What Oxford’s missing COVID-19 cases tell us about contact tracing in college towns and a new normal this fall
By Erica Hensley and Kelsey Davis Betz | July 12, 2020
When Oxford Mayor Robyn Tannehill announced last month that she found 162 college-aged COVID-19 cases that were not included in Lafayette County’s total tally from the Mississippi State Department of Health, confusion erupted.
The University of Mississippi, located in the county, tweeted that Tannehill’s announcement was the first they’d heard of it. The state health department balked initially, reiterating that county-of-residence — in college students’ cases, usually where their parents live — dictates where their case will show up, but said they’d work with college towns to improve their unique reporting situations.
This is a problem for Tannehill and leaders in college towns across the state, as “contact tracing,” or efforts to track individuals with an infectious disease and who they’ve interacted with, are falling short. The issue, according to Tannehill, is that she needs to make policy decisions based on real-time positive cases currently in Oxford, especially with the transient nature of college-aged students.
“As a city leader trying to determine what our path forward looks like — what we need to identify quickly are trends, we need to be able to go back to clinics and get an idea for ages, then track back — that’s what we’re looking at. Whether it’s eight or nine cases won’t change policy, but we need ways to identify trends as this continues to be 18-24 year-olds that we believe are people that are just having parties,” she said.
Almost a month later, she says she still doesn’t have all of the data she needs. A few days after her case discovery led to a call with the health department, she realized she wasn’t going to get an accurate-enough count from their reporting. She reached out to 14 local clinics and asked them to start digitally submitting test and result data to her office daily. Nine are now actively sending her daily case numbers.
“I hate to take that approach because I hate to be another burden on these clinics for another report that they have to do every day. I’m talking to these nurse practitioners whose clinics close at 7 but they’re there at 10:30 to 11 every night doing charts for the Department of Health — especially if the Department of Health has that information that they could be sharing with us. It doesn’t seem efficient of us to ask the clinics to take another step to report,” she said. “But we can’t make these decisions in the dark.”
The numbers she has collected – 437 total cases as of Monday, more than half of which are not from Lafayette County – still don’t match the health department’s reporting, which showed 409 cases at the same time for the county. The numbers will likely never match due to reporting inconsistencies, but the discrepancies reiterate that no entity has a full picture of active, local cases. The health department says they were the last to know.
“The clinics knew before we did,” said Thomas Dobbs, state health officer, adding that due to reporting lags, clinics should directly contact the state health department if they see an uptick in cases, or even tests. Dobbs also confirmed the cluster spawned from a fraternity rush party.
Tannehill told Mississippi Today Tuesday that the numbers she has collected on her own influenced the city’s decision to halt reopening plans and scale back to “phase one” where indoor gatherings are limited to 10 people without social distancing and 20 with it. Masks are still mandated in the city. “We wish the state would because the county doesn’t,” she added. “That makes it very inconsistent.”
“We have had a lot of good conversations (with MSDH) and we’re sharing with them the data that we decided to go ahead and collect, because we are still not getting that data from MSDH.”
The delay in sharing results has plagued coronavirus reporting, and with it tracking, since the pandemic started and has only gotten worse as Mississippi cases hit record highs late June. Between a person developing symptoms, getting tested and receiving a positive result, days can pass – often eclipsing almost half of that person’s contagious period. If they haven’t self-isolated during that time, they’ve likely spread it. Additionally, the state health department is the last to receive the results, which first go back to the clinic and patient, Dobbs says.
Dobbs told Mississippi Today that the state health department does not have enough contact tracers – who are also responsible for case data entry – to keep up with ongoing case increases.
Nationally, test lags are popping up again, harkening back to early April when test shortages and delays wreaked havoc on providers, labs and patients. Dobbs says the state lab is still maintaining steady turnaround times. But one of the nation’s largest labs, Quest Diagnostics, recently announced unprecedented demand for testing has pushed past capacity, resulting in most patients waiting an average of 5 days for test results. Mississippi has never released timing or location of tests, but until recently has kept the total number of tests conducted updated regularly.
In the last few weeks, Mayor Tannehill said MSDH did start sharing more information regarding contact tracing efforts in Lafayette that resulted from case investigations locating young people in Oxford, despite their county of residence.
Those data points, Tannehill says, are insufficient and further reiterate the lag Dobbs has warned about. Numbers she received from MSDH this week classified as new cases in July had quarantine periods that were listed as ending in June, she said, meaning there is a mismatch in how and when this information is reported. Most importantly to Tannehill, it paints an incomplete picture of the town’s current case transmission.
“We can’t attribute (cases) to days like they were doing,” Tannehill said of lagged cases. By the time she’s getting some of the new case information, they’re already out of isolation, she says, “We missed the whole thing.”
The health department has not provided an updated number of contact tracers, but say they don’t have enough to meet demand. Documents obtained by Mississippi Today showed about 77 daily tracers in late May, but Dobbs said he’s lost dedicated staff since then. He said Wednesday that MSDH is looking to hire at least 100 more.
While tracers were previously able to maintain a 95 percent closure rate for case investigations, it has since dropped to about 87 percent, Dobbs says. Contact tracing should locate student cases who report a different county of residence. But again, the problem is timing. “The same people that do data analysis are the same ones doing outbreak response,” he said. “We have a talented bench but it’s a shallow bench.”
In June, 681 of the positive cases were out-of-state residents, about 3 percent of all cases then. In theory, all in-state cases should eventually track back to their current location, no matter their county-of-residence listed.
“Sometimes all we get is a name, a birthday and a doctor’s name who did the test — and you can imagine how laborious it is to track back and start your case investigation when that’s all the information you have and that has to be keyed into the system,” Dobbs said. “We’re getting to them and we’re closing out the ones we can get pretty quickly, but some of them are just going on the backburner, so it’s a little bit of a juggle of where they land to be quite honest.”
“The contact tracing and the quarantine piece cannot be a stand-alone effort, it will absolutely fail if that’s our cornerstone,” Dobbs said, reiterating that just like testing, they cannot take the place of prevention. The irony of flat funding over the last decade in the midst of a global pandemic is not lost on him either. The department’s budget has been cut by nearly 10 percent since 2016, netting flat funding since 2010.
“This is a nationwide problem that the country has full-on abandoned public health infrastructure, in ways more than money. Part of it has been this sort of false belief that health care is public health, and if we have insurance then we don’t have to have public health and nothing could be further from the truth. There are gaps that health care will never fill. Health care can’t put people on quarantine orders,” he said. “And there is absolutely zero appetite at all levels of government to fund that kind of work.”
For the University of Mississippi’s role, they say they’re also trying to work with local clinics to get a more precise view of how many students are testing positive. If a student gets tested anywhere other than the university health center, the university has no way of knowing those test results, which contributes to an inaccurate student case count. As of Wednesday, the university counted 67 affiliated cases, up 15 in a week.
“It becomes complicated especially when a student, faculty or staff member goes to an outside clinic to get tested. Of course, we will only know [their test results] if they report to us. Unless there’s a consent involved for their record to be sent over here to show that they did test positive, there’s still privacy laws and HIPAA that have to be considered before people can just share that people tested positive for COVID,” said Alex Langhart, Director of University Health Services.
Langhart said the university health center has asked local clinics to remind students who get tested to report their results back to the university so it can be documented. The university has also been working with MSDH to better coordinate finding those students and improving contact tracing.
As they make plans to re-open campus and in-person learning for the fall, the university has reduced class sizes so that students can be more spread out, required that all wear masks, installed hand sanitizing stations and implemented a host of other preventive measures.
And yet, there are still risks.
“Unfortunately, even the most well-designed campus policies won’t be enough if students don’t strictly adhere to appropriate behavior outside the classroom and off-campus,” said Mikaela Adams, Associate Professor of Native American History at the university. Adams is also a historian of the 1918 influenza pandemic.
She fears that student behavior will lead to massive campus outbreaks, which will lead to large outbreaks in college towns.
“As students return home to their families (because they fear being sick alone on campus, because universities suddenly close, or because they are asymptomatic and don’t realize they are infected), there will very likely also be outbreaks in their home communities,” Adams wrote in a message to Mississippi Today.
She continued: “Although students may experience relatively few symptoms, the same will not be true for many of the people they infect … Such outbreaks could be particularly devastating in Mississippi since many of our students come from rural areas that do not have sufficient resources or the health care infrastructure to effectively manage an epidemic.”
Oxford’s situation is not unique. Any city with hubs of young, transient people likely don’t have a full picture of active cases due to reporting processes and asymptomatic case load. That, on top of unknowns about college reopening protocol worries Beckie Feldman, parent to 18-year-old twins headed to Mississippi University for Women in Columbus this fall.
“As a parent of two kids, I’m terrified,” said Feldman, 53, whose husband is more vulnerable to complications if he contracts the virus. “I want them to go to school obviously, but then COVID-19 hit, as a parent you’re thinking, they’ve got to get their education — but can you take a year off?”
Feldman’s family is still planning on the twins going, but will keep an eye on Columbus’ numbers. But similar to Oxford’s lag, she knows the data she can access online is likely not the full picture of transmission, “It may be that when they come home, they stay in their bedrooms and I’ll talk to them from 6-feet away. It’s nothing that I ever considered experiencing and I know that everybody’s feeling that way,” she said, adding that she feels lucky to be able to take extra precautions, but still worries if they’re enough. “We’re sending them with lots of frozen food and paying extra for a private dorm room so they don’t have to share with anybody, we think that’s worth it,” she said. “I just hope that peer pressure won’t work into the scenario.”
Adams, the professor, echoes Feldman and says it’s a balance for schools and families, but worries about the end result.
“I understand that universities are currently facing very difficult decisions. There is a strong fear that if campuses don’t reopen, students will choose to defer their enrollment or make other choices about their education,” Adams said. “I, like other faculty and staff members, dread the financial consequences of these choices … But, what I dread even more than those financial consequences is the loss of life that I feel certain will accompany campus reopenings.”