[MUSIC PLAYING]
JOSHUA SHARFSTEIN: Welcome
to Public Health On Call,
a new podcast from the Johns
Hopkins Bloomberg School
of Public Health.
Our focus is the
novel coronavirus.
I'm Josh Sharfstein, a faculty
member at Johns Hopkins,
and also a former Secretary of
Maryland's Health Department.
Our goal with this podcast is
to bring evidence and experts
to help you understand
today's news about the novel
coronavirus and what
it means for tomorrow.
If you have questions,
you can email them
to publichealthquestion@jhu.edu.
That's
publichealthquestion@jhu.edu
for future podcast episodes.
Today, Stephanie Desmond talks
to Emily Gurley and Brooke
Jarrett, two Johns Hopkins
epidemiologists who
are at the forefront
of efforts to control
community transmission
of the novel coronavirus.
We hear about their
on-the-ground efforts
to trace the disease, and why it
is a key to slowing its spread.
Let's listen.
STEPHANIE DESMOND:
Thanks for joining me.
EMILY GURLEY: We're
happy to be here.
BROOKE JARRETT:
Happy to be here.
STEPHANIE DESMOND:
Today we're going
to talk about strategies
to control community
transmission of COVID.
Right now, we're currently--
everybody's staying home.
And that is sort of one
of the bluntest tools
we have to control
community transmission.
But there are other
ways to do this.
And one of them is to really
investigate each case,
and see where it
came from, and see
where it may have been spread.
Emily, can you tell me a little
bit about how you do that?
EMILY GURLEY: So
most people by now
have probably heard the
term contact tracing.
Contact tracing refers to
a public health strategy
to limit community
transmission, whereby
you find people in the
community who are infected,
and you get them to
stay home while they're
infectious so they don't
infect anyone else.
So the first step in that
is identifying cases.
So people who have
infections, you identify them
as quickly as possible, and
you ask them to stay home
while they are sick.
Next, you identify everyone
that they have had contact with
and could have infected, and
you ask all of those people
to stay home and
not have contact
with anyone else for 14 days.
That's called a self quarantine.
When you ask the
person who is already
sick to stay home and not
have contact with anyone else,
that's called isolation.
Quarantine is a
very important step
here because you want to
have people already at home
if and when they do
back home infectious.
That's the best
way that we know of
to prevent community
transmission.
And this disease, in
particular, is very tricky,
because many people
who are infected
will never develop
signs and symptoms.
So even if they
don't become sick,
they still should
stay home so they
don't transmit to anyone else.
And many people
who do become sick
are going to be infectious
before they know they're sick.
So it's the
identification of contacts
and asking them
to self quarantine
that's really central
to getting this to work.
STEPHANIE DESMOND: That's
a really big ask, right?
You say, oh, so and so,
your friend is sick,
you had contact with them.
Now you should stay
home for two weeks.
How do people respond?
Brooke?
BROOKE JARRETT: Yeah.
So some people are very
compliant when you ask
them to stay home for 14 days.
They have the
privilege and capacity
to stay home for 14 days.
Perhaps they've already gone
out and had extra money,
or at least a
little bit of buffer
to buy extra food so that
they don't have to go out,
or they've already had a know
how to set up grocery delivery,
or even have Wi-Fi that's
necessary to order groceries.
Perhaps they have a really
strong social support
and community around them--
neighbors, friends, family
who can bring them food.
But that's certainly not
the case for everybody.
We definitely face
a lot of challenges.
And I don't think it's specific
to Baltimore necessarily.
But there are people
who need to go
to work, who are resistant to
stay home if they are feeling
totally fine because they're
already living paycheck
to paycheck.
Or as we know, a large
proportion of people
have lost their jobs over
the past several weeks.
So there are definitely
folks that are resistant.
And then there's also
sometimes when you ask someone
to stay home, I think some of
the best work that we can do
is contact tracers set them up
and create an environment where
they can.
And so that means
policies and programs
that can help people
pay their rents
or avoid eviction, help
out with utility bills,
or even bring food
from food pantries.
STEPHANIE DESMOND: So
Emily, how do you do this?
You go door to door.
I guess that's not really
happening right now.
EMILY GURLEY: No.
So the idea of contact
tracing works for many types
of infectious diseases.
The way you do it is a little
bit different for each one.
So for this pandemic, most folks
are not going door to door.
And there are a few reasons.
One, we have to be really
quick in finding people.
So often a telephone
call is quicker
than going door to door.
Second, if you go to find
people who could be infected,
you have to use the appropriate
protection, such as masks,
gloves, and perhaps
other types of PPE.
And we're still at
a stage where we're
reserving those for our
frontline health care workers.
We don't have enough
for public health yet.
We could go to a place where
we do try to go door to door,
or find people in the community.
You know, some people don't
have reliable phone numbers.
Sometimes you can't
find someone by phone,
and you really want to
go out and look for them.
We're not doing that
right now, but there
may be a time and place where
that becomes more important.
STEPHANIE DESMOND:
Are people reluctant
to share the names
of their contacts?
EMILY GURLEY: Sometimes.
STEPHANIE DESMOND: Yeah.
That could be a challenge.
EMILY GURLEY: Sure.
For a number of reasons.
Generally, it could
be due to stigma.
People don't want others
to know that they are sick.
It could be due to
privacy reasons.
Sometimes people don't want you
to know who their contacts are.
Some people just may
not feel comfortable
sharing their private
information with others.
Maybe Brooke has some
additional thoughts on this
or can share some
of her experiences.
BROOKE JARRETT: Yeah.
Well, I would say
something that I've
been thinking about a little
bit is that we certainly
get varying degrees
of skill when
it comes to contact tracers.
And while some parts of it
are definitely trainable,
I think that you
get a lot more done
if you can connect with
someone over the phone.
Sometimes some of the
first immediate responses
that we get are, how do I know
you're from the city health
department?
Because unfortunately, there's
a lot going around about scams.
Even for instance, some
of the financial aid
that is going out, and
there's scams around that.
Or social security
things happening
when you pick up your phone.
I'm surprised, honestly, that
anyone picks up the phone when
you are trying to call them.
I'm grateful.
I'm grateful that they are.
But yeah, making that human
connection with someone
and saying, you know, I'm
here to check up on you.
We want to know
how you're doing.
We want to protect you.
We want to protect your family.
We want to protect
our community.
And if you can make
that connection,
I think people are much
more willing to disclose
who they were in contact
with because they recognize
that you're not just there
to collect data from them.
You're part of an effort, and
that effort is this larger hope
that eventually we're going to
dig ourselves out of this hole,
and sometime soon.
STEPHANIE DESMOND:
So one of the things
that I haven't told
our listeners is
that you are doing some of
this work in Baltimore City.
And that, Emily, you're
helping to sort of lead
some efforts in this realm.
Could you tell me a
little bit about that?
EMILY GURLEY: Sure,
well, at the school where
we're doing a number of things.
One is trying to put
together some recommendations
for cities, some considerations
around contact tracing and best
practices, so that folks
have some guidance as they
work to build out this
public health function.
Unfortunately, public health
is typically very neglected.
And so for cities and states
who really want to do this well,
and at a scale that will be
required to respond effectively
to COVID-19, they're going
to have to build out teams.
So we're providing
them guidance there.
And we're also going
to help with developing
training materials that will be
available, publicly available,
for anyone.
And we think
specifically one place
they may be used first
is in New York state,
where efforts are already
underway to hire and train
a whole army of
public health workers.
STEPHANIE DESMOND: I wanted
to ask about that scale.
To get this done with
the pandemic like this,
you would think you'd need
a lot of contact tracers.
EMILY GURLEY: You'd think
that and you'd be right.
There's no magic number.
And really, it depends on
how many cases you have.
STEPHANIE DESMOND: You
had told me previously
about a South Korean study.
It looked at how
they trace contacts
and found I believe
it was 30 cases.
Could you tell me a
little bit about that?
EMILY GURLEY: Yeah, sure.
So when we talk about
contact tracing and we say,
you want to find
people's contacts.
Let's delve a little bit
into what that means.
So this means people who we
think have had a potentially
infectious contact.
So potentially
infectious contacts
are very close contacts.
Perhaps you live with
someone, or you've
had close physical
contact with that person.
We also talk about if you've
been close to someone,
maybe didn't have physical
contact with them,
but you've shared a
cubicle with them.
You shared a meal with them.
You were in a
situation for longer
than just a few
minutes with someone
where you were within
six feet of that person.
Those are what we
call close contacts.
Within six feet, why do we
talk about within six feet?
Well, generally, we know
that if you cough or sneeze,
or you're talking
in your laughing,
respiratory droplets
from your mouth
can be projected
around six feet.
So if you're beyond that,
you're probably in a safe zone.
So we ask cases, who are
all the people who you've
had this type of contact with?
And two time periods.
One, during your
illness because you're
infectious during your illness.
We also ask about the two to
three days before your illness
because, as we know with
this disease, in particular,
you can be infectious
before you know you're sick.
So you can imagine in the
course of a day, of course,
it depends on the person, but
there could be a lot of people
that you have contact with, that
you know are in proximity to.
And when we think about people
who've got a lot of contacts,
it gets overwhelming.
But this study from
Korea did a very nice job
at setting out
what the risk looks
like among different
types of contact.
So they followed
all the contacts
they could find, close, people
who spent some time nearby
knowing COVID-19 patients.
So they had 30 patients and they
listed all of their contacts.
Those contacts total
over 2000 people.
So if you're thinking
about contact tracing,
that's daunting.
That is a daunting number.
Just 30 cases, and you need to
follow more than 2000 people.
So they followed up
with all those contacts
to see who got infected, right?
That's what we want to know.
They found 12 infections.
So 12 people were infected.
Among those 12, 8 were household
members of the 30 initial cases
that they were investigated.
So what does that tell us?
That tells us that while it's
possible to infect someone
with many different
types of contact,
not all of those contacts are
at equal risk of infection.
Typically people who have
the closest contact to you
as the patient are the
ones at highest risk.
And so when we think about
contact tracing generally,
this can take off some pressure.
So in this study in Korea, only
about 190 of those contacts
were household members.
So one way to think about that
would be if you only followed
up with those 109 the people
who lived in the house
with those contacts, you
would have identified
75% of all the transmission.
So when we have scarce
resources and this huge need,
it can be helpful to think
about strategies to really
focus and target our efforts
to have the greatest impact.
STEPHANIE DESMOND:
So we are getting
close to a million cases
in the United States.
And it makes me
wonder, is it too
late to be utilizing
this strategy?
EMILY GURLEY: Too late for what?
Would be my response.
Too late to stop
the transmission
of SARS coronavirus 2?
Yes.
Our opportunity to do that
ended a long time ago.
Is it too late to have
a public health impact?
I would say no.
Even in places where you
have clear ongoing community
transmission, this can still
have an impact just because
of the multiplier.
So each individual case,
without any intervention,
can infect two to three people.
And then each of
those can infect two
to three more people.
And each of those
two to three more.
So if you prevent just one
case in that kind of scenario,
you're preventing
dozens of cases
that would have
occurred otherwise
just a few weeks from now.
So it can feel overwhelming,
but there's always,
I think, a reason to start.
The second thing I would say
is that, although we're not
going to get rid
of this disease,
we're taking all these very
blunt population wide control
measures now, telling people
to stay home, work from home.
And what we're doing right now
is a huge effort and an attempt
to bring transmission down.
So if we bring
transmission down,
that means that we're going to
have fewer new cases occurring,
and we'll be able to respond
even better with contact
tracing.
It gets down to a
more manageable number
where we can really
wrap our arms around it
and try to control it.
It becomes a more
tractable problem
once we've taken these
other measures really
to drive the numbers down.
STEPHANIE DESMOND: Emily
Gurley, Brooke Jarrett,
thank you both so
much for joining me.
This was a fascinating
conversation.
EMILY GURLEY: Thank you.
BROOKE JARRETT: Our pleasure.
JOSHUA SHARFSTEIN: Thank you
for listening to Public Health
On Call, a new podcast from the
Johns Hopkins Bloomberg School
of Public Health.
Please send questions to be
covered in future podcasts
to publichealthquestion@jhu.edu.
This podcast is produced by
Josh Sharfstein, Lindsey Smith
Rogers, and Lymari Morales.
Audio production by Niall Owen
McCusker and Spencer Greer,
with support from Chip Hickey.
Distribution by Nick Moran.
Thank you for listening.
