Last week, as coronavirus infected a growing number of Oregonians for the fourth week in a row, the Oregon Health Authority shared reassuring news from a survey of county health departments statewide.
Oregon’s counties, OHA said, had trained a workforce of about 500 case investigators and contact tracers ready to support people who test positive for COVID-19 and track down others they might have infected.
In combination with a team of about 100 people the Oregon Health Authority has got trained and ready to deploy to outbreaks, that put the state on track to meet its target of 600 dedicated public health workers to manage COVID-19 cases.
“We’ve almost quadrupled the number of staff, statewide, that are doing contact tracing. That’s really a huge increase over our baseline, and shows counties and local health authorities have stepped up,” said Dr. Tom Jeanne, deputy state epidemiologist.
Oregon has made considerable progress. Yet a review of the data and follow up with nine of the state’s largest counties suggest that the count of 500 county contact tracers may be inflated — and that it masks serious regional gaps in preparedness.
Oregon’s highly decentralized public health system gives counties wide latitude over funding and management of public health services.
Ten counties account for most of the reported 500 contact tracing and case investigation staff in Oregon: Washington, Multnomah, Lane, Jackson, Lincoln, Marion, Clackamas, Polk, Benton and Hood River. All but Clackamas County provided OPB with some additional description of their workforce.
Conversations with public health officials and a review of the state’s survey data suggest many departments are short staffed and straining to meet the demands of responding to COVID-19.
Some counties are relying heavily — or entirely — on their existing public health department staff who have been reassigned to work on COVID cases part time, at the expense of their other public health responsibilities.
The three counties that make up the Portland metro area — Multnomah, Clackamas, and Washington — still have fewer investigators and contact tracers than the state’s goal of 15 per 100,000 residents.
Statewide, six counties — including Deschutes — reported not having any Spanish-speaking contact tracers, even though the virus has disproportionately hit Hispanic and Latino communities across the state, accounting for about 1 in 3 confirmed cases.
Some counties OPB contacted gave blunt assessments of their own staffing limits.
“We have 11 contact tracers,” wrote Mike Matthews, a supervisor with Hood River County Environmental Health. “No one is doing this full time, all have other duties, and we have not hired any new staff.”
Case investigation and contact tracing
In the absence of a vaccine for COVID-19, case investigation, contact tracing and quarantine are the key strategies for limiting transmission of the virus.
Case investigators contact and interview each person who tests positive for COVID-19 and make a list of anyone the infected person was in face to face contact with recently. Contact tracers get in touch with those contacts, ask them to self-quarantine, and follow up daily to find out if they have developed symptoms.
It’s time- and staff-intensive work.
Based on national guidelines for COVID surveillance, the Oregon Health Authority set a target of deploying 15 case investigators and contact tracers per 100,000 people.
“Based on Oregon’s population, we estimate we need 600 more team members to support active surveillance. This is because contact tracing involves daily one-on-one interaction between team members and Oregonians in isolation and quarantine,” the Oregon Health Authority wrote in an April 30 memo, Oregon’s Plan to Stop the Spread of COVID-19, published as part of the state's reopening plan.
Oregon Gov. Kate Brown included contact tracing as one of her six requirements for counties seeking to re-open their economies.
To meet the governor's criteria, counties needed to show that they had 15 contact tracers per 100,000 residents, or a plan for how to staff up. And they needed tracers with the language and cultural skills to serve all county residents, not just white English-speakers.
To date, Brown has approved requests from all 36 counties to move to Phase 1 reopening, and 32 counties have been allowed to progress to Phase 2.
Counties in Phase 2 allow gatherings of up to 50 people indoors. Bars and restaurants can remain open until midnight.
The Oregon Health Authority has certified each county as ‘having met” its contact tracing requirements.
But it’s still not clear how many counties are meeting the target the state set for adequate case investigation and tracing: 15 full-time workers per 100,000 residents.
For example, the Oregon Health Authority reports on its website that Jackson County has 39 contact tracers “on call,” well over the 33 required to serve the southern Oregon county’s 200,000 residents.
Those numbers don’t tell the full story, said Jackson Baures, public health division manager for Jackson County. The 39 contact tracers the state published in its tally for his county are the entire staff of his public health department, including himself.
“We sent everyone through a very basic training. They’re not on call. They’re working for health and human services in other jobs,” Baures said.
Baures said he tried to explain his staffing limits in his survey answer, and records show the state recorded Jackson County’s total as zero — with 39 on call.
According to Baures, his county has received funding from the state for COVID tracking work, but the county has been unable to recruit, hire and train people.
Using existing employees seemed like the fastest way to make sure the county had the capacity the state required for re-opening.
“In the event that we had a large outbreak, we could reassign people very quickly,” he said.
Benton County and Hood River County officials also told OPB that they have not hired anyone new.
“We need money to be able to build our capacity locally,” a Hood River county staffer wrote in response to one of the state’s survey questions.
The Lake County staff person filling out the state’s survey included a request for more people in the event of an outbreak.
“All of our staff has other programs we are continuing to offer in our community,” they wrote. “It is very challenging to be spread so thin.”
Coos County, which didn’t answer the state’s COVID survey, included a detailed description of its case investigation and contact tracing team in its May 8 application to reopen — and made it clear that other critical services were at risk of getting cut so the county could respond to COVID-19.
The county’s proposed COVID-19 team includes a staffer taken from a women and children’s nutrition program, known as WIC, and two home visit nurses.
“Home visiting nurses are providing this service at the expense of serving their assigned caseloads and generating billable hours,” the document notes. “A long-term solution will be needed to allow these nurses to return to this work and to ensure continuity of care for these children/families.”
Coos County borders Lincoln County, where a major COVID-19 outbreak has crippled the local economy and infected an estimated 3 percent of the total population.
With so many counties relying on reassigned and part-time staff, it’s unclear whether the state’s assertion that there are 500 people available to work full time on COVID case investigation and tracking is accurate.
Jeanne, the deputy state epidemiologist, said the state has made $11 million dollars of federal COVID-19 relief funding available to most Oregon counties to support investigation and tracing of cases.
He said it is appropriate for some counties to rely on on-call or part time workers, given how much COVID-19 case counts can fluctuate day to day.
And he pointed to a key metric that the state tracks to assess its COVID-surveillance effort: how long it takes public health workers to start the process of notifying someone they have tested positive for COVID-19.
“Our system has been generally keeping pace with rising case counts, with a few exceptions,” Jeanne said. “We can track that by looking at the percentage of contacts which are attempted within 24 hours, which has stayed in the range we like, above 90% statewide.”
That statistic masks significant differences in how quickly counties are responding to new cases. In Lincoln County and Union County — two places with significant ongoing outbreaks — public health workers are only reaching out to people who’ve tested positive for COVID within 24 hours about 50% of the time.
Jeanne is concerned that the demands of responding to COVID-19 mean work on other important issues, like chronic diseases and substance abuse, has been put on pause.
“This is an unprecedented global pandemic that is really stressing the already underfunded public health infrastructure in the United States, that’s certainly true in Oregon,” Jeanne said.
The situation in the Portland metro area
By contrast, the three counties that make up the Portland metropolitan area are all in the process of hiring and training a new workforce dedicated to tracking COVID cases, in addition to reassigning some of their existing public health staff.
Multnomah County, the last in the state to reopen its economy, said it received 1,500 applications for 30 new coronavirus-related public health positions posted in May.
Washington County, which had the state’s first confirmed COVID-19 case, has the state’s largest contact tracing system, with 68 full-time employees and tracers who speak English, Spanish, Chinese, Somali and Vietnamese.
Even with those new hires, the three metro-area counties remain below the 15 person per 100,000 resident ratio the state set as a reopening benchmark.
“The state later informed us that, rather than have those employees in place, we needed to show we have the capacity to both handle the current number of cases and also to ramp up quickly should our cases suddenly spike,” said Kate Willson, a language outreach coordinator with Multnomah County.
Jeanne said the governor’s office was willing to allow counties to reopen before they had met the target number of contact tracers because COVID case counts remained low in many places.
“If they were below 15 per 100,000, but appeared to be more than adequately staffed to handle their current and near future cases, that would go into the decision,” he said.
Mary Sawyers, communications coordinator for Washington County Public Health, said it doesn’t make sense to evaluate a county’s preparedness solely based on how many contact tracers and case investigators it has.
Washington County’s teams working on COVID-19 also include nurses, epidemiologists and support service staff who help problem solve for people in isolation, providing groceries and other essentials: 107 people in total.
Sawyers said the county is still looking to hire more epidemiologists, to link cases together and to identify clusters and outbreaks. In the tri-county Portland area, 41 percent of COVID-19 cases haven’t been linked to a known source.
Multnomah and Washington county representatives said they’ve able to keep up with their COVID-19 caseloads so far. Both counties said connecting people with the right social services so that they can stay home for 14 days is the bigger public health challenge.
“When you ask somebody who doesn’t have any symptoms to stay home for up to 14 days, that’s a really hard thing to do,” Sawyers said.
In 6 counties, no Spanish speakers on staff
The governor’s reopening guidelines also spell out that each county’s contact tracing workforce should reflect the local community, and be able to speak multiple languages “as appropriate for the population.”
In Oregon, COVID-19 has had a disproportionate impact on the Hispanic population, which has been well documented. Hispanic people make up about 13% of Oregon's residents, but account for 30% of people infected with COVID-19.
Other racial and ethnic groups and specific communities of immigrants have also been at much higher risk during the first wave of the virus, including Pacific Islanders.
The Oregon Health Authority originally envisioned hiring a large, new workforce to conduct contact tracing, in part, because of the urgent need to reach diverse populations.
That's spelled out in the state's equity action plan for COVID-19.
“New staff will be needed to conduct the steps of active surveillance,” the document reads. “This new public health workforce must reflect Oregon’s diverse communities and include staff with lived experience as well as individuals with fluency in the top languages other than English spoken in Oregon.”
Furthermore, hiring new public health workers could provide relief to some of the same ethnic communities hit hardest by layoffs during the shutdown, according to the equity plan.
Yet six counties — Columbia, Grant, Harney, Douglas, Deschutes and Wheeler — reported having only English-speaking contact tracers. All six have been approved for Phase 2 of reopening their economies.
Of those counties, Deschutes is the most populous, with 200,000 residents, 7% of whom speak a language other than English at home.
"Until June, all of our contact-tracing work that involved Spanish speakers was handled by a full-time Spanish-speaking nurse. Unfortunately, that employee resigned in June," said Whitney Hale, Deschutes County's communications director.
According to Hale, the county is actively recruiting bilingual applicants for the position. In the meantime, it is using a language line and other fill-in people for interpretation.
The Latino Community Association has applied for state funding to assist the county with wrap around services and contact tracing, and the county wrote a letter in support of the application.
Jeanne acknowledged that some counties lack Spanish-speaking investigators and tracers.
On its website, OHA rates the contact tracing systems in all 36 of Oregon's counties as "on track."
Asked why Deschutes County and others are considered “on track” even though they lack Spanish contact tracers, he answered: “Statewide, we are on track. Does that mean that all counties are exactly where we would like them to be or where they would like to be? No, I think there's still work to do. I can't speak to a specific county and what they've done in terms of the linguistic and cultural responsiveness."
Oregon's nascent system for tracking and containing COVID-19 remains relatively untested. The state has one of the lowest rates of COVID-19 infection in the nation. But a test may be coming.
Over the past month, the count of COVID-19 cases has risen at what the governor has called an alarming rate.
Starting this week, Brown made face masks mandatory in indoor public spaces across the state. She implored people to stay at home over the July Fourth holiday, and warned that without further action from individual Oregonians, hospitals could be overwhelmed by new cases "within weeks."
Jeanne said he believes the statewide contact tracing network is enough to manage Oregon’s current COVID-19 caseload.
But he also acknowledged that if case counts continue to rise, he’s uncertain.
“It is a highly dynamic situation,” Jeanne said. “We’re continually, on a daily basis, re-evaluating our needs and our strategies to make sure that case investigation, contact tracing are happening at a very high level, because that’s really one of the most high yield interventions we can do, to slow the spread of COVID-19.