A Crash Course in Contact Tracing

How Trust and Transparency Can Take Down a Virus with Dr. Joshua Sharfstein

Contagious Conversations  /  Episode 15: A Crash Course in Contact Tracing

Crisis management, contact tracers and COVID-19

How much do you really know about contact tracing? And would you have what it takes to be a successful contact tracer? Dr. Joshua Sharfstein of Johns Hopkins Bloomberg School of Health takes listeners through the essential ins and outs of contact tracing during a public health crisis like COVID-19.



(View full transcript)





Below: Dr. Josh Sharfstein gives a live interview from the same personal studio where he has been recording episodes of Public Health on Call.





Claire Stinson: Hello, and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help CDC save and improve more lives.

Joining me today is Dr. Joshua Sharfstein, vice dean for public health practice and community engagement at Johns Hopkins Bloomberg School of Public Health and is knowledgeable about the field of contact tracing. Dr. Sharfstein is also director of the Bloomberg American Health Initiative, and professor of the Practice in Health Policy and Management. Previously, he served as the secretary of the Maryland Department of Health and Mental Hygiene, the principal deputy commissioner of the U.S. Food and Drug Administration, commissioner of health for Baltimore City, and as health policy advisor for Congressman Henry A. Waxman.

In this episode, Dr. Sharfstein discusses the important role of contact tracing related to COVID-19. He also shares information about a new online course through Johns Hopkins, which provides training for people who want to become contact tracers and the importance of collaboration in public health. Welcome Dr. Sharfstein!

Josh Sharfstein: Thanks for having me.

Claire Stinson: We're glad that you're a part of this conversation. So, Dr. Sharfstein, you've had a long career working on public health issues on both a local and national level. Can you tell me what drew you to the field of public health?

Josh Sharfstein: You know, it was just one moment where I realized that public health brought together so many of my interests. It has this incredible relationship with individuals, which I really appreciated as a pediatrician. It has a deep connection to policy and the ability to affect many people at once, help many people at once. It is exciting because things are happening all the time that require immediate responses. There are great colleagues, you get to engage with multiple communities. I was a pediatrician at the Latino Clinic at Boston Medical Center and speak Spanish. So all of a sudden, all these different interests that I had kind of came together and I realized that public health was just an amazing field.

Claire Stinson: Well, it sounds like you've really enjoyed it. And you said you are a pediatrician?

Josh Sharfstein: I am a pediatrician. That's correct.

Claire Stinson: What's your favorite thing about being a pediatrician?

Josh Sharfstein: My favorite thing about being a pediatrician is talking to parents. I just love the relationship that you can have with parents around the health and happiness of their child. I am not seeing patients at the moment, but one of my favorite things to do was to say to a parent, just look at how your child looks at you, and how important you are in their life, and what an amazing opportunity that is for both of you and just to bond with the parent around that. It was just very special.

Claire Stinson: Well as a mom that resonates with me. I'm sure you're a great pediatrician. So Dr. Sharfstein, let's talk about your current role. You serve as the vice dean for public health practice and community engagement at Johns Hopkins Bloomberg School of Public Health. This past semester, you actually taught a course titled crisis and response in public health policy and practice. What are some of the questions students had for you this semester as the pandemic unfolded?

Josh Sharfstein: Sure. So let me just tell you a little bit about the course. When I came to the school, I was asked to start a course to teach and I thought, "Well, I'll do something like public health policy." And they're like, "Well actually there is a public health policy course." And then I said, "Well, what about politics and health?" Because I had these different political jobs in public health. They said, "Well, there's actually a course called politics and health." Something like that. "And we don't want to have two courses called the same thing, so come back with a different topic."

So I thought about it and I talked to my department chair, Ellen McKenzie, and she said to me, "How about teaching a course that you wish you had taken before you went into public health?" And I thought, well, that's easy. I wish I'd taken a course on crises, because you get into public health and there's one crisis after another that hits. Some are bigger, some are smaller. But to you, they can all feel big. I really wish I had understood more about that.

So I set out to try to teach that kind of course, which is what this course is about. And it's about not just disasters and disaster management, but crises, which are things that really command attention and everybody's suddenly focused on public health and what you do next really matters. So really figuring out how a public health leader can identify crises quickly, respond well and essentially learn the lessons of crises in order to prevent future problems and help people become healthier. So that's kind of what the course is about. And of course, we started this year in January and we're always talking about current events. It's like, "Wow, there might be a new kind of virus in China. I wonder whether that might be a pandemic, and isn't that interesting?" And we talked about it a little more, a little more, a little more. And by the end of the class, we were all on Zoom because the school had been closed down in a pandemic.

So we talked about it the whole term. I think we were a little frustrated by various responses. One of the themes of the course is that it's really hard to recognize you're in a crisis. It's really hard. For anyone. Especially if there's such a magnetic pole to just assume everything's going to be normal again. And we, I think, saw that to a certain extent in China. We certainly saw that to a certain extent in the United States. So we were all talking about, "Wow, people really aren't grasping how significant this could be." And I think the students really appreciated the point about how hard that can be in the middle of a crisis.

Claire Stinson: Oh, I'm sure it was a fascinating course. And I'm sure that you got a lot of great questions.

Josh Sharfstein: Yeah, well, I think the main question that students had for me is how come people aren't doing what you recommend in your book? And that's a hard question to answer. The book says, "Acknowledge there's a crisis. Communicate consistently. Have really knowledgeable people as the lead communicators. Find things that people can do. And centralize a response process so everybody knows their role." Not all of those things happened. Some of those things still haven't happened in this country, so I think they were kind of frustrated by that. Actually, the last course that we did, we had a Washington Post reporter attend on Zoom, and they wrote a story in the Post, which was about this dichotomy. Learning the right way to handle crises and then watching a whole bunch of challenging responses in the real world.

Claire Stinson: What a fascinating class to take right now during COVID-19. It sounds like you were the right professor for the job.

Josh Sharfstein: All I'll say is it was fun... The crisis wasn't fun, but it was fun to see the students really paying attention, really learning, and I've kept in touch with a number of them.

Claire Stinson: Well, that's amazing. And it sounds like that's a real world example that provided the perfect way to learn about crises in real time. So Dr. Sharfstein, the general public has a basic understanding of the role that doctors and nurses play in our healthcare system. But as COVID-19 continues, do you think the greater public is gaining an understanding of public health workers who work at the national, state, and local levels?

Josh Sharfstein: I think so. I think it's a bit in fits and starts. And I'm very worried that in some parts of the country, their understanding of public health officials is that public health officials are telling them to do things that they don't want to do, and some people are harassing and attacking personally people who have been working in their own communities to advance health for many years. I think it's a very disturbing trend.

So I think that's just one part of the overall picture, though. I think you have many more people who appreciate the work that's going on. And I think it's sort of coming out in little bits and pieces. So for example, you'll see the health official standing at a press conference, explaining things to the public. You'll see information about testing centers that the health department may be organizing or collaborating on. The dashboards that health departments are doing are an incredibly important source of local information. And then of course you have contact tracing with the health department reaching out to people who are infected and helping them stay safe and then track the virus so other people can't be infected. So I think the knowledge and awareness of public health is growing in this country, and for the most part for the better, although, like I said, I think there's some very unfortunate trends as well.

Claire Stinson: Absolutely true. And this pandemic has really brought so many public health issues to the surface. So let's talk about contact tracing. As the nation looks to reopening and recovery efforts, contact tracing will play a key role. For those listening who may not be familiar with contact tracing, can you explain some of the core functions of a contact tracer?

Josh Sharfstein: Sure. So contact tracing is basically a... you don't have a medicine, you're not using a vaccine, but nonetheless, you are fighting an infectious disease. And the idea is to find where the infectious disease is inside a person, help that person, and then help them stay safe and separated from others so that they don't pass it on to other people. And if they've already exposed other people, you find those contacts and you help them stay safe and separated from other people so that the infectious disease could be a bacteria, it could be a virus, has no place to go. So instead of a virus like the coronavirus infecting three people from every one person infected, maybe the virus doesn't jump to anyone, or it just jumps to one person. So by doing that, you can really slow the rate of infection.

Now for the coronavirus, in some places, there are a lot of people who have the infection and you need quite a lot of contact tracers in order to be able to slow the infection. But in other places where there are not so many infections, contact tracing can be an effective way of bringing the level of infections down to almost none. On a practical level, a contact tracer spends their day calling people, talking to people who are infected, and making sure that they're safe, providing them with resources, asking them who they might have exposed during their infectious period, and then reaching out to those people and having them quarantine themselves, giving them support to quarantine. And by doing that, you can reach them sometimes before they even become infectious, and even if they get sick while they're in quarantine, nobody else is at risk, so it really can slow the spread of the virus.

Claire Stinson: That's very interesting. It's certainly a big deal in the world of COVID-19 and many public health experts have cited contact tracers as critical to helping to slow the spread of COVID-19. What kind of infrastructure is needed to help these tracers be most effective?

Josh Sharfstein: So there are a few aspects of the infrastructure that are important for contact tracing. One is people really need access to testing and rapid testing, meaning you can't be told to wait a week before testing starts. And then when you get a test, you need the results pretty quickly so that you can respond fast. A contact tracer needs to have good information about the phone numbers to reach someone. And then, when you get the contacts, the good information about the contact's phone numbers. It's also really important that there be resources behind contact tracing. So if somebody says, "I'd like to stay separated, but I've got no food at home," the contact tracer should be able to provide food. In other cases, it may be that people say, "Look, I'm living with 10 people in this relatively small place. There's no place I can separate myself from others." The contact tracer should be able to hook that person up with a hotel room or something for the period of their quarantine. So it's important both that the testing and public health system work well, but also that there be a strong system of social supports.

Claire Stinson: Wow, that's really interesting. So lots of important roles for contact tracers, and people are hearing about them in the news so much, so it's so important that we understand this critical role. I will say there's been some public misunderstanding about the role of contact tracers, which can negatively impact the ability of these contact tracers to do the jobs. What is the biggest misconception that you have heard?

Josh Sharfstein: Well, I think there's a misconception that there's some sort of tracking that the person may be doing that is without somebody's consent or understanding. And really contact tracing doesn't need to involve anything that has to do with cell phones. It's just somebody calling and explaining the purpose and helping somebody stay safe and finding out where the virus might have spread to and then helping those people stay safe. That's what contact tracing is.

Claire Stinson: That's a really important point. What would you want us all to know about contact tracing?

Josh Sharfstein: Well, fundamentally it is somebody from the health department who is reaching out to help you stay safe and to help the people you might have exposed stay safe, and eventually to help the community stay safe by reducing the chance the virus can spread. Contact tracing has been used for many diseases over time. Tuberculosis, syphilis, HIV, and each time it's done with a lot of care to privacy and confidentiality, and really can be one of the tools that reduces the harm an infectious disease causes in a community.

Claire Stinson: Thank you for explaining that. It's such a critical function of the response for COVID-19. So it's important for all of us to know about this critical role. So when you look at getting contract tracing programs started and running around the country, are there certain areas or populations where they are needed the most?

Josh Sharfstein: Well, I think anywhere there's COVID, there's a need for contact tracing. I think it's important to keep in mind that contact tracing does depend on trust. It depends on the fact that people will answer the phone, be honest, talk to the public health department. And trust is a complicated concept sometimes, but it is enhanced when people are able to relate to other people. So hiring contact tracers from within the communities that are most affected by COVID makes a lot of sense. Community health workers can be good contact tracers. Baltimore, where I live, is hiring 300 community health workers, largely to be contact tracers. And it's important that people speak the language of the people they're reaching out to. So there are a whole range of ways to make contact racing more effective.

Claire Stinson: Thank you for explaining that. We'll be right back with Dr. Joshua Sharfstein. Since this season of Contagious Conversations is about the COVID-19 pandemic, please visit the CDC website for information and resources for how to protect yourself, what to do if you are sick, and the most up to date guidance and information. Visit cdc.gov/coronavirus. And now back to our conversation with Dr. Sharfstein. So would you say that contact tracers are needed more in urban or rural areas?

Josh Sharfstein: I would take a contact tracer in a rural area, and I would take a contact tracer in an urban area. It's a little bit like green eggs and ham. I would take a contact tracer who's tall, a contact tracer who's short, a contact tracer who is young, a contact tracer who's old. I think what really matters is that they understand the transmission, they care about the people that they're going to be reaching out to, and that they're personable, able to relate to people, can empathize and can make a human connection. That's really important, because this is fundamentally human activity.

Claire Stinson: I love the green eggs and ham analogy. That's great. So let's talk about your work at Johns Hopkins. In May, Johns Hopkins and Bloomberg Philanthropies announced the launch of an online course, which would provide training for people who want to become contact tracers. It's a six hour course. From your perspective, what are some of the key skills to be a successful contact racer?

Josh Sharfstein: Sure. Well Dr. Emily Gurley put together the course. We've had over 400,000 people enroll in the course and well over a hundred thousand people complete the course, pass the assessment. The course has gotten rave reviews, and it's very easily findable for people, if you go to Johns Hopkins and contact tracing course online, and it's free. It is about five or six hours long, and it covers some key topics, including how the coronavirus is transmitted. What contact tracing is. There are videos of actual contact tracing interviews with contact tracers calling actors and actresses playing people who are cases and contacts. It talks about the ethical issues and it provides instruction on how to conduct a good interview. So there's a lot packed in, but it's been pretty popular and it's been required by some contact tracing programs in the United States and other places around the world.

Claire Stinson: Wow. That's amazing. And it's such a fundamental need right now. It sounds like there would be a high demand for a course like that.

Josh Sharfstein: I think it has broken a few records, the scores in terms of how many people are signing up. I think there are like 24 million visits to the website. In addition to the, I think near 500,000 people who have signed up so far.

Claire Stinson: Wow. Congratulations. Well, I wish you continued success with that. Can you share some of the successes we've seen in combating public health emergencies using contact tracing, either in the past or currently?

Josh Sharfstein: Well, contact tracing has been used for different types of infectious diseases. It's how tuberculosis outbreaks can be cut back. It's how sexually transmitted diseases can be addressed sometimes. So contact tracing was also vital for the elimination of smallpox from the world. It's a very long standing public health technique, and it has been able to be implemented with privacy, confidentiality, and care.

Claire Stinson: It has such a critical role both now and in the past, so thank you for explaining that. So in 2018, you authored the book, The Public Health Crisis Survival Guide: Leadership and Management in Trying Times. As states work to get their contact tracing programs established, what are some effective ways for local public health officials to communicate with the greater public about the importance of their work?

Josh Sharfstein: Thanks. Yes, that book came out of the class that I teach on public health crises, and it does, just like you say, indicate that communication is very, very important. So important to be transparent. Here's what we're doing. Here's the data about what we're doing? What questions do you have? I think it's very important, especially with some confusion out there because of apps and other things that have complicated the picture on contact tracing. It's important for public health officials to be explaining what they're doing and what they're not doing and what protections are in place to reassure people that their information will be handled appropriately. And then I think it's important to run these programs well, and that's hard right now because of just the immense pressure that everybody is under.

It really means getting testing to work well, getting the information through the testing system quickly, getting the information to contact tracers who are well-trained, and getting information back so that the results can be tracked. A measure to watch, ultimately, is the percentage of new cases that are coming about among people who have already been found by contact tracers and are already in quarantine and therefore can't pass the virus on to anyone else. So if you start to see that the new cases are really appearing among people you already know about and who already are separated from other people, you're going to win. And that's really what some other countries and some U.S. States like Hawaii have been able to accomplish.

Claire Stinson: Thank you for explaining the critical role of contact tracing, and hopefully our listeners are understanding that contact tracing is really vital, especially during COVID-19. And you've also made the point that public health is collaborative work. As the pandemic continues, how important will collaboration and partnership be in fighting COVID-19?

Josh Sharfstein: I think it's essential, and in many dimensions. So you certainly need collaboration within the public health world, between the CDC, state and local health departments. You need collaboration across, from public health to other sectors like the business community. And you really do need collaboration across different at times antagonistic parts of society. I mean, we need to have both Democrats and Republicans come together around science-based ways to reduce infection and save lives. So I'm hopeful that people can look at the headlines, look at the dashboards, look at the threat that we're all facing together, and find new ways to come together to tackle this problem.

Claire Stinson: All important points. So Dr. Sharfstein, from your perspective, who are the key leaders who need to be a part of this work?

Josh Sharfstein: Well within communities, I think it's a combination of health officials, community leaders, mayors, county executives, the state level, of course the health department, but also the governor's office, very important statewide groups, the prison system. Very risky situation there. Housing, because housing is such an important issue. And at the national level, it's important I think for there to be a very strong voice for public health at the federal level, and I was delighted to hear Dr. Schuchat speak recently, and I think I'd love to hear from her a lot more.

Claire Stinson: Well COVID-19 has certainly affected everyone in some way. So it sounds like you agree that it's just so critical that everyone comes together and is as collaborative as possible right now.

Josh Sharfstein: Absolutely.

Claire Stinson: So Johns Hopkins recently launched the podcast “Public Health On Call,” and you are the host of that podcast. You actually cover a range of topics related to health, including issues stemming from COVID-19. So what has been one of the biggest takeaways for you in working on this project?

Josh Sharfstein: Well, thanks. I was one of the people who got it started. We have a few hosts now, so I'm in rotation with a couple others. We cover COVID-19 as well as racism and health now, with a whole bunch of really interesting interviews. We do one interview in each episode, it's about 15 minutes long. We started it because we realized there was such a hunger for good information about the pandemic. And we have so many great people at Johns Hopkins and in the field of public health generally, who are so knowledgeable that we could pretty easily call them up, interview them, and put them on the air and let's see whether people listen. So it has exceeded our wildest expectations. We've had about one and a half million downloads so far, and we've now covered many different aspects of the coronavirus, from the basic science, to clinical science, to the deep inequities that the coronavirus exposed in our society.

We've covered racism and policing, racism and public health. So it's really been interesting. I'll tell you about one episode that I just totally enjoyed personally, which was, I interviewed the Chair of the English department at Johns Hopkins about The Plague by Albert Camus, which is a book from 1947 about the bubonic plague in a city in Algeria. And it is so crazy relevant to what's going on today in so many different ways. And he was able to help me understand the book, help listeners situate the lessons of the book for not just the coronavirus, but also some of the reckoning that our society is now having in inequality. It's all there in Albert Camus' book.

Claire Stinson: Sounds like such a fascinating podcast and such an interesting episode. Our listeners are going to have to find that episode. Can I ask what your favorite thing is about being a podcast host?

Josh Sharfstein: Well, I just learn so much. I mean, it's just such a great opportunity to talk to people and help them connect with a broader audience, and in the process, I'm learning from them an enormous amount.

Claire Stinson: I would agree. It's an inspiring thing to do, hosting a podcast. Dr. Sharfstein, fascinating conversation. We are so glad to have you be a part of our podcast today. I have one more question that I really enjoy asking our guests. What advice do you have for the future public health leaders of America?

Josh Sharfstein: My advice this year is different from the advice I have given before. My advice this year is realize that this is your moment. That we are now facing a once a century public health crisis in the coronavirus, and we're finally confronting a crisis in racism that is well more than a century old. And we have the ability, because of the attention that is now being focused on these kinds of challenges, to bring the skills and training and insights that public health provides to the point of impact. And this is not a moment to feel like, "Well, I'll wait and see what happens," or, "Let's watch this other...maybe this is something that emergency departments will take care of or someone else will take care of." This is really a moment for public health. I think it's a very exciting time and people should be bold going into this field.

Claire Stinson: Really important advice. Thank you for sharing that. Dr. Sharfstein, we're so glad you were a part of the conversation today. Thank you for being a part of Contagious Conversations.

Josh Sharfstein: Thanks again.

Claire Stinson: Thanks for listening to Contagious Conversations, produced by the CDC Foundation and available wherever you get your podcasts. Be sure to visit CDCfoundation.org/conversations for show notes and bonus content. And if you like what you just heard, please pass it along to your colleagues and friends, rate the show, leave a review and tell others. It helps us get the word out. Thanks again for tuning in and join us next time for another episode of Contagious Conversations.