Cases of COVID-19 were rising steeply two months ago when the dean of the UT Health School of Public Health in San Antonio was negotiating the hiring of hundreds of case investigators and contact tracers to slow the spread of the deadly disease.
In a June 17 email to officials at the San Antonio Metropolitan Health District, Dr. Jack Tsai raised an overarching concern.
“Your ask was to also have all case investigators working on site in a large office space,” Tsai wrote. “Due to financial costs and concerns about COVID infection among case investigators, I suggest a hybrid approach of having some additional office space for key staff but having most case investigators and contact tracers working remotely.”
Two months later, Metro Health still requires all case investigators to work in a cavernous but communal space at the Alamodome that can fit up to 200 people, creating a risk that has led some recruits to opt out of the job.
Case investigators perform the critical task of calling those who test positive for COVID-19 and asking them to recall their close contacts. In a separate process, contact tracers then call those close contacts and urge them to quarantine for 14 days to break the chain of the coronavirus transmission.
UT Health’s $2 million contract with Metro Health called for the school to hire 200 case investigators by the end of November.
On ExpressNews.com: Metro Health waited to hire enough COVID-19 trackers until virus had pummeled San Antonio
Last week, UT Health had hired and trained 50 case investigators. On a timeline directed by Metro Health, they began working at the Alamodome on Wednesday along with about 115 Metro Health staff, many of whom have been pulled from duties such as immunizations, which are down across the country.
The health districts’s plan to scale up the workforce as needed, rather than hiring and training more workers before another wave strikes, has alarmed some public health experts who worry that San Antonio is on thin ice with COVID-19. Workplaces and schools are beginning to reopen, raising the threat of another surge of infections, hospitalizations and deaths.
Jimmy Perkins, a former dean of the UT Health School of Public Health in San Antonio, watched with dismay in June as Metro Health officials rushed to bolster a meager workforce, in part by urging their own staff to work overtime on case investigations and contact tracing as infections surged. Thousands of cases were backlogged, never to be investigated.
On ExpressNews.com: Metro Health ‘overwhelmed’ by COVID-19 surge
Now Perkins is concerned Metro Health hasn’t learned from its previous mistake.
“It’s the same philosophy that we had two months ago. And you see where that got us,” Perkins said. “You can’t hire and train people fast enough to keep up with the epidemic. So here we are, we’re in the same predicament. We’re understaffed if we were to have another upturn. And we’re going to have some kind of upturn when people get back to going to school.
“When people die from something like this and we know how to prevent those deaths, and we’re not doing everything we can to prevent those deaths,” he said, “somebody ought to be questioned about that.”
Metro Health Director Colleen Bridger said the city department has enough case investigators and contact tracers to handle the current load, as well as any coming surge.
Fifty more case investigators hired by UT Health will join the workforce in September, she said, even as Metro Health returns 43 redeployed staff members back to their original jobs.
“I think what we’ve created here is a happy medium because we do have 165 people, and we’re going to add 50 additional starting Sept. 1,” Bridger said. “I think if you ask anyone, including the critics, when they think the next spike will happen, they will say after Labor Day. We will have 215 people trained and ready to work for that surge that happens after Labor Day.”
Metro Health has doubled the number of investigations completed in an eight-hour shift from five to between 10 and 12, Bridger said, meaning that investigators can now process from 1,650 to 1,980 cases a day.
“We literally have more people doing case investigations than we have cases to investigate,” she said. “We’re not going to 3,500 (cases) tomorrow. That’s not how this pandemic has been working. So if we get to the point where we need to bring in those other 100 (UT Health case investigators), then we will do that. The last thing I want to do, though, is to have a bunch of people getting paid to sit at the Alamodome or sit at their homes doing nothing. I can’t defend that either.”
Cases of COVID-19 have fallen in recent weeks from daily highs of up to 2,000 to an average of about 250 a day. On Friday, Bexar County reported 150 new cases.
On ExpressNews.com: Tracking COVID-19 – coronavirus by the numbers in San Antonio
For contact tracing, the city has relied on emocha, a mobile technology company.
Right now, “all contacts are getting a call within 24 to 48 hours,” Bridger said.“We are transitioning that work to the state, which plans to hire 4,000 people to do contact notifications across the state. If we determine the Texas Health Trace staff cannot keep up with notification of the two to three contacts per case, we can either return to emocha or deploy more UT Health staff to do the work.”
‘Cause for concern’
On Aug. 8, a few days before the 50 case investigators hired by UT Health began working at the Alamodome, a contact tracing work group met virtually to discuss updates.
Tsai, the dean of UT Health and a member of the work group, was present at the meeting, which wasn’t public.
According to notes of the meeting, Tsai raised the same concerns he had in June: “Dr. Tsai added that the School of Public Health is looking into remote options because several prospective case investigators were concerned about COVID-19 safety inside the Alamodome. While there is adequate space, hundreds of people in one place was cause for concern.”
The notetaker added in bold: “UT SPH prefers an option to work remotely to adhere to COSA COVID restrictions on gatherings.“
Emergency orders by the city prohibit any gatherings or events of more than 10 people, whether indoor or outdoor. Local government operations are exempted from the rule.
Experts warn that the virus is airborne and spreads more easily indoors.
“As far as I’m concerned, once you step indoors, in my opinion, the 6-foot rule is useless,” Perkins said. “We’re getting more and more evidence about that every day.”
The option for case investigators and contact tracers to work remotely varies across the state.
Some of the 48 on staff at Austin Public Health work remotely, while others work on a rotating schedule onsite. At the Houston Health Department, all 300 case investigators and contact tracers work inside a convention center.
Adelita Cantu, a professor at the UT Health San Antonio School of Nursing and co-chair of the contact tracing work group, said some people hired by UT Health dropped out after learning they could not work remotely.
“Right now, (Metro Health) brought in 50 to 60 and they closed the job recruitment,” Cantu said. “They definitely had a lot of people who applied, and they were going to start out with this amount. They originally hired more, but when people found out that there wasn’t going to be a remote option, they dropped off.
“Individuals were told they did not have a remote option,” she added. “And most people thought they were and did not go with the offer for not having that option.”
Tsai declined to be interviewed for this article. A UT Health spokeswoman replied to emailed questions.
“Dr. Tsai does not want to comment about prospective case investigators,” she said. “He is hopeful there will be a remote option. The school is planning for additional leased space within its building for case investigators.”
Last month, Bridger said case investigators would “probably not” work remotely, “at least not in the near future.”
“For people who haven’t been doing this for their public health career, they need to be in a location where they can ask questions, where they can get that ongoing daily kind of huddle — here’s what we’re finding, here’s what we’re doing, here’s how we’re working around x, y, and z,” she said then. “So at least for a month or so, we’re going to need to be still co-located and figuring out together how we’re addressing this ever-changing situation.”
On Friday, Bridger said Metro Health has made some technological strides, and an option for remote work is on the horizon. She did not offer a timeline.
“Once staff are trained and the new processes are developed to allow remote work,” Bridger said, “we will.”
Mayor Ron Nirenberg said Metro Health ought to support a remote-work option for case investigators who might prefer it.
He said he was encouraged by the efforts of the health district to increase its workforce.
“I think we have to make sure that we have the capacity to trace the number of cases that we might experience at the high point of a peak, and not what we have now,” Nirenberg said. “And based on the operations that have been put in place previously, we needed to hire up, and that’s what they’ve been doing.
“We don’t want to find ourselves in the same situation we found ourselves in in June,” he added.
Cantu, co-chair of the contact tracing work group, said expanding to allow remote work is critical as fall approaches. She cited a recent warning by Dr. Junda Woo, medical director at Metro Health, that coronavirus outbreaks are bound to occur in schools despite the best preventative measures.
“If that’s the case, then the more tools we have at our disposal to mitigate an outbreak, you want to have that process in place,” Cantu said. “I think being remote, we would certainly have more access to people who want to do it, and feel safe to do it, too.”
Bridger said anyone concerned about Metro Health’s current workforce should be reassured by the math.
“I think they’re more worried than they should be,” she said. “I think that perhaps having a better understanding of the complete picture might help them. If we have the same surge tomorrow that we had last month, we are 100 percent staffed and ready to deal with that.”