Cleveland-Area COVID-19 Contact Tracing Delayed By Missing Information

Dr. Amina Egwiekhor, a local physician who helps Cuyahoga County trace people who have COVID-19, picked up the phone recently to call someone who has tested positive.

Sunlight streamed through the windows on the warm, late-summer morning as she made a not-so-sunny call to a person about their test results.

“This is Dr. Egwiekhor from the Cuyahoga County Board of Health,” she said. “Are you aware of your test results for COVID?”

This is the same introduction she has used during her many calls to confirmed cases since the pandemic began back in March.

Egwiekhor and some 75 other contact tracers work at the Cuyahoga County Board of Health's office in Parma, but they have to rely on information sent to them from the numerous testing sites around the county and from the labs where the coronavirus samples are tested. That information chain, however, has often been slow.

While this particular person she spoke with tested positive for the virus in mid-July, Egwiekhor called her for the first time in mid-August.

That was the first time the board of health had enough information to contact the person, despite her testing positive nearly a month before, Egwiekhor said.

“Either it's because the system did not upload it, or … sometimes there's missing information, so it takes a while,” she said. “Sometimes … what we'll get is maybe a name, and then we have to reach back out and say, ‘OK, what's their address? Do you have a contact phone number, things like that.’”

Tracking and tracing the spread of COVID-19 in Cuyahoga County has been hindered by delays in test results from labs and incomplete information from testing locations, Egwiekhor said.

Contact tracing is the process used by health departments during infectious disease outbreaks to track who has been exposed to a person who has tested positive for the virus.

When a person tests positive for the coronavirus, the lab where they were tested reports the result to the local health department in an information packet submitted via fax, or through an electronic system. 

But those packets often don't include a vital piece of information: contact information for the person who tested positive. This makes it difficult for county contact tracers to immediately reach out to the person who tested positive, said Romona Brazile, who heads up the Cuyahoga County Board of Health’s contact tracing efforts.

“It may be missing a phone number, or maybe missing an address,” said Brazile. “We move forward as much as we can, even if something is missing, but that does definitely kind of hold up the process.”

These issues have occurred when tracking other communicable diseases as well, she said.

The problem with a disease as contagious as COVID-19, though, is that a person who came into contact with an infected individual could potentially be spreading the virus to others before the health department is able to reach them, she said.

 “Sometimes we have people who are tested and they kind of continue [coming into contact with others] until they get the positive result, and then there's additional people who've been exposed,” Brazile said.

The back-and-forth communication with the labs or testing sites holds up the contact tracing process even further, Egwiekhor said.

In this case, the infected individual and her family members, who also tested positive, had already been quarantining, she said.

“Because we're now kind of in the thick of it at this point, people know that if [they] have symptoms, [they] pretty much need to keep away from other people at this point in time,” she said. “A lot of the times when you do call people, even if it's a delayed call, they've already started isolating themselves and doing everything that they need to do to protect not only themselves, but their family members as well.”

Health officials have also encountered labs that were not reporting results to them, Brazile said, either because they were not set up with the electronic reporting system, or were not aware they needed to be.

“They may send those results by e-mails, or we may find out, ‘Hey, there's a lab that's doing this testing and they're not reporting,’ and so there's a literally test results that we're unaware of,” Brazile said. “Getting that lab to submit us the test results is part of our challenge.”

The health department in neighboring Medina County has also experienced contact tracing delays due to missing information from testing sites, said Health Commissioner Krista Wasowski.

Some testing locations were only collecting email addresses from individuals who were tested, she said. Officials can email the person asking them to call, but they would prefer to call or mail them directly, she said.

“The lag time in being able to contact someone does reduce the effectiveness of contact tracing, and the ability to quickly get in touch with someone who may have been exposed,” Wasowski said.

While a phone call is the preferred method of contact in Cuyahoga County as well, people may not answer, Egwiekhor said.

If neither a phone number nor address was provided by the testing site, there is not much the tracers can do until they get that information, she said.

Relying on paperwork has also contributed to the lags in contact tracing, Brazile said, and the board of health is transitioning to an electronic system, where officials will input information on computers, which will mitigate some of these issues.

Other local health departments nationwide have  called for the use of technology, such as apps, to speed up the contact tracing process.

Information Gaps Persist Even After Making Contact

Contact tracers will call three times in a span of about two days, and leave voicemails asking the person to call back if they do not answer, Egwiekhor said. If they still don’t hear from the person, the health department sends a letter instructing them to quarantine and call the department, she said.

Occasionally, individuals are hesitant to give contact tracers information, said Brazile. She worries this is due to the pandemic being a heated political topic for some people.

“Unfortunately, this has become very charged in the public,” she said.

In some cases, people have refused to provide any information, she said.

“People … don't believe in it, they think it’s a hoax, they hang up on us, they cuss at us,” Brazile said. “So, our contact tracers have had to absorb that in trying to do their job.

Health officials in Medina County have encountered hesitancy from individuals as well, which Wasowski attributes to people not wanting to inconvenience their friends or family members they have come into contact with.

They may also have a hard time recalling all of their interactions, she said.

“They don’t want to over-estimate who they may have been in contact with,” she said. “It is something that’s a little uncomfortable, and is a little taxing, especially if you’re not feeling well.”

“It’s a whole network”

The contact tracing process relies on many different entities – from the testing sites, to the health departments, to the infected people themselves – so officials in both Cuyahoga and Medina counties are asking individuals to prepare as much as they can on their own.

Individuals can do their part by giving as much information to COVID-19 testing sites as possible to mitigate information delays, Egwiekhor said.

 “Just making sure that when you are getting the test that you're giving all of the information that contact you if your test comes back positive,” she said. “It's a whole network. We’re all working together to kind of help with mitigating and preventing the spread.”

She also recommends isolating as soon as you start feeling symptoms.

Wasowski suggests taking note of every person you come into direct contact with, and keeping your social circles as small as possible.