Lloyd Kimble is an investigator. He doesn’t solve crimes. He doesn’t shadow unfaithful spouses for divorce attorneys, audit taxpayers, or even dive to the bottom of seas in search of sunken treasure.
No, Kimble, a 55-year-old Navy veteran, is a detective of an entirely different sort, one most people never think about.
He investigates the spread of disease.
And if you live in Memphis or Shelby County and you catch COVID-19, you can expect a call from Kimble or one of his colleagues at the Health Department.
“Once we find out that a person has been infected, they have a positive test, our job is to do a couple of things. Number one, we have to notify them. So that’s a big deal. It’s scary,’’ says Kimble, the Health Department’s investigation supervisor for tuberculosis control who, like all other available hands, has been conscripted to help track the coronavirus outbreak in Shelby County.
“So, we have to try and be as considerate as possible of what they’re being told. And then we have to start to establish that trust. Because we’re going to have to interview each person at length. First interview I did took almost two hours.’’
What Kimble is describing is contact tracing, a public health investigative method that’s leaped into the American consciousness in recent weeks as the coronavirus pandemic spreads across the country. Its aim is to determine how, when and where each infected person caught COVID, then establish who, in turn, they might have passed it to through direct contact – all part of a massive effort to corral the infection, monitor it and, finally, eradicate its threat.
“It involves us being all in this together. And just understanding what the risk is,’’ says Kimble.
He realizes his questioning can seem intrusive, especially when a person suspected of possible infection is advised – ordered, really – to stay at home.
“One thing that they have to also understand is that there’s a reason why we’re asking you to stay home. You know, we don’t want you to infect people that you care about,” he said. “And what better way to make sure than the people in your world are not infected is if you know you’re at risk, is to exercise some personal responsibility. If the order is saying stay at home, if you know that you’ve been around somebody who’s infected, the right thing to do is to stay at home.’’
Contract tracing here does not involve GPS tracking or other intrusive high-tech measures used in some Asian and European countries to contain the coronavirus threat.
Nonetheless, officials say some restriction of our freedom of movement is necessary to defeat COVID.
“It really is about balancing our social and economic freedoms and our desire to be independent with thinking about others in addition to ourselves,’’ Shelby County Health Department Director Alisa Haushalter told reporters this week while discussing Stay At Home orders by County Mayor Lee Harris and other local mayors requiring citizens to stay in their residences unless engaged in “essential’’ services such as healthcare, law enforcement and food supply.
“And again, listening to stories from other countries where they’ve had mass deaths as a result, I think will lead us to to recognize that we all can take action that is not going to just help us individually and our families, but our community at large. It will be challenging. But I trust that as people rally together and we come together, we’re going to make a difference together.’’
How contact tracing works
Each contact tracing investigation starts with a positive coronavirus test.
When the Health Department is notified of that result, Kimble’s team goes into action.
One of nearly 25 frontline investigators will make a phone call to the infected person to conduct an initial interview.
“It is to get a picture of what your life looks like in a nutshell,’’ Kimble says.
But it’s much more than that. Subjects can expect a detailed exploration of their personal lives to help determine how they might have contracted the infection and who they could have passed it to through contact.
“We have to find out what is the date that they first started feeling symptomatic. When did they start coughing? When did their temperature rise, that sort of thing. And then we have to establish what’s called an infectious period based on that date that the symptoms started. So, if a person became symptomatic on Monday, we go back two days prior to that,’’ Kimble said.
“So, we have to ask a lot of questions that might seem a little routine, a little mundane, and very repetitive because we’re asking things like, where did you wake up this morning? Who were you with? Where did you have breakfast? Who were you with? Where did you have dinner? Who were you with? We have to go through their entire day to try to find out what kind of contacts we’re talking about.’’
By “entire day,’’ Kimble means a series of entire days: An inventory of each day including the two days before a subject began exhibiting symptoms to account for the incubation period.
Sometimes, people are hesitant to cooperate. Reasons vary. Some people are just more private than others. Some may have something to hide. For example, Kimble, who oversees three investigators who typically explore tuberculosis infections, has found that undocumented immigrants at times won’t cooperate for fear they might be arrested and deported.
“In general, there’s a big mistrust of any government association,’’ he says.
Building rapport is essential to get people talking.
“One of the main things is you have to put people at ease. You have to talk to them and you got to give them a reason to open up to you and share information.’’
When that doesn’t work, the team will do what’s called a re-interview: A second investigator will call a subject utilizing a fresh approach.
Investigators have more intensive tools at their disposal including an account with ClearChecks, an online background check program.
“Clear is a very effective tool in order to find out about a person’s life,’’ Kimble said. “You know, you can look up things like driver’s licenses, cars that are registered to that person, addresses, previous addresses, phone numbers, bankruptcy information, criminal record information, all kinds of things that we have at our disposal digitally. So, yeah, I mean, we have tools like that.’’
Establishing direct contacts
A central aim of the investigation is to determine an infected subject’s “direct contacts.” Essentially, that involves people with whom the subject has come in close contact with for a duration of 10 minutes or longer. That can include riding in a car together, eating together and other close activities.
“The contacts that he identifies or she identifies could be that person who is responsible for the transmission to the current patient. So, we’re concerned about that, but we’re also concerned about who else could get sick,’’ Kimble said.
Once those contacts are identified their names are turned over to the Health Department’s “Epi Team’’ or Epidemiology Team for monitoring. The Epi Team then phones these direct contacts every day for two weeks checking for symptoms of COVID.
Additionally, a letter known as a health directive is sent.
People caught up in a COVID investigation can receive one of three directives:
— A letter advising those diagnosed with COVID-19 they are “required to remain in isolation’’ for a minimum of seven days subject to “daily active public health monitoring.’’ Monitoring ends when a subject has had no fever (temperature over 100 degrees) for three consecutive days. Isolation involves not leaving home or receiving visitors.
— A person identified as a “household contact’’ to an infected person receives a letter requiring him or her “to remain quarantined at home for 14 days after the infected person is well.’’
— A person identified as a “non-household contact’’ is also required to remain at home for 14 days with daily monitoring.
“You’re almost ordering them: Hey, you must stay home,’’ Kimble said.
“… If they become symptomatic within that next 14 days then (they’re) going to get tested. And if that test is positive, they then become the patient. So it begins again.’’
Health Department spokeswoman Joan Carr said the agency is not using GPS tracking to ensure that infected and monitored individuals stay at home.
“That’s not being discussed here,’’ she said.
News accounts of contact tracing reveal much more stringent measures in some parts of the world. The New York Times reports that measures in South Korea, for example, include placing the infected in government isolation shelters and using phone location data and credit card data to trace prior movements. GPS monitoring is used to see if potentially exposed individuals leave home.
Italy, meantime, is using drones to surveil citizen movements, ABC News reports.
In an exchange at a news conference last week, Health Department director Haushalter said officials can use “GIS mapping to tell where people have been’’ but the eyebrow-raising statement wasn’t a reference to the type of methods used in some countries.
“Dr. Haushalter says that in that excerpt she was talking about using GIS mapping to map hotspots and look for common locations where cases had been to indicate a possible common source of exposure. The Health Department does not and has never used cell phone data to track people’s movements. That was not what she was referring to at all,’’ spokeswoman Carr said in an email.
Kimble says investigators are actively searching for those hotspots. They could tell the infection first arrived in Shelby County’s “more affluent areas’’ through citizens who’d traveled out of state or abroad but it’s harder right now to know the county’s hot spots for transmission, he said.
“We don’t know yet. See that’s an after the fact thing. You know, once you find out where it’s happening, then you can see where it’s been. And you can kind of get a guesstimate,’’ Kimble said. “But it’s when you’re in the middle of it, the data is so brand new, it’s so fresh… The numbers are increasing to the point where as time goes on, the tracking will become better and (we) can see the linkages.”