Last year, as cases of Covid-19 spread across her Houston community, public health official Guadalupe Valdovinos was pulled from her job contact tracing sexually transmitted diseases (STD) to work on contract tracing cases of the novel coronavirus. Her professional experience came in handy: Valdovinos had been tracking cases of syphilis, chlamydia, gonorrhea and HIV, notifying those with positive test results of their diagnosis, advising them on treatment, finding out who their partners had been, and then contacting those partners to try to prevent further spread of the diseases. She estimates that more than 60 percent of her time was spent traveling, often driving to patients’ houses to knock on their doors and sometimes meeting them in public places—like the parking lot of a McDonald’s—where she would invite them into her car to discuss their diagnoses.
“We’re supposed to have contact with them within 24 hours of an assignment,” she says. “We’re immediately out in the field to show the sense of urgency. Once field operations were suspended, of course, we couldn’t do that.”
When her job duties shifted in April to tracking cases of Covid-19, her work moved entirely to the phone and her hours skyrocketed. She worked seven days a week, sometimes as many as 12 hours a day. More than half of the 40 STD and HIV field services staff in Houston worked similar hours on Covid-19, according to Beau Mitts, the chief of the Bureau of HIV, STD and Viral Hepatitis Prevention at the Houston Health Department.
Workers left to focus on STDs, which before the pandemic had been increasing in case volume, were overwhelmed. Specialists who transitioned to Covid-19 work had to adapt to contact trace a new disease with many unknowns. They consulted and comforted some patients who had lost their jobs and many who were afraid. “It was very exhausting,” Valdovinos says. “When all of this initially took place, we heard a lot about nurses and doctors and how they were reaching these points of exhaustion and what they were going through. However, I don’t think [the press] shined a light on people behind the scenes.”
Valdovinos was not alone in her work shift from STDs to Covid-19. In August, the National Coalition of STD Directors (NCSD) released the results of a Covid-19 survey of STD workers. Thirty percent of surveyed STD and HIV disease intervention specialists (contact tracers), like Valdovinos, were dispatched to track the coronavirus. Interviews with public health officials this fall revealed that some places still had up to half of their STD specialists working on Covid-19. And in January, NCSD released another report from survey results stating that 37 percent of STD program staff had been redeployed to work on Covid-19. That redeployment of staff comes as cases of chlamydia, syphilis and gonorrhea have reached their highest numbers in decades in the United States.
“The implications and the disruptions to STD prevention have been deep and profound,” says David Harvey, the executive director of NCSD.
The Centers for Disease Control and Prevention (CDC) tracks three main STDs caused by bacteria—chlamydia, gonorrhea and syphilis. Chlamydia may cause painful urination or discomfort during sexual intercourse and eventually lead to testicular pain in men and infertility in women. Gonorrhea causes discharge from sexual organs and can lead to infertility in both men and women. Public health officials categorize syphilis into primary and secondary syphilis, an infection which causes sores and a rash and can damage the brain and nervous system, and congenital syphilis, which occurs when a pregnant mother transfers the disease to her baby—who may contract a fatal infection.
All of the diseases, also called sexually transmitted infections (STIs), increased markedly from 2014 to 2018, the last year for which official CDC data is available. Harvey identifies three factors: a lack of awareness among the American public about the diseases, a lack of screening and diagnosis by healthcare providers and not enough funding to support prevention and contact tracing. All three diseases, in most forms, can be treated with antibiotics. But no vaccine exists for prevention, which is why contact tracing for the three diseases is so important to control spread.
Contact tracing starts when someone tests positive for an STD at a clinic, and a report goes directly to a local health department. A disease intervention specialist then contacts the patient, ensures that they’ve been treated and then asks for partners who may also have been infected. The disease intervention specialist then contacts those partners, notifying them they may have been infected without revealing the source’s identity, and gives them the necessary information for testing and treatment.
Melverta Bender, the director of the Office of STD and HIV at the Mississippi State Department of Health, writes that specialists are sometimes threatened because they are contacting strangers with unwelcome news while asking sensitive questions, but the specialists must recover to encourage testing and treatment.
“I liken contact tracers and disease intervention specialists to skills that social workers bring to helping people navigate the healthcare system, and supporting them through what is a very difficult diagnosis to hear about,” says Harvey.
The transition to Covid-19 work has hindered STD work in departments that were already hurting before the pandemic hit. Phoebe Thorpe, the chief of program development and the quality improvement branch at the CDC Division of STD Prevention, writes in an e-mail that prior to Covid-19, half of health departments in the U.S. experienced budget cuts and hiring freezes, which led to STD clinics closing and staff reductions for disease intervention specialists.
“I would say that public health in general has been chronically underfunded, which is a problem and that’s affected all levels,” says Philip Chan, the medical director of the Rhode Island Department of Health and a professor of medicine at Brown University. “[The problem] was put on display somewhat during Covid-19, but a lot of these issues have been apparent to many of us who work in public health.”
Chan says Rhode Island disease intervention specialists already had to scale back on tracing cases of gonorrhea before Covid-19. Then, as early as March of last year, disease intervention specialists in the U.S. began working on Covid-19 instead of STDs. “There was a time in our state when there was no [STD] contact tracing happening because everyone was pulled into Covid-19,” says Chan.
When the pandemic hit San Francisco, specialists had to transition away from interviewing every single case of syphilis, a disease on the rise in the city, and focus their reduced resources on interviewing subjects to avert congenital syphilis.
As the pandemic moved into the fall, many STD specialists were still working on Covid-19. Susan Philip, acting health officer for the City and County of San Francisco, says a third of her 18 HIV and STD specialists were focused on Covid when she was supervising them in a different position. In Mississippi, Bender writes that 11 of her 22 staff members were working on the pandemic.
While many of the nation’s estimated 3,000 intervention specialists tracked cases of Covid-19, others trained or supervised new Covid-19 contact tracers; more than 50,000 such pandemic workers now exist according to a survey conducted by the Johns Hopkins Center for Health Security and NPR. Many disease intervention specialists struggled with the new duties and their own caseloads. “We’re seeing a lot of burnout and exhaustion,” says Harvey. “And so we think these disruptions are going to last for a year and a half to two years.”
In Mississippi, where STD contact tracers would normally reach out to people in person, they switched to phone and email outreach, which has been less successful. Bender writes many patients don’t answer calls or respond to email, and don’t provide as much contact information for past sexual partners. Philip says that though there’s an 80 percent response rate for Covid-19 in San Francisco, the response rate for STDs is likely lower.
The CDC won’t have official STD statistics for 2019 until at least this year because the pandemic has affected the ability of public health departments to report statistics, and 2020 stats aren’t available yet either. But current reports from Mississippi, San Francisco and Rhode Island all show a decrease in STD numbers. “That’s not to say that cases are decreasing necessarily,” says Chan. “It’s really a reflection that people aren’t getting tested as much, and we don’t know how Covid-19 is affecting true STI incidence.”
Harvey says a mass disruption in STD clinical services and prevention has also occurred during the pandemic. Almost all sexual health clinics in the country have been forced to shut down or drastically limit hours and services, according to a report the NCSD released in October. “What I would say broadly speaking is that the first issue we’re worried about is further rising STDs once Covid lessens because people are not getting tested and treated,” he says. “So we think this is going to further fuel an already out-of-control STD epidemic.”
Chan says to deal with the epidemic, public health departments need more employees for contact tracing and improved technology to allow experts to engage more with patients. In San Francisco, the main clinic for testing and treating STDs is offering more telehealth options and is working to implement testing by mail. Mitts, who still spends more than half of his time in Houston working on Covid-19, hopes new technology and surveillance systems used for the coronavirus will be used to improve how STDs are tracked and monitored in the future. In Mississippi, Bender’s team began virtual learning courses to help with prevention, but she’d eventually like to have mobile clinics that could travel to lesser served rural areas for testing, treatment and support.
According to Thorpe at the CDC, to improve the nation’s response to STDs and other infectious diseases that may emerge, the disease intervention specialist workforce that has eroded over the past two decades needs to be built back up.
“We spend a paltry amount of money in this country on STD prevention,” says Harvey. “Congress provides about $160 million and then states provide a little bit of additional money to support these efforts, but it is a drop in the bucket for what is needed.”
Philip says contact tracing work around the coronavirus may help raise awareness of the value of disease intervention specialists across the nation, and hopefully lead the public to respond more when they are contacted about STDs. She and others hope that by reaching out about the value of a strong core disease intervention workforce, changes will occur. “We are doing what we can to capitalize and make sure that we don’t squander this newfound understanding among the public, among policy makers, about what public health is,” she says.
Harvey also hopes the shortfalls in public health the coronavirus has exposed will lead the United States to bolster its infrastructure and staff. “We can build it bigger, better and smarter—so that we have an army of contact tracers to deal with Covid, STDs and other infectious disease needs.”
In October, Valdovinos finally returned to contact trace STDs, but the nature of her work changed. Rather than driving out to meet people, everything had to be done over the phone. The biggest difficulty of her work before the pandemic was dealing with patients angry about their diagnosis, but she had learned how to deal with that after five years in the job. The biggest difficulty she faced was not being able to reach patients. The sense of urgency created by a knock on the door or a letter left at the door was replaced with a call coming from an unknown number. Many people didn’t respond. Valdovinos doesn’t have exact stats, but she guesses her response rate has dropped from 70 to 50 percent.
With the lost time due to the pandemic and the Houston STD and HIV field services crew still not fully back—at least 15 percent were still working on the pandemic in December—Valdovinos has a backlog of cases. She isn’t able to respond as quickly as should to each case, which she worries could lead STDs to continue to rise in Houston. “If the rates are increasing; our workloads are increasing. However, we’re not having an increase in staff. So what does that mean?” she says. “What happens is were not able to efficiently intervene in the spread of disease, and therefore it is continuing to grow.”