Around the world and across the nation, the race is on to limit the spread of COVID-19. In northern Nevada, when a person tests positive for the virus, a team of dedicated individuals known as contact tracers are running that race each day – a combination sprint, relay and marathon.
They’re employees of the Nevada Public Health Training Center, a program of the University’s School of Community Health Sciences. For the contact tracers and their colleagues, this is far more than just a job – it’s a personal mission with meaning and a lot of heart.
“I didn’t expect this to be so emotional,” Cynthia Cabrales, a member of the center’s contact tracing team, said. “I did not think it was going to be like this, that I would be this invested into it. And honestly, emotionally it is a strain sometimes, but I think at the end of the day, it’s good. It feels like I’m doing something good, I’m helping people, I’m educating, and even if there is that emotional burden, it feels like it’s worth it.”
As the coronavirus spread in northern Nevada this past spring, the Nevada Public Health Training Center was well positioned to ramp up its efforts to hire, train and deploy contact tracers to address the urgent needs of the community. The center has grown significantly in the past six years from a single program and a single employee to dozens of active programs and upwards of 150 employees.
“The contract tracing training and implementation programs were established at a time when we had earned the trust of our public health partners, coupled with the ability to be flexible and innovative to respond to their emerging needs,” Gerold Dermid, the center’s director, said. “We have such an inspirational and diverse team of employees that are responding through contact tracing, running a call center, providing point-of-operations support, and analyzing data, all to meet the immediate needs of our community.”
The current crisis has shone a spotlight on the center’s work with community partners such as Washoe County District Health. “This partnership exemplifies the center’s long-term plan of establishing academic health districts with the state and local health jurisdictions to have a more coordinated approach to improving the health of our communities,” he said.
Contact tracing: how it works
With the objective of quickly acting to limit the risk of exposing others to COVID-19, contact tracing is the practice communicating with those who have tested positive for the virus, and then reaching out to those with whom that person has come in contact.
“I know that the work that we’re doing is important. I know that because I receive amazing feedback from so many of the cases that we call – ‘Thank you!’ … ‘Wow, I’m so happy to have guidance’ … ‘It’s just nice to just talk to somebody about this.”
Under the umbrella term of “contact tracers,” there are two distinct roles. The Nevada Public Health Training Center’s “disease investigators” focus on contacting all individuals who have tested positive for COVID-19, which they refer to as “the case.”
Those calls then produce a list of people with whom that case has had recent, significant contact. That list of “contacts” is turned over to a different group of “contact tracers” hired by the state, separate from the University. Their job is to alert those they call about the potential exposure, and to advise them to follow current COVID precautions, including isolating and watching for symptoms.
Meanwhile, the Nevada Public Health Training Center’s disease investigators stay on their cases.
The process starts when an individual is tested for COVID-19, perhaps because they have symptoms, are required by their employer, or have been exposed to a person known to have contracted the virus. Contact information is collected at the time of the test.
In northern Nevada, if the test is negative, Washoe County District Health calls that person and sends a letter with the good news.
If the test comes back positive, Washoe County calls and sends a letter with that outcome, followed by a call with more information from a disease investigator as required by law. Those called are advised to follow Nevada’s current state and local COVID requirements for isolation (following a potential exposure) and quarantining (for those who have tested positive).
The center’s disease investigators are under contract with the State of Nevada. Many are housed at Washoe County Health District. Others are at Carson City Health and Human Services and some are at the Nevada Public Health Training Center’s satellite office in Stead.
The contact tracing effort accounts for most of the center’s staff, with nearly 70 contact tracers and their 10 supervisors, along with another 70-plus people managing and supporting their effort in the call center, operations, epidemiology, biostatistics and data analysis, and project assistance.
This staff supports Washoe County Health District, Carson City Health and Human Services, Nevada Division of Public and Behavioral Health and Nevada’s tribal communities.
The contact tracing staff didn’t exist until July when the hiring began, almost overnight, with the rapid assistance of the University’s Human Resources team.
The disease investigators are organized into teams of about a dozen each. When possible, the same disease investigator will follow-up on the same cases for continuity and familiarity. When that’s not possible due to schedules or developments, the case notes each disease investigator enters into the database daily provides important background information.
Each disease investigator is scheduled for four 10-hour days each week, as a rotating team. Calls are made seven days a week from morning until early evening, reaching people at home, work or sometimes in the hospital. Some people don't answer or respond to messages. The calls last from 20 to 40 minutes on average, but can be shorter or much longer depending on the situation, the language and whether it is the first call with that case or a follow-up.
Taylor Dunn is one of the center’s original disease investigators, recently elevated to lead disease investigator with supervisory responsibilities. From Colorado but recently living in Kosovo, Taylor and his fiancée moved to Reno for her unrelated employment with the University. Dunn’s work with the Peace Corps and other nonprofit health outreach efforts, plus customer service skills honed while working in his family’s real estate business, provided a solid foundation for and an interest in the position as a disease investigator.
“We have such an inspirational and diverse team of employees that are responding through contact tracing, running a call center, providing point-of-operations support, and analyzing data, all to meet the immediate needs of our community.”
“For me, my passion might not be medical in nature, but it’s very much helping people and interacting with people,” Dunn said. “This job gives me a chance to do both at a time when it’s needed. This has been a nice transition to something that fills my cup a little bit in terms of helping people on the needs side of things.”
His work involves helping his cases to remember their recent contacts. “For the most part, people are able to think back, ‘Where have I been?’ – luckily, because most people are limiting their exposures out in public,” Dunn said.
Dunn arrived in spring, just as COVID-19 was shutting down Nevada, as did his colleague Jahkota Anderson-Laking, also a lead disease investigator. Anderson-Laking is a University alumnus from Reno with degrees in psychology and sociology, whose experience includes work at a behavioral health clinic. “Once I started the position, I felt like it was a really good role for me because I was excited to be able to help people and actually have meaning for each case,” he said. “Each disease investigator really does get to have a meaningful impact on everybody that they call.”
As a disease investigator, timing is crucial. People with COVID can be contagious for the two days or so prior to becoming symptomatic. The disease investigators take into account when the symptoms first appeared, when the test occurred and number of days it took for results before the case was in the cue to call.
According to Dunn, the new team naturally inherited a backlog of cases when they first began their work, but over time as training was completed and the operation became more fully staffed, the team caught up and caseloads became more manageable.
Those being called are generally eager participants.
“They just found out within the last 24-48 hours that they’ve tested positive and they aren’t feeling real well for the most part, so they’re looking for information,” Dunn said. “I think there’s been a lot of information flying around but a lot of it doesn’t necessarily agree with itself. I think they feel pretty good about the fact that they have somebody on the line whose job it is to help walk them through this process and interview them.”
With the clock ticking and limited resources, there are clear priorities. “The guy who shops for groceries while infectious, that’s not a good thing but hard to contact trace for in terms of who they came in contact with,” Dunn said. “So that’s not the highest priority at this point. What is high priority is the individual they know they were in close personal contact with for longer than 15 minutes.”
Beyond the phone call: identifying and meeting community needs
COVID-19 has been shown to have disproportionately impacted people of color and those in Latinx (Hispanic, Latina/Latino) communities. Diana Sande is a contact tracer supervisor and oversees the Latinx COVID response and outreach for the center, serves as a liaison with area faith-based organizations and is working on strategic planning and operating procedures. She describes her Spanish as “global” from living and working in many places around the world.
As disease investigators and contact tracers began calling hundreds of people, it became evident to Anderson-Laking and his colleagues that providing information about COVID wasn’t enough; tangible help was needed.
People were losing jobs, often didn’t have money for groceries, and without family or friends to help, they had no way to obtain food since they were homebound. Sande’s group has developed a robust community resource guide, available in English and Spanish, and worked with community businesses, nonprofits and agencies to provide food, housing assistance, help with bills and even some human connection. As disease investigators and contact tracers come across people in such circumstances – and there are many – they get Sande’s team involved.
In a recent month, food and/or housing assistance was provided to more than 60 individuals or families.
“One of the most wonderful things about northern Nevada,” she said, “is how this community came together during the lockdown, what they did to support the local businesses and each other, so we want to continue that.”
Bilingual contact tracing
The Latinx population, which represents 45% of Washoe County’s positive COVID-19 cases, is among those who’ve been especially hard hit on the health, unemployment and socioeconomic aspects of the pandemic. For Spanish-speaking cases, the center has 18 bilingual disease investigators, as well as an interpretation service for the non-bilingual disease investigators.
“Part of the process of truly doing a good job of contact tracing is creating rapport,” Sande said. “That is something really difficult to do even if you speak the language, but it’s definitely much more likely to create rapport when the person on the other line feels like they’re talking to their people. They can hear it in your voice. Now all of a sudden, the distrust for the government isn’t as great.”
Luis Godoy was moved to join the effort as a bilingual disease investigator. “When I saw the pandemic really hitting the Latinx community,” he said, “I just felt the need to help in a different realm and maybe have more of an impact among more people. That’s what drove me to help in this.”
A Nevada native, Godoy is a Sparks High and Nevada graduate in health sciences, biology and biochemistry, before earning his masters in physiology from Washington State University. His clinical background includes work in hospital surgical wards.
“I think we get a lot of mostly grateful people that just are happy we’re calling, happy we’re helping ease their fears,” he said. “Especially when they can speak to someone in Spanish.”
Among Godoy’s Spanish-speaking colleagues are Cynthia Cabrales and Dulce Leyva.
Leyva was motivated to become a disease investigator after seeing coronavirus’s impact of her family back in Sinaloa, Mexico. She moved to Reno 18 years ago to work and study, became a U.S. citizen, married and started a family in northern Nevada.
For the past decade, she’s worked for the state’s Early Intervention Services, helping infants and toddlers who have special needs such as autism and Down syndrome. She started interpreting for families who speak Spanish to help them to understand the special needs of their babies. “That experience is what opened the opportunity for this job, which has been a blessing,” she said.
Cabrales is also a Reno native and McQueen High grad. Her mom hails from El Salvador; her father from Durango, Mexico. She’s pursuing her education to become a nurse, possibly in the ER, ICU or OB/GYN. Contact tracing helps provide her with experience and the chance to help educate others, along with herself, on protecting health in the pandemic, she said.
The three share not only a common language and a common experience, but a palpable commitment to the people they contact, driven by passion and empathy.
“You were the only person who was speaking Spanish at the moment. I do not have family here … but you were like an angel who spoke to me and gave me that hope to keep fighting.”
For Leyva, disease investigation stirs a combination of feelings. “I have to say that the most important for me is fulfilling – helping and feeling like you make a difference,” she said. “The reality is that there are days when it’s overwhelming and we just try to cover as much as possible. And that sometimes creates the pressure to say, ‘Okay, I can help one more person today. I have to give this extra.’ We know that that phone call will help and will go a long way.”
Good days, bad days
Disease investigators never know where a case will end up. “Sometimes you start with a case and end up protecting an entire family,” Leyva said. “Maybe they don’t have a positive test on their own but they do they have all the symptoms and signs, and have been just directly exposed and have to quarantine. So you start with a whole house and the people in that house have some kind of contact with somebody else, and soon you don’t have one house, you have three.”
While those who have tested positive are often eager to speak to a disease investigator to glean information and guidance, the conversations are not always easy or welcome.
“There’s so much ‘interwovenness.’ It’s important because we’re just not one disease investigator dealing with the cases, we’re dealing with cases together.”
“It’s emotionally devastating for them and for us,” Leyva said. “We really don’t want to but we have to do it. There’s no other solution so we try to give all the help possible within our power. But they still have to pay the rent and maybe haven’t worked for two months and it’s very emotional.”
A good day for a disease investigator is “being able to have a family that I was able to connect with, able to answer their questions, able to know that they were helped,” Godoy said.
“For me yesterday was one of those good days,” Leyva said. “I have a case that finally got released from the hospital after five weeks. He didn’t think he would make it out. He’s still fragile but he’s home, with oxygen. He said, ‘You were the only person who was speaking Spanish at the moment. I do not have family here … but you were like an angel who spoke to me and gave me that hope to keep fighting.’”
But there are tough days, too – like Cabrales experienced the previous week.
“It was just stressful because I had a few cases where I just wasn’t able to do as much as I wished I could have done,” she said. “And the frustrating thing is you have a family and they are about to be released and someone else in the family tests positive. I have a family that unfortunately kept having to stay home and the breadwinner lost his job because he had to keep pushing it out.”
‘Lying on my floor’: the exhausting and rewarding life of disease investigators
Two themes emerge from visiting with the center’s disease investigators: a dedication to supporting the people they call, and a commitment to each other as colleagues. It’s the team support that helps get each other through the tough times.
“We’ve only worked two months,” Cabrales said. “In that time we’ve gotten pretty close. Everyone who works as a disease investigator, well, we’re always helping one another.”
“This is very important,” Godoy said. “There’s so much ‘interwovenness,’ if that’s a word, between everything that happens. It’s important that we all have a strong bond. I think we’ve built our bond together based on what we go through. It’s important because we’re just not one individual, one disease investigator dealing with the cases, we’re dealing with cases together.”
The work is as exhausting as it is rewarding.
“I would say that typically I'm energized throughout the workday,” Anderson-Laking said. “However, when I get home, I am totally drained and I’ve found myself lying on the floor many nights. It’s why I’m so impressed with every single disease investigator, that they keep coming in and keep doing such excellent work.”
However, he said he is not seeing burnout among his colleagues, which he attributes to the fulfillment inherent in the work and their passion for helping others.
“I think that there’s a general attitude of happiness at our workplace, which is awesome,” Anderson-Laking said. “I also know that the work that we’re doing is important. I know that because I receive amazing feedback from so many of the cases that we call – ‘Thanks!’ … ‘Thank you!’ … ‘Wow, I'm so happy to have guidance’ … ‘It’s just nice to just talk to somebody about this.’”
As the sprint-relay-marathon continues, the contact tracers run on, fueled by the knowledge that Anderson-Laking and his colleagues are making a difference.
“I probably couldn’t find another job right now that is more gratifying,” he said.