Maricopa County public health officials aren’t conducting COVID-19 case investigations or contact tracing that meet federal guidelines, as cases in the county and state continue to rise and Arizona becomes a new national hotspot. 

The county’s efforts to track cases rely on text messaging rather than direct phone calls for positive individuals. Those who test positive and receive a text are then asked to fill out a form that asks them to recall anyone they were in contact with rather than the county conducting a live interview.

Only about 20% of case investigations are being completed through this process, officials confirm. Those who don’t fill out the form receive a phone call from an investigator to complete the investigation and identify contacts.

The pared-down process has drawn criticism from U.S. Rep. Greg Stanton, D-Ariz., who said it leaves people vulnerable. He questions why more federal money provided to the county for responding to the pandemic wasn’t committed to tracing efforts early on, before the major spike hit.

“The County squandered this precious time,” Stanton wrote. “It acted slowly and only ‘started’ to ‘gear up’ in early May — and for a level of staff that was far below what experts predicted would be necessary to safeguard a population the size of Maricopa County.”

County health officials, who now are dealing with one of the biggest case spikes in the U.S., said they are prioritizing older and high-risk individuals with direct contacts and making sure all positive cases are notified so they can begin alerting people they may have been around.

When a person in Maricopa County tests positive for COVID-19, they receive an automated text message from public health officials asking them to fill out a form.

“Maricopa County Public Health recently learned that a person with this phone number tested positive for COVID-19,” the text message reads. “Public Health will be calling you if you are at high risk for severe illness from COVID-19 or if you live/work in a high risk setting.”

Positive individuals, many of them sick with the disease, are asked to fill out a form that details their living situation, if they live or work in congregate settings, if they have symptoms, if they’ve been hospitalized, or if they have underlying conditions. 

They’re also asked to enter information for their close contacts, described on the form as anyone they have been within 6 feet of for longer than 10 minutes during the time they were contagious, which includes the two days before they developed any symptoms.

With this contact information, public health will then reach out to these close contacts and provide information.

“Please consider providing the names and phone numbers of your close contacts for this purpose only,” the form says.

Many positive cases in Maricopa County do not receive a phone call from public health workers. Neither do most close contacts of these positive cases. The county said it makes calls to only high-risk and older people who test positive. 

Only about 20% of positive cases actually fill out the texted form, the county confirmed Friday. 

“It’s much better than nothing, but I think that it’s far from ideal,” said Stephen Kissler, a postdoctoral research fellow at the Harvard T.H. Chan School of Public Health, of the county’s contact tracing method.

The way the county is operating isnot exactly how case investigations and contact tracing are supposed to work, according to guidelines from the U.S. Centers for Disease Control and Prevention and public health experts.

In a typical situation for an infectious disease, the positive case and all of their close contacts would receive phone calls from public health workers. The first phone call to a positive case can be lengthy, as they work through the places they’ve gone and the people they’ve seen. Contacts would be well aware that they had been around a positive case. 

Contact tracing is seen as a vital part of slowing the spread of the disease. If contacts of positive cases are informed quickly that they have been exposed, they can stay home and avoid spreading to others. In some Arizona counties, this traditional practice appears to be taking place.

Maricopa County intended to conduct fuller case investigations and contact tracing — county public health officials have said as much over the past few months. But their operation has not met CDC guidelines for full contact tracingfor months, even when the number of cases was much lower than it is now. 

County officials said they were prepared to investigate about 500 cases per day. But the last few weeks have often seen more than 1,000 or even 2,000 new cases per day in the county.

As of Friday, Maricopa County had 39,626 known cases, per state data. Identified cases have increased by about 300% since June 1. More than one-third of all the county’s cases have been reported in the last week.

The county’s investigations and contact tracing process drew a strong response from U.S. Rep. Greg Stanton, who wrote a scathing letter to the Maricopa County Board of Supervisors detailing the various ways the county’s practices are falling short.

“The situation is a disaster. It is costing lives. It is inexcusable,” Stanton wrote.

County spokesman Fields Moseley said in an email to The Arizona Republic that the board of supervisors “appreciates the congressman sharing his opinion about Public Health operations.”  

“Our Department of Public Health is dealing with the disease spread in real-time and making pragmatic decisions based on the ever-expanding body of knowledge about this new virus and the explosion of new local cases,” Moseley said.  

What CDC recommends for investigations and tracing

The CDC outlines how case investigations and contact tracing should work. In a case investigation, public health staff reach out to a patient to help them remember everyone they have been in close contact with. Public health workers would then start contact tracing by reaching out to these contacts who were exposed to the positive case.

This should be done “as rapidly and sensitively as possible,” the CDC says. Contacts are only told they have been exposed to a positive case, not who the case is.

Contacts should be given “education, information and support to understand their risk.” They should be informed on how to monitor for symptoms and encouraged to stay home and maintain social distancing for 14 days after exposure to the positive case, the CDC says.

“To the extent possible, public health staff should check in with contacts to make sure they are self-monitoring and have not developed symptoms,” the CDC says.

On a Maricopa County website where positive cases are directed, the county says people will receive a call “within a few days” of submitting the form to follow up on responses and get more information.

But the county confirmed Friday that only high-risk people and those over age 65 are currently receiving phone calls.

Details of what the county does now

When positive tests results come in to the county, every case is sent a text message from the public health department asking them to fill out a survey. Positive cases soon receive an automated phone call as well.

Everyone older than 65 is called directly by a public health investigator, according to Sonia Singh, county health department spokeswoman. Others only get the text message, she said.

Public health employees look over the surveys and if any cases are high-risk, such as people who live in a congregate setting, they are directly contacted by a case investigator, Singh said. The others do not get a phone call.  

The survey asks cases to list close contacts and their phone numbers. Those contacts are then contacted to enroll in the Sara Alert System, a public health app where individuals can monitor their symptoms and public health will be notified if they develop COVID-like symptoms.  

Cases and contacts are also given a phone number they can call if they need resources to self-isolate. 

“This process allow(s) for low risk individuals to be tracked in the system quickly and efficiently and allow Public Health to prioritize those who have the highest risk of severe disease and those who pose the most risk of spread to public health,” Singh said.  

Singh said the text message system was rolled out in late May and since more cases have been in younger age groups, they’ve been more responsive to texts than calls, she said. 

“Only very recently did we add an option for cases to opt out of a phone call and then began prioritizing high risk individuals for a follow up phone call,” Singh said. 

But, few people actually respond to the survey and provide public health the information it needs to map the disease and understand its spread.  

Singh said more than 20,000 people have received a text message with the survey. More than 35% of people open the questionnaire, and almost 20% complete it, Singh said. A case investigation via text and contact information is gathered for fewer than one in five cases.  

Singh added that in addition to the texting process, people who don’t complete the questionnaire receive a phone call from an investigator to complete the investigation and identify their close contacts. It’s not clear how quickly that call happens.

County planned to do more, but didn’t

Other than in the earliest weeks of the pandemic, Maricopa County has never been at the point of conducting case investigations and contact tracing to CDC standards.  

On April 23, when Arizona’s stay-at-home order was in place, Maricopa County assured the public it was ramping up its contact tracing efforts to be able to perform full traditional case investigations and contact tracing for every single positive case and their contacts. The county planned to call all those individuals.  

The county announced it would expand capacity by up to 10 times its then existing staff of 25 disease investigators. Officials said details were still in the works.  

Part of the point of the stay-at-home order was to buy time to expand capacity and prepare things like contact tracing so the public health system would be prepared for a potential surge of cases.

Maricopa County explained in late April that it had been performing “case-mediated contact tracing,” a less intensive form of the public health practice. Other than early on in the pandemic, when case numbers were relatively low, the county had not been calling each and every contact.  

Instead, public health workers interviewed each case and then asked the case to reach out to their contacts themselves and provide information on potential exposure and symptoms to watch for. Public health did not contact the case’s contacts, as traditional contact tracing requires.  

The county was scaling up employees so that it could return to “traditional contact tracing investigations,” Dr. Rebecca Sunenshine, medical director of disease control for the Maricopa County Department of Public Health, said at the time. Some funding for that would be from CARES Act dollars, she said. 

“Right now, what we want to do to have more complete surveillance of the disease in our community is we staff up, we put this plan in place and we will have more people so we go back to directly contacting every person who is a potential contact,” county spokesman Fields Moseley said in late April. “So more thorough contact tracing.” 

But that appears to never have happened. Instead, case numbers became overwhelming and the practice devolved further, so that many cases never even received that initial phone call from public health, not to mention any public health employees’ reaching out to the contacts.  

“Investigators are part public health, part detective and part social worker trying to establish rapport with this person that they’ve never met, and trust, and at the same time trying to cover as much information as possible without judgment,” Sunenshine said in late April. 

Sunenshine said in late April that interviews could take between one and three hours. But now, unless an individual is considered high-risk, interviews are by and large not taking place at all. 

Stanton: County has no thorough plan

The way the county has conducted contact tracing since late March violates core CDC principles for this process, Stanton wrote to the county supervisors Thursday.

“More troubling is that County public health officials have no plan to thoroughly contact trace all positive COVID-19 case, and do not yet know what it would take to put the nation’s fourth-largest county in a position to do so,” Stanton wrote.

Stanton questions why the county wasn’t prepared to properly trace more cases, how officials are using funding from the federal government and why the county hasn’t been forthcoming on its lack of preparedness.

The county was given $399 million from the federal government as part of the CARES Act to cover costs related to the pandemic. A press release from the county shows $175 million was set aside for “future needs.”

And $93 million went toward the response to the health emergency, with $25 million for testing, $15 million for “enhanced contact tracing and disease investigation,” $10 million for personal protective equipment and $5 million for long-term care facilities.

Other funds went to providing assistance to people and families, like rental programs and assisting people who are homeless. Some went to helping small businesses, while some also went to upgrades to spaces to make them safer, like handwashing stations.

Stanton said the county spent $15 million, less than 4% of what it received through CARES, on case investigations and contact tracing, while a bigger chunk of money, $25 million went to offset paid-time off for county employees

He shared estimates from health organizations that say the county should have more than 1,000 contact tracers, possibly as many as 8,500, in order to effectively do the job.

The Sara Alert system, he wrote, is helpful, and other public health agencies use it as a supplement to help patients and contacts track symptoms after they’ve already spoken to public health workers.

Marcy Flanagan, the county’s public health director, told Stanton’s office that she estimated the number of needed contact tracers based on an average of 200 cases per day during the stay-at-home order. 

Essentially, Stanton concluded, the county wasted time during the stay-at-home order by not adequately preparing for its response when cases would rise. Flanagan told Stanton’s office that the county started in early May, well into the stay-at-home order, to prepare for about 500 cases per day.

“This is an exceptional breach of the public trust,” the congressman said.

The county has said multiple times that it has a partnership with Arizona State University to assist with contact tracing. Flanagan told Stanton’s office that more than 200 volunteers were contact tracing for the county as part of that partnership, the letter says.

But, he wrote in the letter, ASU told his office they do not have a contact with the county as of Thursday, and ASU is not doing contact tracing.

On Thursday, ASU professor Megan Jehn, who is working on the partnership efforts with the county, told The Republicvia an emailed statement that the university is supporting the county with case investigations, but not contact tracing.

The university is also helping the county with a large serological survey effort and hotspot investigations, Jehn said. 

“We are in the process of standing up a large case investigation team (primarily global health, nursing and social work students) to provide surge support for the county. We anticipate that this will be a very large and sustained effort,” she said. 

ASU spokesman Joseph Caspermeyer said the university has been in “recent discussions” with the county public health department about supporting a variety of efforts, including case investigations, testing, social support services, modeling and hotspot investigations.

“We anticipate a very large and sustained effort,” he said. “Case investigations will begin on Monday, June 29; ramping up to the county’s requested volume of 700 case investigations each week by mid-September.”

Stanton called on the supervisors to put more money toward case investigation and contact tracing. He said the county must come up with an immediate plan to trace every case.

Why isn’t more being done? 

Flanagan defended the county’s current contact tracing system at a Wednesday press briefing.

She said in May, the county was able to contact 200 new cases each day, but with additional staff, that capacity rose to up to 500 new cases each day by June 10.  

But the county has often recorded 1,000 or 2,000 new cases in a day since then — surely exceeding that contact tracing capacity. 

Flanagan explained that except for the 5 to 7% of cases for which they never find contact information, the county makes contact with every single individual who tests positive. By and large, that’s through a text message and most individuals do not actually speak to a case investigator or public health employee.  

“We are reaching out to every single positive case that we have contact information for within 12 to 24 hours of us receiving that test result,” Flanagan said Wednesday.  

But the county is not “reaching out” in the traditional sense of a through case investigation and contact trace where a trained public health expert walks through all the details of a case and tells contacts all they need to know. Answering questions is an essential part of that, requiring a two-way conversation.  

Kissler, the Harvard professor, said it’s easier to change people’s behavior and share information when people are contacted individually by a tracer instead of just sent information. 

But, he acknowledged, what the county is doing may be all that’s possible at this time because tracing is so resource-intensive.

One of the hopes was that, with physical distancing, the numbers of cases would be brought down to more manageable levels for contact tracing, he said.  

“And we never really reached that point, unfortunately. So I think that we’re kind of left with some of these stop-gap solutions in terms of contact tracing,” Kissler said. 

Moseley said the text and automated phone call system was implemented to adapt to younger demographics. Contacts will soon also be getting a call and text.  

“Part of CDC best practices is automating and digitizing the tracing process to reach thousands of cases more efficiently and for the majority of cases, texting is their preferred method of communication,” Moseley said.  

“The investigation team is working seven days a week and must be sustained for at least the next year,” Moseley said. “It is important to train a team built for sustainability which is exactly the approach we are taking.” 

Reach reporter Rachel Leingang by email at [email protected] or by phone at 602-444-8157, or find her on Twitter and Facebook.

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