As an infectious disease nurse during the COVID-19 pandemic, Debbie Sorensen works as a memory detective on a tight deadline.
The mystery she's trying to untangle is where an infected person has been and who's been with them. Her sleuthing tools include a telephone, a wall calendar and the firm, but calming voice that comes with 20 years of experience with the Salt Lake County Public Health Department in Salt Lake City.
On a recent weekday she puts her interviewing skills to use when calling a young woman who had tested positive. Sorensen goes through a five-page "investigation" form with the woman, collecting information needed to learn who else may have been exposed to the virus — and how to find them.
"Do you live in an apartment or a home?" she starts. "And how many people live with you?"
Known as contact tracing, this kind of investigative work is fundamental to an effective response to infectious diseases, experts say. Contact tracers like Sorensen want to determine who needs to be tested and possibly isolated to slow the spread.
"Could you tell me what day your symptoms started — what day you started getting ill?" she continues.
Sorensen and her colleagues are busy, averaging five cases a day. As Utah's most populous county, Salt Lake has more than half the cases in the state — recently climbing above 6,400 — and it has a positive test rate of around 6%. Over the past few months, contact tracers in the county have made an estimated 35,000 calls.
Across the U.S., states are building similar armies of contact tracers, having trying to contain the spread of COVID-19. Utah is among the states at the forefront of the effort, more than tripling the number of its investigators and tapping state employees to help monitor people who are in quarantine.
Before the pandemic, Sorensen was one of the county's 30 investigators. Since getting its first coronavirus case in early March, Salt Lake County has added 100 more as the health department reassigned other nurses and staff.
State officials say they realized during the early stages of the pandemic that testing alone wouldn't be enough to stop viral spread, Lt. Gov. Spencer Cox says. He characterizes contact tracing as the surgical approach needed to get past the "sledgehammer" of extreme social distancing, especially because many people who can spread the virus may not yet have developed obvious symptoms.
"It's really important to find those contacts and test them to see if they're [also positive for the virus] and if they are, then to isolate them," he says. "We're actually working backwards as well, to try to find the source of that spread."
Contact tracing: What it looks like
Within 24 hours of a positive test, contact tracers reach out to a patient, then trace back two days before symptoms first appeared. They use calendars, social media — anything that can jog a memory. They gather phone numbers, email and physical addresses to track down contacts.
All of that can take hours. Although each person identified typically has seven or eight contacts, they also can have as many as 100. Co-investigators then interview those contacts to see if they have symptoms and need to be tested.
Tracers also tell each person contacted whether they need to go into isolation (when they have tested positive for the virus or they have COVID-19 symptoms) or quarantine (if they have merely had prolonged contact with someone who has tested positive).
Most people are willing to help, even if they feel awful and tired, says Tair Kiphibane, the infectious disease bureau manager for Salt Lake County.
"Some said 'I've been waiting for you guys to call me,'" Kiphibane says. "They're so ready to just unload the information that we are trying to gather."
Some people contacted worry about privacy or deportation
But not everyone is receptive, says public health nurse Lee Cherie Booth. Some worry about privacy concerns, or they distrust the government. Others fear deportation because of their immigration status.
Investigators work to build trust and educate patients on why they need to cooperate. If that doesn't work, contact tracers may try another approach to help a patient understand why their assistance is needed.
"Sometimes we use guilt tactics," Booth says. " 'You don't want to be the one spreading this infection. You wouldn't want grandma or grandpa to get it.' " Appeal to their heart strings."
If that doesn't work there's not much else an investigator can do, Booth says. Often, they can offer little more than empathy, especially when someone is worried about losing their job or concerned about social stigma.
"You are pleading with their — hopefully — common sense," Booth says. "Sometimes there are no good answers other than 'I hear you.' "
Homeless and quarantined
LuAnn Miller didn't need to be coaxed into quarantine after displaying symptoms. But she did need a place to go.
After recently returning to her native Salt Lake City, Miller, who is 64, was homeless in mid-April when she started to experience respiratory problems like she'd never felt before.
She'd been staying at a women's shelter, looking for a place to live, and worried she'd been exposed to the virus there. Following a brief stay in a local hospital, where she was tested for the coronavirus and later came up negative, Miller spent the next 10 days in the care of Salt Lake County.
For local residents who, like Miller, don't have a home or a safe place to quarantine or isolate, county officials have repurposed seven buildings into shelters. To help protect the privacy of the people in those shelters, the county does not disclose the location of these buildings nor allow media visits.
Elsewhere in Utah and around the U.S., officials have turned to local hotels, college dorms, nursing homes and even military barracks for this purpose.
In Salt Lake, the county-owned and leased buildings alternate between serving as isolation units and temporary residences for quarantine — depending on the area's shifting needs. The buildings can accommodate up to 444 people, including families, says Nicholas Rupp, a spokesperson for the county health department.
More than 500 people have stayed in the county's facilities since the outbreak began, according to the health department. Miller said the decision to go into quarantine was easy for her.
"I wanted to make sure I was safe and others were safe," she says. "I felt they [county employees] were very concerned about us. They were so protective and loving."
Staffed by employees from other departments who have had their jobs affected by COVID-19, the county estimated it will spend $2.5 million on the quarantine and isolation facilities and operations. Salt Lake expects to be reimbursed by the federal government through the CARES Act, Rupp says.
Help for other people who can't self-isolate or quarantine at home
The county first opened its facilities to the unsheltered, then expanded its services to include other people exposed to the virus who needed shelter — such as people who live in abusive households, those who live in small apartments and members of large families where one or more members had tested positive for the virus, Rupp says. The average stay in the quarantine and isolation facilities is around a week, but has been as long as 20 days, county officials say.
Members of the community who come into these facilities for temporary isolation after testing positive for the coronavirus are housed with others who have tested positive for the virus. So far, only about a dozen such cases have subsequently needed to be hospitalized for treatment of COVID-19 symptoms.
According to guidelines, Rupp says, the temporary residents of these facilities who have been isolated because of a positive coronavirus test stay until a) their symptoms are gone and it has been 10 days since the onset of symptoms, or b) three days after a fever breaks without the aid of medication — whichever is longer. When the time to leave the facility comes, the county offers those who have been isolated or quarantined in one of these buildings transportation back to their homes or wherever in the county they choose to go.
Miller says she was housed for about 10 days in a building with other people that contact tracers had determined had likely been exposed to the coronavirus — in a ward-like setting with about 50 to 60 cots. She had three meals a day and access to showers; a staff member at the facility even ran to the store on Miller's behalf to buy vitamins. She was given protective masks to wear and had her clothes cleaned. And when she mentioned that she missed playing music, someone at the facility mentioned it to the owner of a local store, which donated a ukulele.
County officials report few problems with their guests, as officials refer to those staying at the facilities, though Miller says she had some of her pain medication stolen the first few days of her quarantine. Staff members do not manage or dispense medications, Rupp says. They will get prescriptions filled, so guests can safely maintain their quarantine or isolation.
Officials in Salt Lake County do not track how many people follow a contact tracer's request that they self-isolate or quarantine themselves, Rupp says, nor do they track demographic data on race or ethnicity.
The number of people staying in the facilities fluctuates. On some days officials have fewer than 10 people in quarantine or self-isolation. During a COVID-19 outbreak at a local men's shelter, the county housed as many as 140 patients at a time, Rupp says.
Miller says during her time in quarantine there were fewer than a dozen people housed in the facility — and not all the residents were interested in hunkering down.
"There was a group of people who fought to get out of there," she says.
Salt Lake officials say 50% to 80% of those who come into prolonged contact with an infected person end up testing positive. Around 11% of infections arise from community spread. But as Utah reopens its economy, that number could increase.
Kiphibane says that prospect makes her nervous.
"If we're gonna — maybe — hit another big spike or something, then I would think that we might need more manpower," she says.
Hot spots beginning to flare
State officials say they're preparing for those larger outbreaks — and they may need to take action soon.
At the start of June, Utah saw its highest single-day numbers of new coronavirus cases since the outbreak began — 546 cases reported on Saturday, according to the state's department of health, with cases spiking particularly high in some areas.
That's happened as most places in the state — save for Salt Lake City, which is still considered moderate risk — have loosened social-distancing restrictions and increased the size of gatherings that are now permitted. Health officials worry this easing of restrictions in certain areas will increase exposure to the coronavirus and cases of COVID-19, especially as protests against police violence continue.
Like many county and regional health departments in Utah, state officials are adding contact tracers, too. In late March, Utah launched a program for state employees to help with the next step in the tracing process: active monitoring.
Monitors follow up with the close contacts of people who have tested positive for the virus to see if those contacts have symptoms or have fallen ill. More than 1,000 state employees volunteered for this job, and 150 or so have been trained so far, including Diana Monago.
An employee of the state's Department of Public Safety, Monago says she jumped at the chance to help.
"When I first heard about it, I said, 'Oh, yeah, sure. Whatever I can do to help,'" she says.
Latinos hit hard by COVID in Utah
Within a couple of weeks of raising her hand, and after a two-hour web training, she was making calls. Monago, who is a native Spanish speaker, now leads a team of 13 active monitors in the state program, including several who are also fluent in Spanish.
Latinos, who number around 14% of Utah's population, make up roughly four out of 10 COVID cases in Utah. The Spanish-speaking monitors on Monago's team are averaging about 15 calls a day, which is two to three times more than the calls conducted in English.
Monago, who is originally from Peru, says it can be a challenge to persuade Latinos to get help if they've tested positive or need to get tested; some hesitate, she's found.
"I think it has a lot to do with the cost," she says. "They don't know where to go. They don't know if people speak English where they're going. We'll try to reassure them that 'It's safe for you to get tested. These are free testing sites that you could go to. Please get help.' "
While those who themselves have tested positive for the coronavirus might welcome a call from a contact tracing investigator, others who are simply being monitored because of a possible exposure to the virus often get upset when her team calls, Monago says.
"I would think, if I was in that situation, I would be very happy that they're monitoring me," she says. "A lot of people — I'm surprised by how they get either annoyed or upset."
Working from home, Monago recently dialed a Spanish-speaking woman named Maria who was about to end her 14-day quarantine at home. (NPR agreed to use only Maria's first name to protect her medical privacy).
Maria never developed symptoms.
"I'm happy to hear this," Monago says in Spanish.
Maria was still worried, though, because her husband had tested positive for the coronavirus. Monago explains that, while she can't give medical advice, the woman should check with a doctor to make sure she's healthy, adding that Maria's husband should isolate himself from the family — probably outside their home.
Before ending the 15-minute call, the two women discuss where to get more information in Spanish, and how to get further testing and test results.
Unintended consequences of quarantine
A man named Doug Winward was also on Monago's call list. He, too, was coming to the end of his 14-day monitoring period, after having been exposed to a co-worker who tested positive for the virus.
"Have you experienced any of the symptoms as far as fevers, coughing or maybe difficulty breathing?" Monago asks Winward when she calls. "No? You've been good? Awesome."
It had been a challenging couple of weeks for Winward, a 51-year-old single father of three children, ages 12, 10 and 7. Winward works in construction, and when his boss tested positive for the coronavirus, Winward — who had no symptoms — was sent home from the job site, too. Since then, he has been quarantining himself, away from others, as best he can.
On his way home that first day after getting the news about his boss' test, Winward stopped at a market and bought $500 worth of groceries, all out of pocket, he recalls.
"I'm thinking to myself, 'I need to go home and quarantine for 14 days,' and I was like — 'Whoa whoa whoa — I have to go home and still feed my children?' We ate pork and beans and hot dogs a lot of nights."
Adding to the stress of a lost paycheck, Winward says his ex-wife sought to get custody of his kids while he was in quarantine. He ultimately tested negative, but remained homebound, without pay, for the duration of his quarantine.
When Monago reached out to him by phone when the two weeks were up, Winward was ready to be done with the whole episode — and be back on the job. The quarantine had taken a toll on him — financially, emotionally and psychologically.
"When the only person you have contact with is the Health Department calling at the same time of day with the same generic questions — 'Are you feeling OK?'" he says, "... it was disturbing."