A nationwide effort is underway to bolster the public health workforce as states launch efforts including multistate collaborations and virus-tracking technology to identify new cases of COVID-19 and their contacts.

An economic relief package enacted in March included $150 billion in state aid related to the coronavirus, while the most recent bill includes $11 billion more for state efforts on testing and outreach to contacts of infected people. Another $1 billion will fund federal testing and contact tracing efforts at the Centers for Disease Control and Prevention.

But contact tracing, in which public health officials track and alert individuals who were exposed to COVID-19 patients, is a resource-intensive exercise and will likely require more dedicated funding, experts say. The United States would need at least another 100,000 workers to adequately track person-to-person transmissions, according to a Johns Hopkins University estimate. 

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If the workers are paid the average community health salary of $17 per hour, a full-time, one-year workforce would cost around $3.6 billion. Experts estimate that the total could reach $5 billion after factoring in the costs of training and pay for more experienced disease investigators.

The price tag seems small in the context of the multitrillion-dollar spending bills Congress has enacted since the pandemic began, but a fear exists that tracing efforts could take a back seat to more urgent priorities — like food and cash assistance to the 26 million workers who reported losing their jobs in the past five weeks.

The explosion in federal aid also triggered a frenzy among public and private entities, including county and state governments. Marcus Molinaro, executive of Dutchess County in New York, credited Democratic Gov. Andrew Cuomo for his leadership during the outbreak but noted that testing and tracing efforts are driven by counties. 

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“But when governors like ours talk about the need to establish testing sites, to roll out antibody testing and to expand the tracing of positive cases, it is in fact county governments that are responsible for effectuating those expectations,” Molinaro said on a call with reporters.

Dutchess is 90 minutes north of New York City and has 2,200 confirmed cases, 1,800 of which the county is actively tracking. Molinaro, who recently lost his father to COVID-19, estimates that the economic shutdown cost the county 50 percent of its tax revenue. 

New York is among several states, including California and Maryland, where officials are seeking to ramp up contact tracing. 

The lack of contact tracers is just one component of a long, slow decimation of public health investment. Ravina Kullar, an expert with the Infectious Disease Society of America and a UCLA adjunct faculty member, called tracing a “cornerstone” of preventive medicine.

Disease detectives interview and track potential infections through direct outreach to exposed individuals and by mining records like airplane passenger logs. The technique was used in recent outbreaks of viruses like Ebola and Zika, but its practice is well-rooted in more common afflictions like tuberculosis and sexually transmitted diseases.

David Harvey, executive director of the National Coalition of STD Directors, estimates that around half of the country’s 2,000 STD tracers have been reassigned to coronavirus efforts. Many of the investigators are people of color, a factor that is critical to building trust in minority communities that have long suffered from health disparities. 

“This is a very specific set of skills,” Harvey said. “It’s a workforce that comes from the communities we are trying to reach.”

Coordination across states

The CDC is in the process of placing additional tracers in all 50 states to boost local efforts, but states are also joining forces with one another. 

New York state, New Jersey and Connecticut are launching a tri-state tracing effort with the help of billionaire and former New York Mayor Mike Bloomberg, Johns Hopkins University and public health organization Vital Strategies. Coordination efforts are critical to tracking those who live and commute in two different areas, Cuomo said Wednesday.

“Blur the government jurisdictions because they don’t really make sense,” he said. “Put everybody together, work together.” 

There are around 700 tracers in the state right now, according to numbers Cuomo presented at a news conference Wednesday, and the state will be recruiting more from the 35,000 medical students at the State University of New York and the City University of New York.

That’s a very different picture from the one in Wyoming, the least populous state in the nation, which has 326 confirmed cases and seven deaths. Department of Health Public Information Officer Kim Deti said the state reassigned five staff to assist its existing five tracers and is also receiving help from county workers. 

Tracking through technology

Tech companies are also jumping in to stretch the reach of a limited public health workforce. Apple and Google are building a Bluetooth-enabled monitoring system that would discreetly ping and record interactions with other nearby phones through randomized ID numbers that frequently change in order to protect privacy. Users later would receive alerts if they were in the vicinity of a person who ends up being diagnosed with COVID-19.

The companies plan to release information to developers by next month and then integrate the technology into their existing platforms.

North Dakota built its own app to allow users to voluntarily track their locations and also plans to incorporate Apple and Google’s technology when it becomes available. Republican Gov. Doug Burgum, a former software CEO, said the app evolved from discussions with friends at Microsoft who developed an app allowing North Dakota State University football fans to find each other at away games.

“If we can do targeted isolation in quarantine, we can contain the spread as opposed to asking everybody to practice physical distancing,” Burgum said Wednesday on C-SPAN.

Apple and Google’s software is voluntary. The companies say consumers’ locations will not be tracked by GPS and Bluetooth interactions that detect proximity to people with COVID-19 would be kept private.

A number of states are also partnering with Mitre Corp. to use its symptom monitoring platform Sara Alert to keep in touch with exposed individuals during the recommended 14-day quarantine period. The platform offers government officials dashboards that track consumers’ self-reported symptoms.

Voluntary tracing apps have been a success in countries like Taiwan and South Korea, but privacy issues will likely hinder tracing efforts in the U.S. A Kaiser Family Foundation poll released Thursday found that just 50 percent of respondents would download an app that would alert them to possible exposure to the coronavirus.