Disease investigators work to contain a spike in COVID-19 in Boulder County

A significant spike in COVID-19 cases sent Boulder County Public Health looking for reinforcements to help contain the spread. On June 10th, the county's graph started climbing in the wrong direction, with over 175 new cases in just over a week and more since.

BCPH has about 25 people on staff who do contact tracing, a critical step in shutting down an outbreak. That wasn't enough, so the health department reached out to the state for more investigators so they could reach all the positive cases within the critical 24 hour window of being diagnosed.

"The only way to stop the spread is to stop the people who have that disease from being in contact with more people," said Chana Goussetis, Public Information Officer for BCPH. "We have to work quickly, because people are out living their lives. We ask who they've been in contact with. It can be sometimes hundreds of people for one case depending on how social someone is."

The Colorado Department of Public Health and Environment, CDPHE, requires that all positive cases of COVID-19 are reported to county health departments. Case investigators call those people and begin a conversation about the disease and how to stop it from spreading.

"The goal is to try to understand how you got it, who you contacted, how it's affected you, and answer any questions you may have," said Boulder County Epidemiologist Carol Helwig, who oversees a team of case investigators.

Once the county is notified of a positive test for COVID-19, an investigator calls that person and asks for contact information for anyone they've recently been around for more than 10 minutes, within six feet, while they were infectious and two days before having symptoms. The investigator notifies those people so they can get tested and follow precautions for control, which may include quarantining for 14 days.

"It's a box-it-in approach," Helwig said. "We identify every case, every contact, test everyone, and implement the measures. We have enough testing. Capacity is there, absolutely. We didn't have that at the beginning."

Most people have cooperated with the contact tracing process, but some are leery. That's why case investigators stress that their personal information will be kept private. Goussetis said the name of the infected person is not revealed. "We just say you might have been exposed to a person who tested positive. We never share identifying details. It's natural for people to not want to share who they have been hanging out with or don't want to be very clear about where a party may have been. But we're not interested in what people are up to. We're interested in who they may have been in contact with."

Goussetis also said there is fear from some of the Spanish-speaking community "who naturally feel uncomfortable sharing their info with the government if they don't have residency. We're trying to get the message out that we are not contacting immigration. That is not relevant to us. We are only interested in health. Our investigators have to be really adept at helping people be relaxed, that they can trust us, pull out parts of the story that are really important, and can get to exposure points. It takes some skill. You have to be good with people and data."

Contact tracing is an important part of the investigation, but epidemiologists are also trying to learn more about how COVID-19 is spread and the characteristics of the disease. "Most of what we know is through this process," said Helwig. "What put someone at risk, what are symptoms, what underlying health conditions do they have and what outcomes do they have for the disease? The more we gain this information the more robust our understanding will be."

That information can then be translated into action. If there is transmission in a workplace, then guidance and protocols can be developed.

Disease investigation isn't anything new. It's how health experts learned about polio, measles and many other diseases. Boulder County Public Health already had a staff of epidemiologists and case investigators, but they had to quickly expand for the coronavirus pandemic. "We did more in the first few weeks [of the pandemic] than we do in a year," Helwig said.

The county got creative in adding staff, solving two problems. Many workers haven't been able to do their regular jobs because they involve face-to-face contact with the public, so the county shifted them to BCPH.

"We have an amazing team of people; people with a background in social work, skilled at motivational interviewing, staff who have worked in restaurant inspections, so they are very good at working with facilities, the public, implementing guidelines and communicating risk information," Helwig said. "Everyone is very empathetic, present and engaged and aware every time they're doing a call. And that commitment to wanting to serve the community, is definitely a trait of the team."

Colorado provides additional investigators when a county asks for help, as Boulder did for this outbreak. New technology is also in the works to make the process of disease investigation better and more efficient. The county is working on a program to automate texts to check in with people who have the disease, as long as they give permission.

There will soon be software to help different counties better communicate with one another. But, there are no plans to use mobile apps that track where individuals go, something that has been used in other countries. There are privacy concerns about using the technology in the United States.

New technology won't be ready to address the current spike in cases in Boulder County, which Helwig said is primarily due to people in their 20s who gathered in groups to socialize. They have reported symptoms like loss of taste and smell and a mild cough. And while they may not be having serious symptoms, they can spread it to others who are older or are more susceptible to having a severe case, or dying.

That's alarming to health officials and the governor, who called out the behavior that led to the Boulder County spike in his news conference last week when the number of new cases climbed over 100.

"Many of those students also have jobs. They work in retail, work in restaurants," Polis said. "Those precautions that people are taking are so critical at preventing those 108 students from spreading to thousands of Boulder residents."

Polis and health professionals urge those infected, and the rest of the community, to stay vigilant; to wear a mask in public, to keep six feet away from others, to wash hands, to stay home as much as possible, to keep groups to 10 or fewer people and to isolate or quarantine if infected or exposed. Polis said there are a lot of reasons to care, whether it's your own life, the life of your loved ones, the new freedoms we're enjoying, and Colorado's economic recovery.

"It comes down to personal responsibility," said Goussetis. She said BCPH is getting a lot of complaints about people who are not following the rules. Enforcement, so far, has been focused on education, but the county does have the authority to fine people or even put them in jail for breaking public health ordinances. "We can't be everywhere and can't control individual activities. It's up to all of us to do as much as we can by following instructions," she said.

Contact tracing is a vital part of preventing more extreme measures like another lockdown.

"We are very concerned that many residents feel we are out of the woods," said Goussetis, who urged Boulder County residents to be extra cautious. "We are not out of the woods by far. We will be dealing with the virus for at least a year. It's a bummer. I get it. It's not what any of us wants to be doing. I just want folks to hunker down right now until we can get it under control."