How states are handling the challenges of contact tracing


Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.



AMA Chief Experience Officer Todd Unger talks with Marcus Plescia, MD, about the progress of contact tracing in the United States.

Learn more at the AMA COVID-19 resource center.


  • Marcus Plescia, MD, chief medical officer, Association of State and Territorial Health Officials (ASTHO)

AMA COVID-19 Daily Video Update

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Unger: Hello. This is the American Medical Association's COVID-19 update. Today we'll get an update on contact tracing from Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, or ASTHO in Atlanta. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Plescia, it's been more than two and a half months since we spoke to you and unfortunately the numbers have only gotten worse. Let's talk about where we are right now with contact tracing in the United States. And are some states doing better than others?

Dr. Plescia: Yeah. We're getting there and we've certainly made progress since we last talked, but we're still really not where we need to be. I think every state and a lot of local communities have begun to hire contact tracers and they're building up a workforce. But it's not clear whether that workforce is big enough. We had estimated that we probably need at least around 100,000 people across the nation. And last estimates I saw were maybe in the 40,000 range. So that's a step in the right direction.

It is challenging to scale up something as complex as this, but I think we clearly need more contact tracers. We're trying to shift a little bit more to really using metrics and not just how much is enough? We've started to think, well, maybe we know if we've got enough if we're able to contact people quickly enough and if we're able to track people down in a timely fashion. In that case the system works. But I don't think that we're getting the kind of stats we need on that. And I think it goes back to a little bit more need to pay some attention to the process, make sure that we've got the number of people we need. And maybe look at some of the training that we're doing for them.

Unger: What's the biggest obstacles to scaling the number of contact tracers?

Dr. Plescia: The biggest obstacle to scaling, I think it's just, it's more the logistics. This requires hiring significant numbers of people in a lot of state and local health departments, that's a somewhat slow process. What we've seen is that many of them for that reason have chosen to contract with outside groups who can come in and hire up and scale something like this up a little bit more quickly. But even that contracting process takes a little bit of time. And that's not a bad thing. The reason things take time in government is because we want to be transparent. We want to make sure things are done in a fair way. And so I think there's a little bit of that at play here.

Unger: Is this an issue of funding?

Dr. Plescia: That's a little bit hard to know. We're hearing from our leadership that there is quite a bit of funding from the federal government coming down to the states now. There was a significant appropriation that went out from the last congressional appropriation. It went out for testing, but the understanding was that money could be used for contact tracing as well. That was a figure along the lines of $10 billion. It was a lot of money.

The question is how much of that is getting eaten up by testing. Testing is expensive and states are having to cover a lot of the costs for it. But as we understand some of those resources have been able to be used for contact tracing. So, I think that's helped states and locals get started. Clearly though, in the long run, there's going to need to be some more resources. I understand that's been in some of the discussions around the most recent potential congressional funding, but as we all know that seems to have been delayed a little bit.

Unger: How do delays in testing, which we're seeing in many places across the United States, then inhibit our ability to do contact tracing well?

Dr. Plescia: Yeah, that is the biggest problem. It's the biggest frustration. If you think about it, if you're waiting five to seven days to get a test result back, which we've seen in some communities where they're having surges, if you're waiting that long that's too late. First of all, you don't even know for certain that the case is positive. And so making sure those people are staying at home, you're potentially missing the window for that. But five to seven days out most of the contacts they will have, if they're going to be positive, they will have turned positive themselves. And you've missed that window where you can really try to get them to stay at home and limit their contact with other people, which is probably the most effective part of contact tracing.

Unger: So it really is tied very closely together with testing to make this work?

Dr. Plescia: Yeah. And I think what we're beginning to find is that contact tracing is going to work best in the communities where they actually have things fairly well under control. So maybe it's a better intervention when you get to a good place to stay there because this pandemic and this infection requires states to be on it every second. You can think you're in a really good place and the next thing you know your rates start drifting up. So I think contact tracing is really useful there to keep, once you get your rates down, to keep them down.

I think once rates go up and you have some of the situations we've been seeing in the Southeast and the West, I think it's very hard to rein that in with contact tracing alone. I think a lot of states and contact tracers themselves are getting frustrated. They can't keep up. They're not getting the results back in a timely way. So I think it still helps, but I think the real value is going to be get things under control and then use contact tracing to keep them there.

Unger: Yeah. It's just another example of where the system just gets totally overwhelmed in all regards, and it's just really unanticipated. Are there any states that are doing this well and doing reopening well?

Dr. Plescia: So there are several states that are doing contact tracing well. Massachusetts is a long standing example. I think all of the states in the Northeast have fairly good... Actually every state is hiring significant numbers of people, so I think they're all doing it quite well. New York City is beginning to emerge as an interesting model; Washington, D.C., a couple of the cities out on the West Coast. So, some of the big cities we often see those as the places we can look to get some of the best practices as we learn what works and what doesn't.

Unger: What's interesting about that model? You mentioned New York City. Are they doing something novel or different?

Dr. Plescia: It's mostly that I think they have been able to hire a pretty significant number of contact tracers. They've really looked at hiring people who will be recognized in their communities who may be able to build trust faster and get people to participate in contact tracing, because that's been a problem too. Sometimes people don't want to tell us who their contacts were and we hadn't really anticipated that, but that's something we're seeing.

So I think New York has been able to look at hiring practices that help with that. And New York and Washington, D.C., both are beginning to come out with some really good metrics, not just how many people do we have but how effective are they? Are they getting in touch with the cases quickly? Are they tracking down the contacts in a day or two, which is really the ideal? And to begin with they weren't. They were figuring it out. But the last I saw it seemed like some of those success rates were starting to trend up a bit and we felt like this is a system that's starting to really come together and begin to work well.

Unger: This is just a simple question. What actually triggers a contact tracing event? A positive test? How does that actually get transmitted and what's the operation there?

Dr. Plescia: Yeah, it's generally a positive test. I think that this is varied in some communities where it's taking so long to get the tests back. They're trying to do a little more communication with whoever is administering the test. This is where physicians could come in. We talked a little bit about this on the last call.

I think physicians could be really helpful, because if somebody has the cardinal signs and symptoms of COVID they probably have it. And you may want to counsel that person a little differently and do some of the things that a contact tracer would do as far as really trying to drive home to them how important it is for them to isolate and not infect other people. So we're starting to see some of that.

But the ideal is that the testing would be quick. You'd have some kind of electronic report in that went straight to the contact tracing program, so that very quickly and seamlessly all of this stuff would move into play.

Unger: You mentioned before that there might be a realization that this is working better in places where it's under control and to keep it under control. We've seen in New Zealand, for instance, that strategy of go early, go hard. Are there any other countries that are doing this type of thing really well that we can learn from?

Dr. Plescia: Yeah well, many of the Asian countries were our first examples. Korea, some areas in China, Singapore, Hong Kong. I think there've been some good examples. Japan, I think has had some good results recently. Now, those are countries that are, those are societies that are very different from ours. So you have to be careful how much you directly adapt something that works there. But they are important because they do make the clear point that contact tracing can work and can be very effective if you can get it into place properly.

And that's probably the main thing we've looked to those countries for is the encouragement that this is worth a try. And even they have struggled. They've had to deal with, when issues aren't going well, stepping back and trying to figure out what's going wrong. And they certainly, they have their rates under control much better than us, but if you follow the media they have hotspots and they have things start to turn the wrong direction. And they're just good at acting quickly to get those things back under control.

Unger: Well, one of the hot topics right now is, of course, school reopenings. Can you talk about how contact tracing will be important in areas where schools are opening for either hybrid or in-person learning?

Dr. Plescia: Well, another thing that we've learned about contact tracing is that there's an infection control piece of it. So really, when you have cases using contact tracing to keep the disease from spreading. But we also learn an enormous amount from the contact tracing interviews. We learn where did people get exposed? What did they do once they started getting sick? Did they think they might have COVID and stay at home or did they just continue to go about their work and their business?

And so we're getting really good data to help us understand the pandemic better. And I think that will apply really, really well in schools and college settings. I mean, yes, I think there's an infection control piece that if we can move in quickly with contact tracing in some of the school settings, particularly in some of the school settings where they've organized it so that students and teachers are staying in a similar group, a pod, as we call it. So, a group of students and two or three teachers, those are the ones who were together every day. So if you get an infection in that group you know you really just have to focus on that group. You don't have to worry as much about did other groups get it because they weren't in contact.

So I think contact tracing will be helpful to control outbreaks when we see them in schools and colleges. But probably the bigger thing is we can really learn a lot more about if kids are contracting COVID, where are they contracting it and who are they contracting it from? And then the other big thing is, the big question is do kids in schools who become positive, are they going to be a major source to take it back out into their families and communities? Because that's where things could really get problematic and out of control.

Children and kids, they seem to fare pretty well when they get COVID. They don't get severely ill for the most part. And that would be our number one concern. We wouldn't want to send kids back to school if there was a substantial danger for them. It doesn't appear to be the case, but there is a danger that they could take it back out into the community where people are, who may not fare as well.

Unger: Well, I know that ASTHO has been working on a lot of COVID related issues since the pandemic began. Can you give us an update on those efforts and what you're working on right now?

Dr. Plescia: Yeah, the two things that... We're doing a lot of work, and I suspect your audience will be interested in this, on the vaccine. And there's a lot of questions about when might a vaccine be ready? How effective will it be? What are the different platforms? But we've really trying to decide, okay, let's hope for the best and expect that there will be a good vaccine, that it'll be ready fairly soon. And then how are we going to distribute it and get it out there? And who's going to get it first? Because when it first comes out there's going to be limited supply. So we're doing a lot of work on that.

I think that some of who's going to get it first is probably pretty obvious, and health care providers are going to be at the top of that list because we have to protect health care providers. And we also have to make sure that they don't become a vector, that they're in touch with so many sick people, they could easily be a cause of spread. So, that's probably fairly predictable.

We have good distribution systems. Many clinicians are going to remember from H1N1 in 2009, how that worked. We had a system that worked where providers and other entities would make requests into the state. The state would put those orders out, but then CDC would actually work through a distributor to distribute directly to the providers. So you don't have the state as a go-between and another sort of thing that might slow things down.

That system seems to work pretty well. We're hoping that's what the federal government will go forward with, but it's not entirely clear. The Department of Defense is very involved in the distribution. It's possible that they may play a role and may use some of the sectors and mechanisms they have to get supplies out. That could be a good thing.

This is going to be a heavy lift to get the vaccine out and get it to patients. But we just have to be careful that we don't end up... Whenever you start building a new system in the middle of a pandemic you're asking for problems. And so we're glad we've got something that's tried and true that we can start with, and then hopefully we can build on that with some other approaches.

Unger: You mentioned you have a question about... Go ahead.

Dr. Plescia: I was about to change the subject to another thing we're concerned about, but did you have anything else?

Unger: You mentioned earlier in terms of the order of who's going to get this, from what I've seen there's a question about whether you start with people who are most apt to get serious complications from COVID, or on the other hand, people that are probably most likely to be vectors or spreading that. Do you have any sense of how those discussions occur?

Dr. Plescia: Yeah. The, ACIP, the American Council on Immunization Practices, that's their long standing role, is they help to strategize not just things like the vaccine schedules and the vaccine dosing, which all of us clinicians are very familiar with, that ACIP is the ultimate source of that. But ACIP also is brought in, in situations like this to advise on how should we prioritize the vaccine when it first comes out?

And you have to be realistic about this. It's going to come out, hopefully, in maybe the tens of thousands of doses until things gear up. So there aren't enough doses to really concentrate on people who could become severely ill. There are hundreds of thousands or even millions of people who are at risk to be severely ill. So I think the initial, if we're talking about tens of thousands, we're really going to be talking about health care sector and other critical industry workers who we really need to make sure we protect. And then we'll roll it out from then. Obviously, as more doses are available we would probably tend to look towards trying to immunize people who are at greater risk.

Unger: You mentioned you had another thing you wanted to talk about in closing?

Dr. Plescia: Yeah, the other thing we're very interested in is safe voting. Everybody knows we're coming up on an election. An election is very, very important to our democracy. And so we're really starting to try to work with states a little bit to understand what their polling processes are going to be. And I think we've gotten to a place where even if it's in-person voting, we can make that safe, but we need to be very thoughtful about it. And we need to be doing some of the background work now, or it'll be on us before we know it.

And so we're beginning to talk about some of the things to do at the polling sites to make sure that people maintain social distance. But also we've got to protect the people who are working the polls. And we got to make sure that people aren't scared to come out and work the polls, and then we don't have enough workers. So we're trying to begin to look at some of those things, and we feel like that's a very important role for public health right now.

Unger: Well, thank you so much to you and ASTHO for doing that and playing that important role. I really appreciate you coming back on the COVID Update and sharing your perspectives.

That's it for today's COVID-19 update. We'll be back tomorrow with another segment. For updated resources on COVID-19 visit Thanks for joining us and please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.