’s job to tell the wife about the girlfriend, only to contact the girlfriend.

When someone gets a call from a Maine CDC contact tracer, they aren’t told that they might have been exposed to the coronavirus by a specific, named individual. Instead, they are told that someone they have been in contact with tested positive.

Robinson said there have been occasions where people don’t want to share contact information. In those instances, she said, Maine CDC staff instruct them to have the contacts call them.

COMPARING NOTES

In Barclay’s case, she provided the Maine CDC contact tracer with a long list of people she contacted before getting sick. She said the five weeks between March and April were the sickest she’s ever been, and she had malaria when she was in her 20s. Barclay also reached out to some of the people after she tested positive to let them know. Because so much time had passed, none of them were concerned about getting sick, though, she said. However, three of the people she was in contact with were sick around the same time she was.

Tina Lee poses for a portrait inside of her home in Camden recently. Brianna Soukup/Staff Photographer

One of the people who wasn’t on Barclay’s list but who could have been under different circumstances was her neighbor, Tina Lee.

Lee, 63, ended up testing positive for COVID-19 in early May but hadn’t recalled interacting with Barclay for months. They have since been talking about their shared experience with the virus.

Lee’s list of contacts, in contrast to Barclay’s, was short. She had lunch with her daughter, who lives in Portland, on Friday, March 13, just before Maine first started imposing restrictions. After that, she didn’t go anywhere. She started to develop symptoms four days later, and her illness lasted through April before she was finally tested.

Lee said the Maine CDC contact tracing experience was painless. They asked her questions, tried to jog her memory. But her movements were limited.

Tina Lee poses for a portrait inside of her home in Camden on Thursday. Lee is currently infected with the coronavirus, which she believes she contracted in March. Brianna Soukup/Staff Photographer

“I know they called my daughter, but I don’t know where they took it from there,” she said. “I think (Meg and I) comprised the two opposite scenarios in terms of contacts, but we were both responsible enough once we got symptoms.”

When the pandemic first reached Maine, the Maine CDC had 15 contact tracers. That total has now more than doubled and is expected to increase fourfold in the coming weeks as needed. A report last month from the National Association of County and City Health Officials said each state should have 15 contact tracers per 100,000 people during normal times. During a pandemic, the rate should double to about 30 per 100,000 people.

Maine has 1.3 million people, which means it would need between 200 and 400 contact tracers based on that calculation. Under the plan outlined last month, the state would top out at 200, which includes the 50 volunteers who will be trained to supplement the work of professionals.

“The rate of growth of the disease has not outpaced the number of contact tracers needed,” Dr. Nirav Shah, the Maine CDC director, said at a briefing this month.

Robinson said she expects her staff to be even busier as more and more people venture out, increasing their chances of becoming a contact. As part of the reopening, restaurants and other retail establishments where people may have extended contact, such as hair salons, are being asked to keep names and numbers of people who visit to help with contact tracing.

In addition to hiring more staff, the state has implemented a system, called Sara Alert, that allows cases and contacts to report symptoms and update the Maine CDC by email or text, or through an online portal, which will cut down the amount of time tracers spend on the phone.

The response has been good so far, officials said last week.

Some, though, might be wary of sharing too much digitally. An Axios-Ipsos poll of 1,000 Americans conducted between May 8 and 11 found that only about half would participate in a voluntary coronavirus “contact tracing” program tracked with cellphones. The reluctance to trust digital data sharing makes contact tracers even more important.

Still, the same people who have downplayed the risk of coronavirus or have angrily called for lockdown orders to end are likely the same people who might balk at contact tracing as some infringement on personal liberties.

Robinson said the biggest message she tries to get across with each call is: “We’re just trying to protect you and the people around you.”

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