Susie Welty, MPH, runs a cutting-edge recent HIV infection surveillance program which helps identify those at highest risk of HIV infection across several African countries and parts of South East Asia. (George Rutherford, MD, is the principal investigator for this IGHS program.)
Welty now finds herself, along with a dozen other IGHS faculty and staff members, doing nearly the same work tracing COVID-19 infections right here in San Francisco. She was among about a dozen IGHS staff members who responded to a San Francisco Department of Public Health (SFDPH) call, days before the city issued the first shelter-in-place order in the United States, for UCSF medical and public health experts to help manage the coronavirus crisis.
“After having to travel 3,000 miles for our work, getting to do it on the frontlines for our own community, using the skills that we’ve learned and taught, has been really rewarding,” Welty said. “We’re talking to people whose houses I bike by every day on my way to work.”
Now, San Francisco is leading the country into the next phase of the pandemic – contact tracing and targeted quarantine – and UCSF is a partner in those efforts. Contact tracing is Epidemiology 101: To contain the spread of an infectious disease, you identify those who may have been exposed through close contact with someone sick. The contacts are directed to testing and often quarantined to prevent further spread.
Mike Reid, MD – an assistant professor, infectious disease doctor at Zuckerberg San Francisco General Hospital and program leader at the Institute of Global Health Sciences – is driving IGHS’s contact-tracing work for SFDPH with big assists from Jess Celentano, MS, and Karen White, MPH. Rutherford is more actively involved with guiding the city’s public health policies.
Reid was initially assigned at SFDPH to notify San Franciscans who tested positive for COVID-19 and provide them with basic medical guidance. As part of the process, Reid and other medical volunteers asked patients who they had been in contact with. The problem was, SFDPH did not have enough staff to act on the information that the medical interviewers were gathering.
Looping in IGHS colleagues and others at SFDPH, Reid found a way to get it done. This week, IGHS staff will begin training many of the city’s librarians – who have been idling at home since public libraries closed last month – to do the labor-intensive work of notifying those who have been exposed to COVID-19. For those who are quarantined and test positive, the program offers support to allow them to stay at home and away from others until the risk of infection has passed.
If contact tracing is basic epidemiology, why is the program UCSF and SFDPH are rolling out being hailed in national news as groundbreaking, one might wonder. Does UCSF have a secret sauce?
“Our secret sauce is just passionate people,” Welty said, then added: “We’ve been working in different settings having to scrape together programs, and all of those different scenarios have put us in a good position to support SFDPH. We’re able to deal with a lot of technological and political challenges – I mean, we’re on conference calls and doing virtual work all the time with our colleagues in Africa and other places.”
The challenge facing SFDPH wasn’t just manpower. The contact-tracing program would have to roll out fast, collecting test results from labs across the city. It would have to be staffed by volunteers with no public health training. And they would all have to work entirely from home, with no face time, no telephone extensions and no shared computer network.
Last week, the IGHS team started making calls, using a customized version of a cloud app called CommCare. The app creates a new file for each contact a COVID-positive person provides. It automatically generates texts telling people to expect an important call from the Department of Public Health. It also texts everyone who is under quarantine prompting them to report any new symptoms. IGHS staff is working with the software maker to resolve issues that come up.
The UCSF team has produced training materials and call scripts in multiple languages. They’ve won funding to adapt the scripts and processes with the CDC for other hotspots to use.
Global health is, at its core, the art and science of getting quality healthcare to people and countries that lack resources. The expertise has proven essential to slowing the spread of the coronavirus in San Francisco. Though known for the wealth the tech boom has ushered in, a large, diverse population in poverty hiding in plain sight.
The contact tracers have found one four-bedroom house where each bedroom is rented out to an entire family, with all of the families sharing the kitchen and bathrooms. Another group of contacts live in a single-room occupancy building where communal bathrooms serve 20-some people.
The majority of contacts the team has reached out to, they say, have been Spanish speakers. Public data on COVID infections in San Francisco reports that 23% of cases are Latinx; in 30% of cases, the patient’s race is unknown.
Each contact-tracing team has a medical lead. In addition to giving advice about symptoms to be on the lookout for, the medical leads work with patients to adapt medical advice to their real-world circumstances.
Community medicine doctor Pooja Mittal, MD, a clinical lead in the contact tracing program, told me about one multigenerational family, where the COVID-negative grandparents tried to stay away from the sick parents. The parents remained in their room, communicating with the rest of the household exclusively by phone. The kids did all the cooking.
The team knew poverty would limit contacts’ ability to comply with quarantine. They have lobbied the city to provide food and other services to contacts.
“We’re only as strong as our weakest link,” Welty said. “We haven’t done a good job of taking care of people, and we’re paying the price now. None of us is going to be able to come out of this until all of us can come out of it.”
Reid, who could spare just a few minutes by phone during his bike commute, has a unique perspective into the clinical side of the pandemic, where health care providers have garnered public adulation for caring for contagious patients, and the preventative public health side of the pandemic, which is often seen as less sexy.
“There are about 30 patients with COVID across UCSF facilities, including the VA,” he said somewhat breathlessly, with the wind whipping into his phone. “We’re not talking about an overwhelming disease burden. If you want to know where the magic is happening, where the work is being done, it’s in public health. If we flatten the curve right now in San Francisco, it’s because of the phenomenal creativity, energy and enthusiasm of our public health professionals – including from IGHS.”
Reid sees the COVID pandemic on a par with the 1906 earthquake that launched UCSF and the AIDS crisis that made it into a global health powerhouse.
The team is using what they’ve learned around the world to serve their own community. “But,” he added, “if we’re to have any existential academic value in the long term, it’s in rapidly translating our lessons learned – and our failures learned – to our partners in Africa and around the world.”