Brett Dahlberg, WCMU, Author at �鶹Ů�� Health News

Another Pandemic ‘To Do’ on the List for Schools: Contact Tracing

Brett Dahlberg, WCMU — Thu, 13 May 2021 09:00:00 +0000

Chris Hodges, the principal of Gaylord High School in Otsego County, Michigan, never thought he’d be a contact tracer.

“I definitely thought, you know, ‘Why — why am I doing this?’” he said with a laugh. “That’s not what I went to school for.”

In what has become a regular part of his school day, Hodges fields reports on his charges such as hearing from the Health Department of Northwest Michigan that a student had tested positive for the novel coronavirus and was in school for three days when she might have been contagious.

One Tuesday in April, after the school day was over, he found himself walking the almost-empty halls with a laptop and a tape measure, making a list of other students who sat close enough to their sick classmate that they would need to quarantine.

Lisa Peacock, health officer for the department, said that without the school district’s help it would be “literally impossible” to keep up with contact tracing.

The school-age population for a growing share of recent coronavirus cases across northern Michigan, and Peacock said quickly identifying people exposed to those cases and telling them how to quarantine is crucial to protecting communities and containing spread.

Gaylord High School principal Chris Hodges measures the space between seats in a yearbook class. A student in the class tested positive for covid, and Hodges is working with the local health department to trace people who might have been exposed to her at school. (Brett Dahlberg/WCMU)

When Hodges first started helping the health department with contact tracing, he found himself calling teachers on weekends, holidays and late in the day after they’d gone home, asking them where a particular student sat and struggling to orient himself in the classroom as they described the student’s position over the phone.

It happened so often that he’s now requiring each teacher to keep an up-to-date seating chart in a bright-yellow folder on top of their desk so he can find it easily.

But in this case, the teacher, Hannah Romel, was still at school. The student Hodges was tracing is in her yearbook class, which has different seating arrangements every day. Romel handed Hodges the three charts, and he got to work.

In each place Romel had marked the student, Hodges extended his tape measure to the surrounding desks.

Teachers have spaced their seats out as much as they can, he said, but sometimes they can’t quite get to the 6-foot distance to avoid counting as close contact.

(The federal Centers for Disease Control and Prevention last month to allow for 3-foot distancing between desks, but only in communities where transmission is low. In this district, Superintendent Brian Pearson said, during Michigan’s recent surge in cases, 6-foot separation is the standard.)

Hodges moved quickly, both because if he didn’t complete the contact tracing the same day, the school can’t open the next, and because he wanted to get in touch with the families of students exposed to the virus right away.

“We want to make those phone calls as soon as we can, so that those students aren’t at work, aren’t at church, aren’t going to other people’s houses. We want to prevent the spread of covid not only inside our walls, but in our community,” he said.

Hodges will then pass on information about who was in close contact with the student to the local health department. Other nearby school districts run similar operations.

Nationally, this kind of relationship between schools and health departments is not typical in normal times, but it is happening with some regularity during the pandemic, said Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials.

Public health funding over the past few decades, she said, forcing local departments to cut staff members who could have boosted their .

Still, getting schools and health departments to work together can greatly help communities, Casalotti said.

Peacock, the local health officer, said that once her staffers get word of exposures at local schools, they will also get in touch with the families to talk them through the details.

“People always have questions,” she said. “They have questions about ‘What does this mean? What does it mean that I’m quarantined for 14 days?’ We recognize that.”

And, in some cases, the health department needs more information than Hodges can give, Peacock said. They might want to find out whether a coronavirus variant is at play, or do a more detailed investigation of how students got sick and where they were when contagious.

Back in Romel’s yearbook classroom, Hodges found two students sat just shy of 6 feet from their classmate who tested positive. They’ll need to quarantine for two weeks from the date of their last exposure.

Romel said she’s still surprised to hear the news that a student is sick.

“I worry about the kid,” she said. “I hope that it’s a mild case, and they get to just be OK and get back to school after their quarantine period and come back and be learning with us again.”

After a quick chat with Romel about whether the class did any group work on the days in question (they didn’t, which Hodges said is a relief, because it complicates his process), he headed off to the next classroom.

In all, 14 students will be quarantined as a result of exposure to this coronavirus case.

It’s a lot, Hodges said, but it’s a far cry from the number of quarantines stemming from a single day last month when 15 students tested positive, and each of them had several close contacts.

Making phone calls to families informing them their child will need to stay home from school for up to two weeks is not an enjoyable part of the day, for him or the families, said Hodges, but he’s gratified to play a role in mitigating the extent of the pandemic.

This story is from a reporting partnership that includes WCMU, NPR and KHN.

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Do-It-Yourself Contact Tracing Is a ‘Last Resort’ in Communities Besieged by Covid

Brett Dahlberg, WCMU — Fri, 08 Jan 2021 10:00:00 +0000

The contact tracers of Washtenaw County in Michigan have been deluged with work and, to cope, the overburdened health department has a new tactic: It is asking residents who test positive for covid-19 to do their own contact tracing.

Washtenaw is a county of nearly 350,000 residents who live in and around the city of Ann Arbor, about 45 minutes from Detroit. Until mid-October, a county team of 15 contact tracers was managing the workload. But by Thanksgiving, more than 1,000 residents were testing positive for the coronavirus every week, and the tracers could not keep pace.

In Washtenaw County, the process starts with people called case investigators, who receive lab reports of positive coronavirus tests. Their job is to call anyone who has tested positive, tell them they need to isolate and ask them for the names of people with whom they have had close contact. After creating a list of potentially exposed “contacts,” investigators pass it to a new team to start the actual contact tracing. As the number of positive cases builds, the number of calls tracers must make swells.

But in recent weeks, it’s not just the number of positive cases that has increased, overwhelming the capacity of case investigators — so has the number of contacts that each infected person has, said contact tracer .

“There’s just so many more people that are gathering and that are exposed,” she said. “It used to be, we had a case, and maybe that person had seen two people, and now it’s a whole classroom full of day care students or a whole workplace.”

The work to keep people who have been exposed to the virus away from people who have not is crucial, said public health professor , because it breaks viral transmission chains and prevents the virus from spreading unchecked through a community.

Beck teaches at the University of Michigan and runs the campus program for tracing coronavirus exposures among students.

When you’re trying to contain an infectious disease, she said, running out of contact tracers is “not a situation that you want to be in.”

But it’s happening now in health departments in Michigan and around the U.S. where contact tracing workforces , but not fast enough to keep pace with the pandemic’s spread.

As a result, health departments are asking some residents with covid to reach out to their contacts on their own.

Trying ‘a Compromised Strategy’

Once billed as stemming the spread of the virus, contact tracing has fallen apart in many regions of the country. It’s a systematic breakdown that , a professor of global health law at Georgetown University, said hasn’t happened since the spread and stigma of HIV and AIDS in the 1980s and ’90s.

In Michigan’s rural Upper Peninsula, a public health district spanning five counties residents that its tracers were overwhelmed and that they might not receive a call at all, despite testing positive. Health workers would need to focus their efforts on residents 65 and older, teens and children attending school in person, and people living in group settings.

In Michigan’s southwestern corner, contact tracers in Van Buren and Cass counties can with their calls. It’s the in Berrien County: “If you test positive, take action immediately by isolating and notifying close contacts,” the county health officer urged residents in a .

Health officials have taken similar actions in all regions of the country, including , , and .

Within many health departments, the shortage of contact tracers has been exacerbated by the communications challenge of relaying a recent change in from the Centers for Disease Control and Prevention — it reduced the quarantine period from 14 days to 10 for some individuals exposed to the virus.

The idea behind the change the risk of transmission after 10 days of quarantine was low, and shorter quarantine periods might increase people’s willingness to comply with the orders. But the shift also meant that contact tracers had to spend time learning and explaining the new procedures just when caseloads were exploding.

“It makes things more confusing,” said Bacolor, the contact tracer in Washtenaw County. “People might be hearing something different from their job or school than they are from the health department.”

Asking infected people, some of whom might be sick, to call their own friends and families — in effect, conduct their own contact-tracing operation — is far from ideal, public health experts said.

“It is a last-resort tool,” said Beck, the University of Michigan professor. “It is the best that we can do in the situation that we’re in, but it’s a compromised strategy.”

Contact tracing is more than just alerting people to a potential exposure so they can quarantine. Part of the process is to conduct carefully structured interviews with those exposed, to determine if they’ve developed symptoms of covid-19. If so, contacts of those people also need to be traced and told to quarantine, to prevent the virus from proliferating through successive chains of people in the community.

Trained contact tracers also often ask valuable questions to learn more about how the virus was transmitted from person to person so that local health officials can piece together an understanding about which settings and activities seem particularly likely to promote spread — and crowded bars, for example — and which are unlikely to generate outbreaks.

Contact tracing is a key part of a tried-and-true strategy known as “test, trace and isolate.” Public health professor Beck said the strategy has been used and it works — when there are enough people and enough time to do it properly.

And she said effective contact tracing can help mitigate the economic pain of a pandemic because it means that only people with known exposures to the virus must stay away from workplaces and school and refrain from other activities.

But success requires significant investment in public health infrastructure, something that Beck and other researchers said has been lacking for decades in the U.S.

This story is part of a partnership that includes and KHN.

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‘You’re Going to Release Him When He Was Hurting Himself?’

Brett Dahlberg, WCMU — Tue, 29 Sep 2020 09:00:36 +0000

When Joe Prude called Rochester, New York, police to report his brother missing, he was struggling to understand why Daniel Prude had been released from the hospital hours earlier. Joe Prude described his brother’s suicidal behavior.

“He jumped 21 stairs down to my basement, headfirst,” Joe said in a video recorded by the responding officer’s body camera in the early hours of March 23. Joe’s wife, Valerie, described Daniel nearly jumping in front of a train on the tracks that run behind their house the previous day.

“The train missed him by this much,” Joe said, holding his thumb and pointer finger a few inches apart.

“When the doctor called me and told me that they released him, I’m saying, ‘How you going to sit here and tell me you’re going to release him when he was hurting himself? Come on. You weren’t sworn to do that,’” he said on the body camera footage.

At the point of this recorded conversation just after 3 a.m., Joe and Valerie Prude knew only that Daniel was missing, delusional and vulnerable. They didn’t know his next encounter with the police would be fatal.

Police would find Daniel minutes later ― naked, acting irrationally. Because he spat in the direction of officers and allegedly said he had the novel coronavirus, officers placed a white hood, called a “spit hood,” over his head. When he started trying to stand up, despite being restrained by handcuffs, an officer placed much of his body weight over Daniel’s head and pushed it into the pavement.

Daniel died a week later when his family took him off life support. The county medical examiner’s autopsy described his death as a homicide and listed the immediate cause of death as “complications of asphyxia in the setting of physical restraint.” The incident as another example of a Black man killed after an encounter with police.

Less attention has been paid to what happened to Daniel Prude in the preceding hours, when he was treated and released after a psychiatric assessment at Strong Memorial Hospital, run by the University of Rochester Medical Center.

Joe Prude called police at about 7 p.m. on March 22 because he needed help getting Daniel to the hospital. Daniel had been having problems with a PCP addiction, Joe told officers. Now he had begun telling Joe and Valerie that people were out to get him, and he wanted to die.

By about 11 p.m., Daniel was released from the hospital, according to Joe and police records. “He was calm as hell when he got back here,” Joe told police.

That didn’t last.

“He was fine for a little bit, then all of a sudden started acting crazy,” Joe said. He told police that Daniel asked him for a cigarette, and when he went to get one, Daniel took off running. He was barefoot, wearing only a tank top and long johns in 30-degree weather.

“He was gone. Track star status. Hauled ass like Carl Lewis,” Joe told the officer.

Around 3 a.m. the next day, four hours after his release from the hospital, emergency dispatchers started fielding calls about Daniel Prude. His brother reported him missing, and a tow truck driver spotted him, naked and bloodied, on West Main Street, police records show.

Police body camera footage shows that by 3:20 a.m., officer Mark Vaughn was pressing Daniel Prude’s head into the pavement.

While restrained, Prude stopped breathing. An ambulance crew resuscitated him, but he was in critical condition. His brain was damaged after being deprived of oxygen. He died a week later at Strong Memorial after being taken off life support.

The University of Rochester Medical Center said patient privacy laws bar it from discussing the specifics of Prude’s treatment and release, but, in general terms, spokesperson Chip Partner said, the hospital is bound by a that requires patients to be released within 24 hours unless they have a mental illness that is likely to result in serious harm to themselves or others and that requires immediate observation, care and hospital treatment.

The details of Prude’s encounters with law enforcement and the health care system offer a look into the practice of emergency psychiatry, and how, in the U.S., mistakes in that field are disproportionately borne by Black people.

Medical decisions in a case like Daniel Prude’s are high-stakes, with little margin for error, said Dr. , chief medical officer of the National Alliance on Mental Illness.

“Emergency psychiatric assessment is very challenging, and the potential for catastrophic outcomes following your decision is very real,” he said.

The hospital where Prude died has faced scrutiny over its treatment of psychiatric patients and discharge procedures before.

In , federal inspectors found security officers at the hospital had used law enforcement restraint techniques against a pediatric psychiatry patient, breaking her arm and sending her to the emergency room.

, inspectors found the hospital discharged a patient who was in the emergency room with a history of dementia and multiple medical problems despite a discrepancy in her address between her medical record and the information she gave hospital staff.

, inspectors found that hospital staff had placed patients in ankle and wrist restraints without an order to do so, and placed another patient in restraints without documenting when the restraints were released. Restraints are meant to be used only with a physician’s order, and require precise documentation of their use.

None of these incidents at Strong Memorial Hospital garnered media attention at the time they happened or at the time the reports were made public.

Strong spokesperson Partner said that immediately after the April 2018 inspection the hospital changed its public safety protocol to eliminate the use of law enforcement techniques to manage a violent patient unless that patient is being arrested.

He said updated staff training and discharge protocol after these incidents now mitigates the risk of discharging someone who was not ready to be released. “These protocols were well established in 2020 and had absolutely no bearing on the evaluation or treatment of Daniel Prude on March 22,” Partner said.

Prude’s case is unusual because the consequences of the decision by doctors to release him have played out so publicly, said Duckworth. Usually, emergency room psychiatrists never find out what happened to their patients.

“You make a very big decision, which usually has no known outcome. You put this person in the hospital, you go on to the next patient. You send this person home, you go on to the next patient,” he said.

Duckworth said he would not second-guess the actions of Prude’s hospital team in the moment, but with the benefit of hindsight, “there’s overwhelming evidence that he had a psychotic illness and was quite vulnerable,” he said. “He didn’t need to die.”

In a statement, URMC said its treatment of Prude was “medically appropriate and compassionate.”

Several oversight organizations are investigating.

, which certifies hospitals to receive federal funding, it’s reviewing Prude’s treatment at Strong. New York state’s Justice Center is investigating on behalf of the state Office of Mental Health.

The university medical center itself is still conducting an internal clinical review.

In response to questions from NPR and KHN about whether the hospital’s treatment of Prude could have been affected by his race, Partner said the medical center asked , past president of the American Psychiatric Association, “to conduct a third-party independent review through her lens as a national expert on racism and bias in psychiatric care.”

In a separate interview before the request from URMC, she described how unconscious bias can cloud clinicians’ judgment and make it difficult for them to make the best possible decisions for their patients.

“It is very clear that in today’s health care system, bias is built in structurally,” Stewart said. “Seeing a tall, imposing Black man who is behaving aggressively puts in place a series of ideas and thoughts and assumptions that direct decision-making.”

Psychiatric disorders in Black patients are than in white patients, Stewart said. Unequal treatment starts early.

Black boys than white boys of the same age, said Stewart, who is also the director of the .

“So a Black child with a meltdown is described as aggressive, obstinate, oppositional,” she said, “as opposed to traumatized, depressed, anxious.”

Those expectations follow Black boys through adulthood and in the health care system, increasing the odds that doctors will view Black men as a lost cause and , Stewart said.

She stressed that she does not have any direct knowledge of deficiencies in the care of Daniel Prude, but she said that Black men, like Prude, are disproportionately likely to be misdiagnosed, mistreated and written off as a result of structural bias and unconscious racism.

A group of medical students at the University of Rochester wrote in that Daniel Prude was “sentenced to death by our failed healthcare system.”

“Not only do our current models of healthcare leave gaping holes for individuals such as Daniel to fall through, but they do so in manners which are fraught with racism,” the students wrote.

Partner, the medical center spokesperson, said the psychiatry department’s will evaluate Daniel’s treatment for potential bias. He said the medical center “recognizes that we have a long way to go before we can confidently say that our policies and practices are universally culturally appropriate to the populations we serve.”

Both Stewart and Duckworth said reducing the role that police play in addressing mental health crises would increase the odds of survival for a person released too early from psychiatric care.

Federal inspection reports show that hospitals across the country have released patients who, like Prude, ended up in grave danger only shortly thereafter.

In , a patient with a history of schizophrenia, post-traumatic stress disorder and suicide attempts arrived at Russell County Hospital in Kentucky complaining of alcohol withdrawal, depression, anxiety and pain. An hour and a half later, the patient was discharged with instructions to “follow up with his/her primary care provider and take medications as prescribed.” Two hours later, the patient was back in the same hospital. A physician’s notes said the patient had drunk a bottle of Benadryl “in effort to kill self.”

In , federal inspectors found that UT Health East Texas Pittsburg Hospital discharged a patient who had verbalized a plan for suicide. The patient got a ride to his truck from the county sheriff. Later that day, the patient was found dead in the truck from a self-inflicted gunshot wound.

at Stafford County Hospital in Kansas, a patient arrived in the emergency room saying she had drunk half a liter of vodka because she was upset and wanted to die. She told hospital staff that she started drinking that day after two years of sobriety and that she “did not feel safe to go home due to the presence of alcohol.” The hospital discharged her 11 minutes later.

, inspectors found that a patient with a history of psychosis went to the emergency room at Mercy Hospital in St. Louis and told staff she needed to get back on her medication. She was delusional, disoriented, homeless and unable to give her name. She was discharged with a voucher for cab fare but no follow-up appointments or services and no plan to ensure she got her medication.

A spokesperson for UT Health East Texas said the health system has since implemented a process for staff to more thoroughly document mental health concerns in patient records. Mercy Hospital in St. Louis said it takes the health and safety of each patient very seriously “regardless of race, ethnicity or ability to pay.”

Neither of the other hospitals responded to emails or calls seeking comment.

This story is part of a partnership between and KHN.

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