Whiteriver Indian Hospital in eastern Arizona saw its
first COVID-19 case on April 1. Physician epidemiologist
Ryan Close, MD, MPH, said that the hospital's service
area, about 18,000 American Indian people on the Fort
Apache Indian Reservation, “had some of the
highest case counts per day as anywhere seen in the
country.” Contact tracing was an important step
to help bring these numbers down.
In addition to treating COVID-19 patients, Close said
that the hospital's role was to make sure residents could
access testing and to proactively test those in close
contact with individuals with COVID-19. The hospital's
contact tracing initiative starts with a phone call, in
which the contact tracer explains that the person
receiving the call has tested positive for COVID-19 and
asks to meet in person to discuss contact history.
Every day, a team of contact tracers wearing personal
protective equipment visits high-risk individuals and
assesses their symptoms. “High-risk”
outreach is focused on those who have tested positive for
COVID-19 and are at particular risk for poor outcomes and
deterioration. This daily effort requires its own team of
about four to six people, who meet with the larger
contact tracing team twice a day.
Besides checking symptoms, Whiteriver Indian Hospital
conducts in-person contact tracing because its service
area has poor cell phone reception and not everyone has
landlines. This was not news to the hospital's public
health nurses, who were already conducting in-person
contact tracing for other communicable diseases. Their
expertise led to the hospital's COVID-19 contact tracing
strategy. Close added that the hospital had to
“quickly double and triple [its] contact
tracing capacity to be able to send people into the
Across the country, contact tracing continues to be an
important step in combatting the coronavirus pandemic,
especially as schools and businesses open up and as
community members become more active outside the home.
In addition, ethnic minority populations have been
disproportionately affected by the pandemic. For
1.3% of COVID-19 cases (in which race and ethnicity
were known) reported to the Centers for Disease Control
and Prevention (CDC) were among American Indian and
Alaska Native (AI/AN) people, even though they make up
0.7% of the United States population. The cumulative
incidence (or cumulative cases of COVID-19 per 100,000
population) among AI/AN people was 3.5 times the
incidence among white people.
In-Person Contact Tracing
Whiteriver Indian Hospital's contact tracing teams travel
with pulse oximeters to test all household members'
oxygen saturation, regardless of whether a person feels
sick. Close has reported cases in which people have not
felt sick but had low oxygen levels: “At the
peak of the epidemic for us, in one in five households
that we would trace, we would find someone who
unexpectedly had low oxygen and had to be
hospitalized.” Now, he said, that happens one
in 20 households.
In addition, a contact tracing team offers to test
everyone in the household for COVID-19. The Whiteriver
Indian Hospital has point of care testing on site, so the
team can collect a test sample, bring it back to the
facility, and have a result in 15 minutes.
If the test result is positive, the team returns to that
home to do additional contact tracing and determine who
outside the home should be contacted (for example,
coworkers or a child's other set of grandparents).
Close said the onsite testing “collapses a
process that in many public health facilities is divided
among institutions.” At Whiteriver Indian
Hospital, the process “all gets collapsed into
one person, which probably cuts down multiple
Contact tracers at Whiteriver Indian Hospital include
public health nurses, outpatient nurses, health
technicians, medical assistants, physical therapists,
physician assistants, pharmacists, doctors, and community
volunteers. Contact tracers travel in teams of two when
going on home visits. Teams are paired up based on how
their strengths complement each other: for example,
pairing someone's medical expertise with another person's
What good is that professional and their 20 years of
education if they can't get from the hospital to the
person's home? A community volunteer will know the
language, the people, the community, and the roads. You
can't buy that [expertise] and you can't train it into
Emphasizing the paired importance of medical expertise
and cultural competency, Close said, “What good
is that professional and their 20 years of education if
they can't get from the hospital to the person's home? A
community volunteer will know the language, the people,
the community, and the roads.” He added,
“You can't buy that [expertise] and you can't
train it into people.”
Of course, these skills are not mutually exclusive: Close
recruited a number of health techs and nurses from the
community, with medical expertise as well as cultural
competency, to the contact tracing team. “As a
white male of privilege and a physician,” Close
said, “I'm trying to be aware of how little I
know about the people I serve so that I can serve them
better, by surrounding myself with people who can inform
me on what I need to know to lead the team.”
Developing Training for Contact Tracers
Up north, the
Alaska Center for Rural Health and Health Workforce
(ACRH-HW) is leading efforts to train enough contact
tracers to meet demand. ACRH-HW is housed in the state's
Area Health Education Center (AHEC) program, which is
funded through the Health
Resources & Services Administration (HRSA). Part of
the AHEC program's work is continuing education and
training, so it was a natural fit for the ACRH-HW to
“rise to the occasion,” ACRH-HW
director Gloria Burnett said.
Alaska did not have many COVID-19 cases at the beginning
of the pandemic, Burnett said, so that gave the state
time to prepare. In May, the Alaska Division of Public
Health projected that the state would need 500 additional
contact tracers to address the pandemic. The division was
looking for someone to create a training procedure and a
way to hire contact tracers in a temporary capacity. In
addition, the state needed experts in using the new
documentation software that contact tracers would use.
Burnett said the ACRH-HW already had established
relationships with many community health centers and
Critical Access Hospitals across the state and could
figure out training logistics, registration, and other
non-curriculum aspects. The Division of Population Health
Sciences, housed at the University of Alaska Anchorage,
had the content matter experts to develop the training
The training is asynchronous, so trainees can work at
their own pace on their own schedules. If a trainee is
inactive for a specified amount of time, they receive an
email explaining that their account will be deactivated
unless progress is made by a certain deadline. Removing
inactive trainees from the program allows people on the
waitlist to fill those vacancies.
In Washington, the Northwest Center for Public
Health Practice was tasked with creating a contact
tracing training for a national public health audience.
The Northwest Center is housed at the University of
Washington School of Public Health and serves Washington,
Oregon, Idaho, and Alaska.
To develop this training, the Northwest Center received
funding from the Kansas Health Foundation and
contributions from the Kansas Health Institute and the
Kansas Department of Health and Environment, because
their state needed a training like this for its
workforce. The Northwest Center assembled a team of
instructional designers, e-learning experts, and subject
University of Washington professor of epidemiology Dr.
Janet Baseman reported that since the Northwest Center
already develops online training, it had the
infrastructure in place to create a training for contact
tracing. That existing infrastructure allowed the center
to create Every
Contact Counts quickly — in fact, they
created the training in under three weeks. Since
Washington was one of the first states hit with COVID-19,
the Northwest Center was able to bring real-life examples
into the training.
Free for public health audiences, Every Contact Counts
takes 60 to 90 minutes to complete. Trainees learn how to
describe contact tracing to the people they're calling
and how to complete interviews. Trainees also watch
skill-building videos and complete quizzes and exercises.
Customizing Training Curricula
Because many organizations don't have the time or
resources to create a training curriculum, the Public Health
Foundation (PHF) has also stepped in to bridge those
gaps by taking existing curricula and creating a
customized training package at the request of health
PHF, celebrating its 50th year, is a
national nonprofit, nonpartisan organization that
develops tools, trainings, and other resources concerning
quality improvement, performance management, and
workforce development. For the last eight years, the
foundation has provided onsite and remote assistance to
about 500 health departments. In addition, its TRAIN Learning
Network has 2.5 million registered learners, 280,000
of whom are governmental public health professionals.
PHF president and CEO Ron Bialek said that when the
pandemic emerged, he saw an increasing amount of
COVID-related training, including for contact tracing.
PHF first developed a set of
tailored live searches on different training topics
available through the TRAIN Learning Network, to make it
easier for people (health departments as well as
voluntary organizations and companies) to find the
training they're looking for. Between March 1 and August
1, PHF received about 125,000 visits to that set of live
searches and over 100,000 trainings taken as a result.
We were hearing from health departments of practically
all sizes and shapes, rural, urban, suburban, that
they're overloaded. They were having difficulty with
figuring out how to effectively train people and,
especially in rural areas, they didn't necessarily have
the time, the equipment, the expertise to develop the
In addition, Bialek and his team wanted to ease the
process of contact tracing for health departments.
“We were hearing from health departments of
practically all sizes and shapes, rural, urban, suburban,
that they're overloaded,” Bialek said.
“They were having difficulty with figuring out
how to effectively train people and, especially in rural
areas, they didn't necessarily have the time, the
equipment, the expertise to develop the training
themselves.” Along with developing a training,
health departments would need to provide contact tracing
forms, consider local privacy rules, and figure out how
to keep track of who has completed training.
To address these issues, PHF launched a free service in
July that customizes contact tracing training curricula
for state, tribal, local, and territorial health
departments. Health departments can choose nationally
available training, state-offered training, and any forms
like privacy policies, and PHF combines them into one
online curriculum package, which can be launched and
tracked through the TRAIN Learning Network.
To date, PHF has received curriculum customization
requests from rural and tribal health departments in nine
states: Arizona, Colorado, Kansas, Idaho, Ohio, Oregon,
Texas, Wisconsin, and Wyoming.
PHF has received about 80 requests total from health
departments of any size. In some cases, Bialek said,
“It turns out the health department doesn't
really want a customized curriculum, but they never knew
where they could even find the training.” So
PHF connected them with a training package that already
existed instead of customizing one for them.
“At the end of the day,” Bialek said,
“we don't want to insist you have to use [a
customized curriculum] package. We want to help you find
what you need.”
At the beginning of this project, program coordinators
thought the easiest approach for this service was to have
health departments contact one person, either through a
call or an email, and explain what they wanted in their
curriculum package. Investigating why that approach
resulted in so few requests, the coordinators found that
even a 20-minute phone call was more time than these
health departments could give.
“So we then put our heads together and said,
'How can we make this even easier?'” Bialek
said. His team decided to create an
online form in which health departments could choose
between building their own curriculum or starting with
the CDC Foundation adapted trainings.
If health departments want to add any local resources,
they send a hyperlink or an electronic file of the
material to PHF. In less than a week, PHF sends the
curriculum package to the health department. Each package
comes with an access code to help health departments
limit access to and keep track of who's accessing the
training. Health departments also receive an orientation
Just by switching to the online form, Bialek said,
requests increased from around 10 requests in the first
couple weeks to its current tally of about 80.
In Alaska, as of July 21, over 1,300 individuals had
expressed interest in becoming contact tracers; of these,
228 people had completed the ACRH-HW training process.
Burnett also pointed out that the first 500 people to
complete training receive a stipend, funded through the
Coronavirus Aid, Relief, and Economic Security (CARES)
Act and matching funds from the state of Alaska.
The ACRH-HW also partnered with the Alaska Native Tribal Health
Consortium to recruit licensed professionals. In
addition, the ACRH-HW markets the training opportunity
throughout state nursing home and hospital associations
and tribal health systems.
We really wanted to make sure that even the spots
throughout the state that might only have one public
health nurse serving had a supplemental workforce to
assist them with those contact tracing efforts.
Burnett's organization made sure every region of Alaska
was represented when recruiting people to take the
contact tracing training. “We really wanted to
make sure that even the spots throughout the state that
might only have one public health nurse serving had a
supplemental workforce to assist them with those contact
tracing efforts,” Burnett said.
In Washington, Northwest Center director Dr. Betty
Bekemeier said that within days of Every Contact Counts
being launched, over 1,000 people had taken the training.
In Kansas, the Department of Health and Environment
requires this training for all new contact tracers.
Bekemeier added that a Canadian organization reached out
and asked if Every Contact Counts could be translated
into French for their service area.
In Arizona, Close and his colleague Myles Stone, MD, MPH,
published about Whiteriver Indian Hospital's contact
tracing efforts in the New
England Journal of Medicine COVID-19 Notes. The
note, published on July 16, reported that the community's
case fatality rate was 1.1%, less than half the state
Whiteriver Indian Hospital has confirmed 2,300 cases of
COVID-19 through its testing and contact tracing efforts.
Close reported that the contact tracing teams have made
contact with 100% of COVID-19 cases and have reached 90%
or more of these individuals' contacts.
Close credited the hospital's success rate in part to its
strong relationship with tribal leadership as well as the
overall community. Since the hospital is on the
reservation and regularly serves tribal members, contact
tracers were familiar faces to the individuals they were
visiting. In addition, the hospital and tribal leadership
established a unified incident command with daily
meetings when the pandemic started so they could
communicate any new developments and work together to
serve their community.
The peak of the pandemic came mid-June in this area.
Close credited the drop in case counts to tribal
leadership, who effectively put social distancing and
mask wearing policies in place.
Challenges Overcome and Lessons Learned
In his service area, which Close described as an
“interwoven” community, some people
rely on others to bring them groceries or run other
errands for them. If a large number of people are
isolating, who's left to help other households? Close
said, “We quickly had to pivot and work very
hard with our tribal partners to put systems in place, to
start aggressively providing food and essential boxes,
which made a massive difference and empowered people to
stay home appropriately.”
Bialek at PHF also discussed the challenges of
quarantining in rural America, especially when people
can't afford to take two weeks off work to stay home.
Bialek wants providers to ask their COVID-positive
patients, “Are you able to stay home? Are you
able to afford to stay home?” If the answer is
no, then the patient needs to be connected to programs
like rent assistance or food banks.
In Washington, one challenge in creating Every Contact
Counts was the quick turnaround time. Bekemeier said that
they needed to create the training quickly, but it still
needed to be good. After the training was created, the
team met to discuss what went well and what didn't.
Overall, Bekemeier said the process went smoothly enough
that “we were still pinching
Her colleague Baseman added, “We just happen to
have a great team that we were able to pull
A really well-trained contact tracing workforce is
There are challenges in over-the-phone contact tracing:
tracking down contacts, getting them to answer the phone,
and building enough trust so contacts feel comfortable
sharing information. Baseman said contact tracers need to
be persistent and empathetic. She said, “A
really well-trained contact tracing workforce is
One challenge in Alaska's training initiative is the
onboarding process: trying to find the balance between
getting new trainees into the field quickly and making
sure they're adequately prepared. Burnett said the
organization has “more than enough entry-level
interest” but needs more licensed professionals
who can lead contact tracing teams and take part in a
Burnett said she and her team assumed they'd be able to
use the documentation software on their personal devices,
but the IT department worried about information security.
They decided to purchase laptops to be used for contact
tracing but the laptops are on backorder. She advised
other facilities to consider the technology and equipment
needed for contact tracing.
But she reminded larger organizations to keep rural
partners' limitations in mind. When the IT department
expressed concern over using anything besides encrypted
computers, Burnett said she pushed back: “You
want somebody in Kotzebue, Alaska, to do this, right?
You're going to have to provide them with a piece of
equipment then, and you're going to have to let them use
their own phone.” She added that
“pushback from that rural
perspective” was important to shift the IT
Burnett also recommended that facilities interested in
helping with recruitment efforts reach out to their AHEC.
Even if the AHEC itself isn't leading contact tracing
initiatives, they most likely know which organizations
Burnett said the bureaucracy, especially working across
multiple organizations, is like “these brick
walls put up that you're slowly chipping away. Well, I
really can confidently say that all partners involved are
trying to do whatever they can to take those walls down
Allee Mead is a web writer for the Rural Health Information Hub. She has written on important rural issues, including maternal mortality and farmers' mental health, and has presented nationally on RHIhub's opioid resources. Originally from rural North Dakota, she has a master's degree in English. Full Biography