After months of intense criticism about the size of the health department’s contact tracing team and its ability to keep up with the surge in COVID-19 cases on Oahu, records show the state is struggling to contact everyone with the virus.

Workers couldn’t reach four out of 10 people who tested positive for the virus in the first two weeks of September, according to data provided by the Hawaii Department of Health. Last weekend alone, a quarter of case files had an invalid phone number.

Despite challenges contacting people, Emily Roberson — the new chief of the department’s Disease Investigation Branch — says the department has made considerable strides in work efficiency.

Hawaii Army National Guard member walks down newly place computer work stations on August 19, 2020 at the Hawaii Convention Center. August 19, 2020
The Hawaii Army National Guard is helping the state conduct COVID-19 contact tracing at office space at the Hawaii Convention Center. Cory Lum/Civil Beat/2020

When Roberson took the reins to lead the state’s contact tracing team in July, she reassigned administrative tasks to free up senior disease investigators to focus on case investigation. Workers that had been recruited from the National Guard and a University of Hawaii training program were assigned other contact tracing duties, such as data entry or making initial calls to people who have tested positive for COVID-19.

The team still deals with antiquated technology, but they had a change of scenery at the Hawaii Convention Center — a spacious upgrade compared to former health department offices.

Since making those adjustments, the workload has been manageable, she said.

“We’ve adjusted procedures so dramatically that we’re able to manage for the most part right now,” she said. “When we talk about scaling up and scaling down in response to the case counts, it’s not just about staffing; it’s also about work tasks.”

Leadership Changes

Until recently, health department officials have not been forthcoming about the agency’s ability to successfully keep up with cases. The disease has sickened more than 12,000 people in the islands since March.

As of Monday, there were about 300 people working on contact tracing and COVID-19 case investigations across the state. Department of Health

The department insisted for months that it had the staff it needed to contact everyone with the virus. It wasn’t until a whistleblower came forward in August that the agency’s challenges with overwhelmed staff and unsustainable workloads came to light.

Roberson’s appointment was announced by Gov. David Ige with fanfare. But she quickly ran into problems — asking to go on leave because there was a lack of clarity about to whom she was supposed to report.  Since returning, Roberson said there have been major changes for the existing team and new hires.

Roberson oversees a cohort of disease detectives whose mission is to identify and isolate people who have had close contact with someone infected with the coronavirus.

There were approximately 300 people involved with case investigation and contact tracing as of Monday, 206 of whom were on Oahu, 40 in Hawaii County, 52 on Maui and two on Kauai. Those include volunteers. That’s up from 126 people in mid-August.

Roberson said she is looking to fill 30 full-time job positions that entail data, clerical, and contact monitoring roles.

To date, only 50 of the more than 400 graduates of a University of Hawaii training program that the health department funded and co-designed have been hired.

Lt. Gov. Josh Green, the state’s COVID-19 medical liaison, who has openly criticized the contact tracing program in the past, said there’s been a palpable philosophical shift at the health department in terms of contact tracing, and Roberson has welcomed more volunteer help.

“That’s a big change for everyone who tried to come and offer help as a volunteer or as professionals who were turned away,” he said.

Problems Reaching People

The department is struggling to reach everyone who is diagnosed with the virus, but not for a lack of trying.

Some phone numbers listed on electronic lab reports are wrong and some are missing entirely.

Other people never call back. In some cases, Roberson says people call the department back once they’ve already completed their time in isolation.

About one in six people called during the first two weeks of September did not respond, including a handful who refused to participate. Another one in six didn’t have a number listed at all.

That can seriously hinder the team’s ability to find people who were exposed and need to be isolated.

“We can’t get a list of their contacts from them if they won’t pick up the phone,” she said.

Roberson stressed that these realities are part of why contact tracing alone cannot be relied on to contain a highly infectious respiratory disease.

“People shouldn’t think that even the most perfect contact tracing will be panacea. It’s not in itself the intervention,” she said. “We can call every person in Hawaii and have all their close contacts but we still need people to socially distance, wear masks and wash their hands.”

The health department’s contact tracers and investigators were only able to reach about 60% of people who tested positive during the first two weeks of September. During the peak of a case surge in August, the team wasn’t able to call everyone, according to Disease Investigation Branch Chief Emily Roberson. Department of Health

While the department struggles to reach people without phone numbers, some people with numbers listed said they’ve never received a call at all.

Melissa Peneyra, 40, never heard from the health department after testing positive for COVID-19 on Aug. 14. She was among 284 people diagnosed that day.

She decided to call her contacts on her own.

“I was like, should I wait for someone to contact me?” she said. “I didn’t feel like death yet but I knew it was coming so I thought, ‘Let me do it now.’”

She called a friend with whom she recently had lunch, the manager of her gym, and her dentist.

Roberson said the department wasn’t able to make initial calls to everyone in July and early August, when case numbers surged quickly and the team focused on contacting the highest priority cases. But as of September, that doesn’t happen anymore, she said.

“We call everyone we have a number for,” she said.

Focusing On High-Risk Groups

When people test positive for COVID-19, the Department of Health receives a notice from their doctor or laboratory.

Contact tracers make the initial call to people diagnosed with the virus. Then experienced disease investigators interview the person to learn more about their possible infection history and to ensure they’re isolated while contagious. Meanwhile, other contact tracing staff work to locate and monitor everyone the patient was in touch with and call them daily to ask if they have developed symptoms.

The Disease Investigation Branch is taking a new approach by flagging cases in vulnerable populations and dividing them among newly created teams dedicated to monitoring infections in certain high-risk groups or settings.

As a result, the department’s response can be “fast and very tailored,” Roberson said.

“The creation of these teams is a reflection of what we learned early on,” she said. “Now we know that there’s something special about these occupations or risk groups that require special actions.”

Department of Health Investigations branch chief Emily Roberson on August 19, 2020
Department of Health Disease Investigations Branch Chief Emily Roberson took the reins of the state’s contact tracing team in mid-July and said she shifted work tasks to make the process more efficient. Cory Lum/Civil Beat/2020

One team is dedicated to infections in health care settings, such as hospitals or long term care facilities; another team is monitoring infections in schools. There’s a team dedicated to gyms, spas and salons, and other teams dedicated to COVID-19 cases in correctional and detention facilities, food services, public housing, and Hawaii’s homeless.

Roberson also created a separate team to focus solely on making the initial calls to people who test positive for the COVID-19 virus, addressing what she said was a major bottleneck in the department’s prior workflow.

This restructuring freed up staff time and ensured that the state is able to call everyone who tests positive for the virus — and if they can’t reach them, call back at least three times a day for three days.

The previous process was to call each positive case at least once within a day. The department would not provide data about performance metrics during the past six months, so it is difficult to discern how the team’s abilities have changed. The two weeks of performance metrics provide just a snapshot.

Reaching more than half of people who test positive for COVID-19 in Hawaii could be enough to keep tabs on the virus, but the cooperation of their contacts is important.

An August study published in the journal Nature found that if health officials can identify at least half of symptomatic people and trace 40% of their contacts, it may be enough to avoid overwhelming hospitals and allow some economic activity to resume.

Not Enough Data

Hawaii is not alone in dealing with contact tracing related issues such as public compliance. But other places have been more transparent than Hawaii when it comes to publishing information about how many cases and contacts are successfully reached and interviewed.

Washington, D.C., publishes details about how many new cases arise from people in quarantine — a figure that helps to signal how well the system is keeping tabs on disease transmission.

The Hawaii Department of Health still has not provided many details about its efforts, such as how many people they got contact lists from — and of those contacts, how many people they interviewed.

The University of Hawaii’s contact tracing training program used actors to simulate interactions that tracers may have as they call COVID-19 patients. University of Hawaii/2020

It’s also not on public record how timely their interviews are. Interviewing people quickly is critical to controlling the disease, according to Marc Lipsitch, a professor of epidemiology and director of the Center for Communicable Disease Dynamics at the Harvard T.H. Chan School of Public Health.

If health officials reach 50% of people diagnosed with COVID-19 promptly — and get to at least half of those people’s contacts within a day, that could make a significant dent in transmission, Lipsitch said.

“You can’t clean up an oil spill with paper towels but you can clean up a small spill in the kitchen,” he said. “A good contact tracing department is like that.”

Going forward, Roberson said the Disease Investigation Branch will collect more information about its success rate in reaching patients and the team’s performance.

“My strategy to earn back that trust is to try and be as open, transparent and honest as possible with the public,” she said. “I can share what we want to do, what we’re trying to do, how it’s going and what we’re learning.”

Civil Beat Reporter Brittany Lyte contributed to this article.

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