In the coming weeks, Oklahoma plans to train hundreds of workers in so-called “shoe-leather epidemiology” – the practice of calling people who have been in contact with someone infected with the coronavirus in an effort to stop the spread of the deadly disease.

As the state reopens from lockdown,  health officials say more than 500 new temporary hires will soon supplement the 250 to 350 contract tracers now working throughout the state.

Contact tracing is a crucial part of the strategy to identify, test and isolate people to break the chain of transmission of COVID-19, the U.S. Centers for Disease Control and Prevention says.

State officials say they are confident their contact tracing staffing plan will allow them to scale up or down depending on the rise or fall in infections.

But even with these reinforcements, some experts say, Oklahoma and most other states are doing too little, and too late.

The state’s current staffing levels fall well below what is recommended by George Washington University researchers, who developed a model based on each state’s current number of cases and other metrics. Instead, Oklahoma should have at least 938 full-time contact tracers and nearly 100 supervisors, the model indicates.

Another organization recommends an even higher number. Even if 500 new hires join to bring the state’s tracing corps to 850, it will fall short of the 30 contract tracers per 100,000 residents recommended by the National Association of County and City Health Officials. In Oklahoma, that would mean 1,200 contact tracers.

Lori Tremmel Freeman, chief executive officer of the association, said many factors can determine how many contact tracers each community needs, but states should err on the side of caution.

“The (potential) consequences are that two or two-and-a-half weeks from now, you are going to see community spread back in the picture because you won’t have effectively contained the virus through contact tracing and quarantining,” she said.

Tracking the Numbers

The exact number of contract tracers in Oklahoma is hard to pinpoint.

Unlike with hospital beds, tests and cases, the state has not released the number of contract tracers or tracing investigations.

Aaron Wendelboe

Aaron Wendelboe, interim state epidemiologist, said the number of people conducting tracing investigations is between 250 and 350 – a level that fluctuates depending on caseloads and other factors.

Many contact tracers have been temporarily reassigned from their normal duties. They include staff from local offices of the Oklahoma State Department of Health, the University of Oklahoma, Oklahoma State University, the Oklahoma City-County Health Department, the Tulsa Health Department, the Oklahoma National Guard and the Southern Plains Tribal Health Board.

The state is partnering with Oklahoma City-based Express Employment Professionals to hire the 500 additional contact tracers. Wendelboe said the number could increase over time.

The staffing firm has advertised for full-time, part-time and weekend shifts that pay between $16 and $18 an hour.

“Honestly, we think we have more (contact tracers) than we need. We are going to be responsible with taxpayers’ dollars.”

Aaron Wendelboe, interim state epidemiologist

Rob Crissinger, a health department spokesman, said people who work or worked in the health industry, such as nurses, are “perfect for this job.” The state prefers workers who have at least a bachelor’s degree, but people with a high school diploma or the equivalent are also eligible.

Other qualifications include an ability to exhibit a professional, positive attitude; a strong work ethic, excellent interpersonal skills, the ability to interact professionally with culturally diverse individuals and the ability to show empathy to distressed individuals.

They must follow all required scripts, policies and procedures, including those for keeping personal information confidential. 

Wendelboe said the plan is to conduct training with this group over the next week or two so they can start making calls shortly afterward.

“We’ll definitely want some supervision there, but they’ll be certainly hitting the ground running,” he said.

The training includes an online course offered through the Association of State and Territorial Health Officials, followed by instruction through the state health department.

Wendelboe said he expects all 500 of the new tracers to begin shifts within the next few weeks. But how many will be needed as the summer approaches will depend on infection trends and other demands.

“It’s hard to know because this is still kind of a brand new thing,” he said.

If Oklahoma needs to scale up, finding more tracers shouldn’t be a problem, he said. There are many applicants as well as those seeking to volunteer.

Is It Enough?

Wendelboe disagrees with assessments that states like Oklahoma should have a minimum of close to 1,000 full-time contact tracers.

“Honestly, we think we have more than we need,” he said. “We are going to be responsible with taxpayers’ dollars.”

Candice Chen

Dr. Candice Chen, an associate professor at George Washington University’s Milken Institute School of Public Health, said each state has specific factors to consider when deciding how many contact tracers to bring on.

Because of this, she and her team created a contact tracing workforce estimator that takes into account state demographics, data from the CDC’s social vulnerability index and updated information on testing and active COVID-19 cases.

She said contact tracing is labor intensive, especially because of the need to follow up with cases frequently and help contacts connect with social services or other resources. The model assumes each contact tracer can start six investigations per day. It also assumes 12 contact notifications per day and 32 contact follow-ups per day.

“There is the acute need to ramp up (tracing), like yesterday.”

Dr. Candice Chen, associate professor, Milken Institute School of Public Health

The model estimates Oklahoma would need 632 contact tracers under normal conditions. But because of current cases, it would need 938 contact tracers and 94 supervisors.

Chen said the guidelines are intended to help states prepare for the future, when more communities reopen and social distancing policies are relaxed. More people will likely need to be notified about possible transmissions.

“There is the acute need to ramp up, like yesterday,” she said.

Time is critical, she said, because contact tracers have a short window to notify individuals of their possible exposure and instruct them to quarantine.

Wendelboe said during the initial weeks of the outbreak, the state was short-staffed and was forced to use an “abbreviated” contact tracing protocol to meet the demand. But he said the state is now in the position to be able to launch a full investigation on any new cases.

He said if cases start ballooning and additional contact tracers are needed, the state has means to bring them on board.

“I actually get offers every day of people offering us contact tracers,” he said. “So I’m just telling you we have the infrastructure to scale up if we need to.”

Easing Worries

But getting enough trained contact tracers and infrastructure to support them is only part of the equation.

Chen said quality candidates are needed to convince COVID-19 “cases,” as they’re called, to reveal what is normally private or personal information. Then they call their contacts, notify them of the risks and, if necessary, persuade them to quarantine.

“You want people who understand the community and understand the culture,” she said.  Then, with good training, they use interpersonal skills to gain trust, offer support and respect and convince contacts to stay home.

Wendelboe acknowledged the challenge may be greater in a state like Oklahoma, where many still see the government as “big brother.”

Resistance to contact tracing can be found on social media, such as in comments on Gov. Kevin Stitt’s Facebook page during his live-streamed press conferences.

“Hell NO no contacting,” one person wrote May 14 after state Secretary of Health and Mental Health Jerome Loughridge spoke about contact tracing last week.

Another person posted a warning to contract tracers, saying she has a six-foot fence, owns a  “pack” of dogs and shows a “No Trespassing” sign. The comment ended with a “good luck” and a middle-finger emoji.

Wendelboe said these types of concerns are unfounded, as contact tracers are told that state law prevents them from unauthorized disclosure of personal information, which is used only for public health purposes.

Unlike in some other areas or countries, Oklahoma has no current plans to use mobile apps to notify someone if they are close to a person who has been diagnosed with COVID-19. Some experts say such apps can be effective, but they also have raised privacy concerns.

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