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Every day, dozens of people report to health department offices across Hawaii. They settle into cubicles, conference rooms — anywhere spacious enough to abide by social distancing requirements and function as a secure call-center.

They sit in chairs within six-foot floor boundaries marked by colored tape. And then they start dialing people around the state who’ve tested positive for COVID-19.

These are the investigators who conduct contact tracing — those who have called and monitored the 580 people confirmed with the virus in Hawaii over the past month and a half — and many of those who have come into contact with them.

is how epidemiologists across the nation are tracking the spread of the coronavirus and working to isolate those who could be contagious. It’s the best way, many argue, to flatten the curve of infection rates and prevent hospitals from being inundated with patients.

It’s also a key tool, , toward hastening the reopening of at least part of the economy.

Five of the 44 investigators on the job are unpaid volunteers, according to Janice Okubo, spokeswoman for DOH.  The volunteers, officials have said, were recruited for their background in public health, medicine and nursing from other DOH divisions and the University of Hawaii.

Correction: A previous version of the story, based on interviews with DOH officials, said there were 70 contact tracers, half of whom are volunteers. The department acknowledged Friday the original  information, which overstated both the number of investigators and volunteers involved in the effort, was inaccurate.

The DOH team works to identify those who were potentially exposed and keep them from passing it on to others, often calling as many as 30 to 50 more people connected to a single case.

But their initial calls to those who have tested positive often occur days after exposure, due to testing delays and the fact that health officials are notified by doctors themselves.

Investigations into single cases can last days and weeks. And the department may announce newly confirmed cases daily, but it can often take several more days to figure out which cases are related to one another.

How Contact Tracing Works

The Hawaii Department of Health announced the state’s first case of the coronavirus on March 6. But the department’s data show that the first recording of symptoms among COVID-19 patients in Hawaii dates back to Feb. 17.

Most have recovered — more than 70% of patients who were not hospitalized have qualified to be released from isolation.

As of Monday, there were about 160 active cases still under monitoring by the department. Officials say social distancing measures appear to be working to slow the virus’ spread in Hawaii.

DOH receives electronic reports of positive cases and that’s when it initiates an investigation, calling the ordering physician and following up with the patient over the span of days and weeks.

Depending on their occupation, DOH will provide isolation requirements based on the length of illness, when they were swabbed, and when symptoms began.

An initial call to the infected patient may last 15 minutes to an hour or more. But contact tracing goes further than one call. That initial call is used to start identifying the web of potential people who may have come into contact with the person who initially tested positive.

It also includes the active monitoring of all of those contacted connections —  those in self-quarantine to assess if they’ve become symptomatic, and others in the hospital. 

Once someone has completed the mandatory 14-day quarantine, and they’ve gone at least a week since symptoms began and three days without a fever, they qualify as recovered and are reported by the department as “released from isolation.”

Those in that category are not necessarily called again.

“Once they’re released from isolation that generally means released from our monitoring,” Park said. “It doesn’t mean the cases don’t reach back out to us, or if we have questions about a contact of theirs — there can be communication with the patients after the fact.”

A Web Of Infection

To become a confirmed case with the department, a doctor must refer a patient for a test and then notify the department about the person’s results. It’s up to the patients themselves to report their own positive exposure to employers and stay home.

Meanwhile, the friends, colleagues and family members of people who have been confirmed are monitored as they home quarantine and isolate, but not tested unless they fall ill. 

Testing, Dr. Sarah Park, the Hawaii state epidemiologist said, is only one limited facet of the process. Park says that’s OK, because they’re already expected to self-quarantine for 14 days to ensure that the virus has passed even if the person has not shown symptoms.

“When you have a positive that’s helpful. A negative result is not necessarily reassuring,” she said. “At that point in time it’s negative. It could be a false negative, or just they came to you at a wrong time. None of these ways will get you out of quarantine.”

During each call, investigators coax patients to recount who they may have had close, prolonged contact with. Patients must remember who they spent more than 10 minutes with, closer than six feet.

“You need to be able to conduct an interview and tease out sometimes very nuanced information,” said Park. “It’s not just about a straight questionnaire. Sometimes in the course of asking questions they remember something else that could be really critical.”

The investigators hear private patient details, so not just anyone can volunteer, Park says. And it’s preferred that they are familiar with the department’s

State Health Director Bruce Anderson said the the department is preparing to double its contact tracing capacity. 

“We want to open up the state and make sure people are identified early on,” Anderson said.

It can be days until the cases confirmed by the health department are made public, as occurred in the Maui Memorial Medical Center outbreak.

It took several days for the health department to determine that an ongoing string of infections was connected by their work at Maui Memorial Medical Center, Anderson said last week. 

At that hospital, one nurse discovered that there was a string of infections because of media reports, not hospital administrators or the state. 

Officials at Hale Makua, an elderly care facility on Maui that had welcomed patients from the hospital, weren’t aware about their potential exposure until days later. 

Perpetually Understaffed

Anderson and Park say the team is understaffed.

“We have 30 volunteers on top of our staff and we’re still barely able to keep up,” Anderson told Hawaii state senators on Tuesday. “We can’t rely on volunteers forever.”

The department is finalizing its request for funds to double its employee count and hire at least 30 and as many as 50 more staff members.

Park, who leads the team, says it’s no secret that the health department has limited manpower — the department has made requests on a near annual basis to bolster its team.

Staffing aside, the department’s COVID-19 tracking team is also dealing with insufficient office space and technology for the skilled hires to use.

The investigators have not yet been able to shift to working remotely from home, because the laptops the department purchased in January have been backordered. Smartphones for each of the investigators finally arrived this week. Laptops are expected to arrive in a week.

Gumshoe Investigators, Meet Virtual Trackers

The Hawaii health department’s approach may seem antiquated, especially when compared to the digital contact tracing that has been credited to slowing the virus in places such as .

But tracking peoples’ movement via their cell phones is just not very realistic in the U.S., said Brandon Kurisu, president of , which runs the data consulting company .

“Because of our privacy laws in the U.S., we’re not able to do that,” he said.

That’s led Upspring to create AlohaTrace, which is collecting similar data but via crowdsourcing. Participants answer six questions and submit their symptoms and whereabouts from their phones and laptops. Within its first week of launching, received responses from more than 7,000 people.

“While it may not be as accurate, if we get enough engagement it could provide similar benefits,” Kurisu said.

AlohaTrace was developed by Upspring along with Central Pacific Bank Foundation and the Hawaii Executive Collaborative. It’s a collaboration with the University of Hawaii, the National Disaster Preparedness Training Center and the Pacific Urban Resilience Lab, which launched a earlier this month.

“Ideally we’d have sufficient testing and work is being done on this, but in the absence of that, what we’re trying to do with AlohaTrace is collect data from the community about symptoms and about who people with symptoms may have been in contact with,” said Karl Kim, executive director of the NDPTC.

The initial, detailed online survey has received responses from 22,000 people who voluntarily shared their information, which is kept confidential.

Eventually, Kim hopes to marry both data sets to gain a greater picture of the virus’ spread — and who it is most likely to affect.

“It’s premised on the assumption that there is a lot of knowledge in the community itself. The fact that we’ve had such an overwhelming response indicates the public thinks it’s important,” Kim said.

The university has already begun to map out the new COVID-19 data with other census datasets to get a greater picture of where more vulnerable populations may live.

Kim says it could be helpful to visualize the population densities of people most at risk, including the elderly, people who have existing medical conditions and people living in crowded living arrangements.

Kim and Kurisu said they did not consult with the Department of Health during the design of their survey. AlohaTrace doesn’t have immediate plans to share the findings of the data with the public. The datasets collected from AlohaTrace will be shared with government and public health officials first.

“They’d hopefully be able to see if there are any hotspots or clusters forming,” Kurisu added. “If there are people who are exhibiting symptoms, where they are and where they’ve been in the past couple of days. That’s the kind of data we’re hoping to give to them. What they do with that data is up to them.”

Can Contact Tracing Help Open The Economy?

The Hawaii business community, economists and even health insurers say contact tracing — and the testing of all who have been potentially exposed, including those who are asymptomatic — will be crucial to reopening the economy.

The health department has always conducted contact tracing and its officials stand by their protocol of recommending the contacts of COVID-19 positive people be placed under mandatory quarantine and tested only when symptoms arise, since the virus will theoretically be beat within the 14-day quarantine time period.

In ongoing investigations of clusters at Maui Memorial, nearly 300 people who may have been exposed have been tested and await their results. The department didn’t divulge whether or not all of them had symptoms, but it’s likely some of them have yet to show symptoms, and others are not infected.

Nationally, America’s digital contact tracing efforts got a boost from the private sector when Google and Apple executives to identify and alert people who may have interacted with a contagious patient.

That data could be useful supplementally, but the state health department has its own priorities in data collection.  Applications such as AlohaTrace that use questionnaires may lack the nuance of the human-to-human interviews, says Park.

“It could be helpful for sentinel surveillance,” she said. “There would be some things that could be learned, such as what could be helpful in the type of questions they ask to help our leaders think about behaviors and attitudes around social distancing.”

Park says DOH is currently in the demo stage of developing its own application for case investigators. The app could be in use by DOH within the next couple of weeks.

Still, the health department’s limitations mean that they do not actively follow up with all patients who have recovered and have been released from isolation.

That’s where AlohaTrace and the university could fill information gaps.

“We should be investing in public health, technologies and systems for better detection monitoring, surveillance, and especially evaluation of strategies and mitigations so that we know — is this really working or not?” Kim said. “That’s what we are trying to do.”