A person who tests positive for COVID-19 sometimes gets the news directly from Dr. David Sweat.
It’s not supposed to work that way.
Sweat is the chief epidemiologist at the Shelby County Health Department, the lead investigator for a team of detectives who track down killers like the novel coronavirus.
The department’s infectious disease investigators don’t run tests for COVID-19. They don’t process tests. They’re not supposed to deliver test results.
Results should come first-hand from the doctor, the clinic, the hospital — the medical provider that conducted the actual test.
If Sweat or one of his investigators is delivering that news, there’s something wrong with the entire process. It’s not moving fast enough to catch the killer. And it’s not working well enough for Memphis to reopen for business.
Health officials like Sweat say they need more testing, faster and more consistent results, and more contact tracing to slow the COVID-19 surge, and stave off another one. Right now, none of those facets of local testing are working adequately.
Memphis has been slow to ramp up testing, averaging about 750 tests a day last week, according to numbers released by the health department. And when tests are given, results can take days. Last week, two local labs processing results had malfunctions, further exacerbating a bad situation.
“Sometimes we’re playing catch up and I’m making some contact calls,” Sweat said. “And sometimes, when I call, I’m the first person who tells them they’ve tested positive. It’s tough. They should already know.”
Tracking and arresting a highly infectious virus is never easy. Speed matters.
The sooner Sweat and his team get word that someone has tested positive, the better their chances of finding, isolating and monitoring close contacts who might be infected and unknowingly spreading the virus.
But the lightning speed at which the novel coronavirus moves and attacks has made testing, tracing, and targeting its path even more difficult and vital.
As the spread of the virus peaks and begins to recede, here and across the country, that sort of detective work will become even more important to control the disease and prevent more outbreaks.
Friday, the head of the Centers for Disease Control and Prevention said U.S. health departments will need an opens in a new windowarmy of contact tracers to track and contain the virus in the months ahead.
“We can’t afford to have multiple community outbreaks that then can spiral up into sustained community transmission,” Robert Redfield told NPR.
Also on Friday, Johns Hopkins University and state health departments issued a opens in a new windowreport that calls for $3.6 billion in emergency funding from Congress that would deploy 100,000 more contact tracers across the country.
Last week, the editor of a leading leading medical journal opens in a new windowproposed deploying 20,000 incoming medical students to support the “test, trace, track, and quarantine strategy.”
Medical students at the University of Tennessee Health Science Center have been supporting Tiger Lane testing here for several weeks.
“We’re so proud of our students, but our public health system needs a lot more help from a lot of other folks,” said Dr. Scott Strome, executive dean of the UTHSC College of Medicine.
“We need more test sites, more staff, and more timely test results to identify, call, test and isolate or quarantine those who are infected. We can’t go five to seven days before we do that. During that time, people are already out there infecting others.”
‘It’s all connected’
Strict social distancing has slowed but not stopped the spread of COVID-19 in Shelby County and across Tennessee.
Local and state health officials predict that a surge in cases is still several weeks ahead of us.
They also agree on steps that must be taken to stop the spread, relax social distancing rules, and stave off a second and potentially more deadly second wave in the months ahead.
More, faster and better testing, which should include rapid-results tests and blood tests for immunity.
More, faster and sustained contact tracing, which must include isolating and monitoring all who are infected.
More sophisticated high-tech methods, such as using cell phone data, to track the infected and target social distancing policies.
The shorter-term goal is to slow and stop the spread of the virus by depriving it of new victims, long enough to lessen its impact and prepare hospitals for the surge.
The longer-term goal is to be ready for when the virus comes back, to reinforce and mobilize the public health system to identify, quarantine and isolate infected people more quickly and effectively.
“Without a vaccine, which is at least a year away, you can’t stop an epidemic unless you identify people who are infected, trace their contacts, monitor and test them, and isolate ones that are positive,” said Dr. Manoj Jain, an infectious disease expert advising the Memphis-Shelby County COVID-19 Joint Task Force.
“It’s all connected. We’ve got to have testing sufficiently available for all symptomatic patients, and successful tracing and monitoring of all cases and their contacts. Social distancing is buying us some time to catch up to the virus, but the virus won’t wait.”
Jain, who lives and works in Memphis, is on the faculty at the Rollins School of Public Health at Emory University in Atlanta.
Friday, Jain and other faculty called on the U.S. government to enlist doctors and other health care providers in the “army” of new contact tracers.
“These providers would be trained, regulated and held to strict quality standards by the local/state health departments and CDC,” they wrote in a letter Friday to The New York Times.
‘Such a broken system’
A person who tests negative for COVID-19 can still show symptoms.
That’s one of the challenges facing health officials as they ramp up testing and tracing.
It’s also a challenge for a person who gets tested.
Tresha Mandel felt a tightness in her chest and had a little trouble breathing on March 23.
She tried to ignore it for a few days, but she’s 65, the average age for fatal COVID-19 deaths in Shelby County.
On April 1, she called her doctor’s office and described her symptoms. A nurse practitioner told her to get tested for COVID-19, just to be safe, and directed her to UTHSC’s online triage questionnaire.
On April 2, she filled out the screening form. “The computer robot said yes, I qualified for the test, and to await a phone call for my ticket number to go to the Tiger Lane testing site,” Mandel said.
Meanwhile, she sequestered herself in her Germantown home, where she lives with her husband, who works for St. Jude, and two sons, one in high school, the other in college. All are working from home.
Thursday passed, then Friday, then Saturday. No word on her appointment.
On Sunday, a friend told her that Methodist’s Germantown hospital was conducting drive-up testing, and she didn’t need a referral or appointment.
“So, at 4:30 Sunday afternoon, I drove there and got tested in about 10 minutes flat from my car,” Mandel said. “They tell me my results will be available in 24-48 hours.”
On Monday, April 6, UTHSC notified her that she had an appointment to get tested on Tuesday at Tiger Lane.
She waited for test results from Methodist. Monday passed, then Tuesday, then Wednesday.
On Thursday, April 9 — 96 hours after she’d been tested — she got her test results. It was negative.
“Even though your test is negative,” Methodist informed her, “you still need to continue to self-isolate for 14 days from the onset of your symptoms and for at least 3 days after you begin feeling well and have a normal temperature without the use of fever reducing medication.”
She cleared that bar waiting for her test results. But lately, she’s been reading about the increasing number of false negatives.
“How in the world can we possibly know our real numbers here with such a broken system?” Mandel asked.
‘It’s a tricky strategy’
Health officials say the system isn’t broken, but it is heavily burdened, and in danger of being stretched to the breaking point.
“It’s a tricky strategy,” said Jenny Bartlett-Prescott, chief operating officer of Church Health who is leading the task force’s testing subgroup.
“You’ve got to test more people to find the virus, and then you’ve got to trace more cases to track it and try to stop its spread. That’s going to take a lot more horsepower than what we have currently. How fast can we get where we need to be?”
Last week, the local COVID-19 task force, which includes the health department, doubled the number of community testing sites from three to six. They plan to add more in the next week or two, including “pop-up” mobile sites.
The goal is to test at least 1,000 symptomatic people every day. And local health officials believe they have the capacity to test up to 3,000 people a day and should.
Expanded testing will help Sweat and his team track and target the virus, now and in the months ahead.
It also will send hundreds of additional tests to labs every day.
National testing labs have been overwhelmed, causing delays of more than two weeks in local test results.
Local labs have had their own problems. UTHSC’s new lab and a local branch of American Esoteric Laboratories both had malfunctions this week that delayed test results for days.
“Inadequate testing in all forms — the inability to do it at all, the inability to get it back in a reasonable time – puts stress on those systems,” Dr. Stephen Threlkeld, infectious disease expert at Baptist Memorial Hospital-Memphis, told The Daily Memphian Friday.
The stress will only increase in the weeks ahead.
‘We’re flying blind’
While Tresha Mandel was waiting for her test results, her neighbor Suzanne Thomas started running a fever. She also had a dry cough.
Thomas had just completed a round of chemotherapy for cancer. Thursday afternoon, her doctor gave her a COVID-19 test just to be safe.
Thursday night, her white blood count dropped. Her doctor told her to go to Baptist’s emergency room.
She was admitted and and taken to a makeshift negative pressure room.
On the way to the room, she noticed the elevator’s walls were streaked with bleach.
She was escorted by a security guard who made sure she kept her distance from other patients.
Nurses who came into her room wore surgical masks over even safer N95 masks. They wore gowns over their scrubs and changed gloves twice each visit.
A doctor who came into her room was covered head to toe and wore a protective face shield over his N95.
“He looked like he’d just walked on the moon,” Thomas said. “I’m glad they were taking such precautions, but I didn’t know what was happening.”
She soon found out. Thomas had become a PUI — person under investigation for COVID-19.
More testing is sending more people to area hospitals. And more people in area hospitals are being tested.
Hospitals are testing many of their own employees. They’re testing patients before they’re sent to nursing home. They’re testing any patient with flu-like symptoms.
Those are necessary precaution that will reduce the chances of the disease spreading. They also compound the pressure on hospitals, testing labs and health department tracers.
On Friday, 65 people with positive COVID-19 test results were in hospitals across the city, 35 of them in intensive care units, and 19 on ventilators.
But as the opens in a new windowDaily Memphian reported, 278 additional patients — 85 of them in ICU — were in area hospitals awaiting COVID-19 test results or diagnosis.
“We have a lot of PUIs right now because testing results have been taking several days, so they can’t be classified as confirmed until those tests come back,” Dr. Jon McCullers, associate dean of UTHSC’s College of Medicine, told the Daily Memphian.
Even when the results do come back, some cases aren’t settled.
More than eight in 10 tests are coming back negative, but some doctors think as many as 30 percent of negatives results are false.
“There are a number of tests coming back negative, but (the patients) are clinically positive,” said Jain.
He’s had patients test negative even when their CT scans shows signs of pneumonia.
He’s had patients test negative twice before testing positive.
And he’s had patients who never tested positive even though they were hospitalized with symptoms.
Why so many false positives?
Maybe a nasal swab wasn’t inserted deep enough to detect the virus, or the virus wasn’t strong enough yet to be detected, or was somewhere else in the respiratory system.
Maybe the test samples were compromised in delivery to the labs or by delays in processing.
And it’s difficult to distinguish COVID-19 pneumonia from other viral pneumonia.
“This virus is so now that on some level we’re all flying blind,” Jain said.
‘Every hour counts’
Thomas’s test came back negative. Most do.
Of the more than 12,000 people who’ve been tested for COVID-19 in Shelby County, more than 11,000 were negative.
As of Sunday, the opens in a new windowcounty health department has confirmed 1,216 cases of COVID-19. They’ve completed 901 investigations, and identified 2,321 contacts connected to those cases. They’ve asked 728 of those contacts to quarantine themselves.
Those numbers reveal the challenges ahead for Sweat and his team.
The number of new cases of COVID-19 keeps rising. So do the demands on his staff to trace, assess and monitor those cases.
The county’s first COVID-19 case was reported on March 8. There were 2 that entire first week of the local outbreak. On April 1, there were 141.
New cases have averaged about 60 a day the past week. The health department reported 100 new cases on Friday and Saturday, but attributed the big increases to a backlog of test results.
More testing is putting a greater strain on the system’s ability to get test results fast enough to start the tracing process soon enough to be effective.
Some results are getting to the health department within hours of testing. Others have taken more than a week.
“Meanwhile, the infection is spreading,” Jain said.
Identifying, tracing, contacting and monitoring all potential COVID-19 cases is a labor-intensive and medically-guided process that requires hours and hours of an investigator’s time.
It begins with “patient zero,” the individual who tests positive for COVID-19.
The public health investigator interviews “patient zero” to find out where they’ve been, what they’ve touched, and who they’ve been within six feet of for at least 10 minutes from two days before they noticed symptoms.
That’s how the health department learned that the first two coronavirus cases in Shelby County were connected and had gone together to Mardi Gras in New Orleans in February.
In fact, the entire Tennessee epidemic could have been sparked by as few as 10 people, according to a opens in a new windowstudy published Friday by Vanderbilt University.
“Six weeks later we have 4,634 reported cases who have tested positive,” Vanderbilt reported. “The true number of cases is substantially higher because there are asymptomatic individuals as well as individuals who may be symptomatic who have not yet received a test or a test result.”
Recently, a local hospital tested all 200 of its transport workers. Only two were infected with the virus, but they’d had close contact with 35 other hospital workers. Six of those tested positive.
The sooner Sweat and his team get test results from labs, the sooner they can contact “patient zero” and start their investigation.
They talk to sick people and ask them to list all of their recent interactions with family, friends and others, starting from two days before they felt symptoms.
Then they must try to get in touch with all “close contacts” —all those who have been within 6 feet of “patient zero” for at least 10 minutes, going back two days before symptoms appeared.
The tracers explain and evaluate the risk of infection, ask those who might be infected to quarantine themselves and, if they have symptoms, to get tested.
The investigation team then turns the case over to the monitoring team. Their job is to check on the condition and isolation of each of contacts for up to two or three weeks.
The local health department has a team of about 70 investigators and monitors who have worked on more than 1,200 cases — or one for every 15 to 20 cases. The team is monitoring more than 700.
In the critical weeks ahead, local health departments will need one contact tracer for every four cases of COVID-19, Dr. Tom Frieden, former CDC director, told opens in a new windowThe Washington Post.
Strict social distancing has made the task a bit easier.
“With the first few cases, each person might have had dozens of contacts from work or public gatherings,” Sweat said. “But since social distancing kicked in, most cases have had very few contacts, mostly with people in their own homes.”
Local and national officials are looking for ways to make contact tracing more efficient and effective. That could allow officials to target social distancing restrictions on those who are infected.
This week, the University of Memphis will release an iPhone version of opens in a new windowmContain, a free app that will tell users when they were within 10 feet of an infected person or a crowded “hotspot.”
Friday, opens in a new windowApple and Google announced a joint effort to develop ways to use smartphones to aid in contact tracing.
City and county attorneys have raised privacy concerns about the apps. But the CDC’s Redfield told NPR such high-tech tracers “are under aggressive evaluation.”
Strict social distancing and expanded testing and tracing already are having a big impact in slowing the spread of the virus.
The opens in a new windowVanderbilt Study says Shelby County’s transmission rate has declined from more than 5 per infected person in mid-March to about 1.4 last week. To stop the virus from spreading, that number will have to go below 1.
“The curve is flattening but it’s not flat,” Sweat said. “Cases are still going up. We’re getting there but we’re not there yet. At some point, we’re going to have to reopen our city, reopen our society. In order for that to happen, we’re going to need a lot more testing and tracing, and we have to do all of that as fast as we can. Every hour counts.”
This story first appeared at dailymemphian.com under an exclusive use agreement with The Institute. Photos reprinted with permission of The Daily Memphian.