In April, the North Carolina Department of Health and Human Services (NCDHHS) announced the Carolina Community Tracing Collaborative. The partnership between Community Care of North Carolina (CCNC), the North Carolina Area Health Education Centers (NC AHEC) and NCDHHS was part of Gov. Roy Cooper’s initiative to slowly lift restrictions by focusing on testing, tracing and trends.
In simple terms, the idea behind contact tracing is to connect with people early who have been exposed to the coronavirus to help stop the spread. According to the Centers for Disease Control and Prevention (CDC), “communities must scale up and train a large workforce and work collaboratively across public and private agencies to stop the transmission of COVID-19.” That was the goal of the Collaborative. Health experts pointed out early in the pandemic the importance for rapid response to control the spread, a fact that is under additional scrutiny now after evidence of the Trump administration’s effort to purposefully downplay the threat of COVID-19.
Characteristics of a Contact Tracer and Investigator
Provided by Kristy Dale, Region 10 Supervisor for Community Care of North Carolina
• Attention to detail
• Caring personality
• Good listener
• Self-directed worker
• Able to deescalate situations
• Stress management
CCNC launched its contact tracing program within a matter of weeks. While they were not previously working in tracing communicable diseases, they had close relationships with NCDHHS and primary care providers across the state. “The work we have done laying that infrastructure allowed us to move rather quickly,” says Christina Page, vice president for performance optimization at CCNC.
The project required a lot of new staff. There are currently over 1,500 full-time and part-time employees supporting contact tracing efforts at the local level across the state, including 846 from CCNC. Some of these individuals work as case investigators and others as contact tracers. “We support the counties where they are in that moment and that shifts and evolves,” says Page.
The Carolina Community Tracing Collaborative (CCTC) is based on supporting existing local health department efforts to meet potential spikes in cases, but each local department must request the program. Despite more than 56,000 positive cases in the Charlotte region, a joint reporting effort of the Charlotte Journalism Collaborative (CJC) uncovered only a handful of success stories tracking the origins of widespread COVID-19 infections since March.
Mecklenburg County Public Health Director Gibbie Harris told reporters that she was concerned the longtime epidemiology practice was not working. In an interview with the CJC’s Nate Morabito from WCNC-TV and David Boraks from WFAE 90.7, Harris said that case investigators are calling more than 800 people a day, but not getting “strict compliance.” The county has yet to request the support of CCNC, funded fully by the state, in their contact tracing efforts.
How it Works
The program is designed to connect positive cases quickly through partners in the CCTC. The county health department receives notification of a positive case and it is entered into an online system called NC-COVID. The case is then assigned to investigators who interview the positive patient and give appropriate isolation orders. According to CCNC Regional Supervisor Kristi Dale, these case investigators liaise with the local health department daily and help to track cases and outbreaks. The investigator enters information into a secure system that is comparative to other state health databases, like those that track HIV and STI infections.
The investigator also asks a series of questions to learn who individual patients have been in contact with. Where did you go in the last 10 days? Whom did you see? Did you visit with that person for more than 10 minutes?
Anyone who has been potentially exposed is entered into another database called CCTO, or the COVID-19 Community Team Outreach Tool. Case investigators continue to follow up with those who test positive, checking on their symptoms and additional contacts. Finally, contact tracers reach out to individuals, letting them know that they have been exposed to someone who has tested positive, recommending quarantine, monitoring and potential testing. Dale points out that contact tracers are reaching out to individuals every few days to check in and see if they need additional resources.
Dale and Page point out that the staff are also helping with basic needs. Many of the CCNC staff come from clinical or public health backgrounds. They are focused on building trust with the community and often provide resources on a wide range of food, hygiene and health needs. Dale says she applied for the position because, like many other self-professed “public health nerds,” she wanted to find a way to help people in the community.
Saving One Life
Staff at CCNC say they are still getting hang-ups and people are not always receptive to providing contact information, echoing Harris. “It’s a numbers game,” says Paul Mahoney, senior vice president of communications at CCNC. He points out that people do not always answer the phone when a contact tracer calls, but there are plenty of success stories where people are calling back and, in some cases, calling back multiple times. “At least then, we’ve let them know they’ve been exposed,” says Mahoney. “It’s their choice on whether they are going to comply with that. At the very least, maybe they are going to wear a mask if they wouldn’t have before. Maybe they are not going to be the one to bring grandma her cake that week, because they realize maybe they should stay away. I think we’re making a difference, even if it’s not enough to stand by itself.”
Terri Duncan, director of the Consolidated Health and Human Services for Bladen County points out the additional challenges that rural areas are facing. The Eastern North Carolina county is the fourth largest in the state by land area, but has a population of only 33,190.
“We were really struggling at the height,” says Duncan. In many rural areas, public health offices do not have a team of employees. It is often just one employee doing the work. “Every nurse here has done some contact tracing and answering of the hotline in the last six months.”
Even though they were struggling with capacity, Duncan was apprehensive of CCNC originally. She considers the residents her friends and family. “I want to treat them as such,” says Duncan. That community feeling was important to maintain. For Bladen County, CCNC staff had to become part of the local health department team, adopting their policies and spending time with them. Currently there are three case investigators and three contact tracers, including bilingual staff.
“We could not have maintained without the help of CCNC,” says Duncan now. Additional support from the program provided local health departments the ability to continue with other important work as well.
Contact tracing is not new, and the regular work of public health does not stop with a new pandemic. For years, public health officials have been using methods to trace HIV and STI infection, along with other communicable diseases. The needs of people who are HIV positive or for HIV/STI prevention still exists. Dale explains that part of their purpose has been providing some relief to health department staff.
Other challenges exist in rural areas. GPS does not always work and there are ongoing barriers to access care and for public health workers to meet people where they are. Programs like NCCARE360 are allowing officials to connect rural people to additional services they need to stay safe and quarantine when needed. The program is the first statewide coordinated care network to electronically connect those with identified needs to community resources.
There is still a stigma associated with COVID-19 as well. Duncan says a lack of understanding and hesitancy to share information hinders the work. She even had to fight back against some residents who wanted her to identify people who tested positive. “As early as March or April, you really should assume that everyone is positive,” says Duncan referring them to guidance from the U.S. Surgeon General.
These barriers all impact the lack of cooperation and that is making some health officials frustrated, but Duncan points out the importance of contact tracing in controlling the virus. “If we can reach at least one person and prevent one serious illness and one death, then yes, it is worth it,” says Duncan.
North Carolina currently has over 180,000 confirmed cases of COVID-19 and over 3,000 deaths. Bladen County only has 798 positive cases as of Sept. 11 compared to 26,781 in Mecklenburg County, but both counties have around 240 cases per 10,000 residents.
qnotes is part of six major media companies and other local institutions reporting on and engaging the community around the problems and solutions as they relate to the COVID-19 pandemic. It is a project of the Charlotte Journalism Collaborative, which is supported by the Local Media Project, an initiative launched by the Solutions Journalism Network with support from the Knight Foundation to strengthen and reinvigorate local media ecosystems. See all of our reporting at charlottejournalism.org.