New cases of the novel coronavirus are so rampant that Missouri's local health departments can't investigate them all, meaning some residents may never hear from public health officials.
It's far from ideal. Case investigations and contact tracing are "a core disease control measure" the Centers for Disease Control and Prevention points to as one of the key strategies for containing the virus' spread.
Figuring out when someone contracted the virus, who they've come into contact with and notifying anyone who's been potentially exposed is key to combating continued spread. However, many local health officials are struggling to keep up as the state has reached a seven-day average of more than 4,000 cases a day.
"They're backed into a corner," Lynelle Phillips, vice president of the Missouri Public Health Association, said of health departments having to prioritize which cases to contact. "They don't have any choice."
The impact is playing out across the state.
Cole County, which has had the third-highest per capita infection rate in the state so far for November, said earlier this month that residents who test positive would be responsible for notifying their close contacts themselves. The county's health department would only continue to provide contact tracing services to the schools as needed.
In St. Louis County, the state's largest and home to the most COVID infections, County Executive Sam Page has asked residents to essentially conduct their own contact tracing as the health department works to prioritize cases most at risk of spreading the virus.
Two weeks ago, Columbia/Boone County Public Health and Human Services announced it would be prioritizing contacting those who most recently tested positive - meaning some may not receive a phone call and instead get a packet of info delivered in the mail.
From Nov. 8-21, the Springfield-Greene County Health Department has reached out to 87 percent of its total cases in some way but has only been able to fully investigate roughly half, or 43 percent, of them.
The Jackson County Health Department had to temporarily close its clinic and reschedule appointments to shift nursing staff to help contact trace and alleviate the strain.
In Shelby County, where there's not enough funds to hire more people, it took a small staff of five most of the day to get through a record 21 cases this month.
"It's driving the bus," said Audrey Gough, the administrator of the Shelby County Health Department, "and we're headed for the cliff pretty quick."
Working to meet demand
In non-emergency situations, the National Association of County and City Health Officials recommends a baseline of 15 contact tracers per 100,000 residents. Given the pandemic's magnitude and the need to quickly complete contact tracing "within hours versus days" the association estimates twice as many will be needed.
Missouri counties struggled to reach that threshold even before the pandemic.
Case investigators work with a person who has contracted the virus to figure out when their symptoms began, where they've been and who they've come into contact with. Contact tracers are tasked with calling a positive case's close contacts in order to notify them of their possible exposure and ensure they isolate and get tested.
In January, the St. Louis County Department of Public Health had three people who could do contact tracing and case investigations, department spokesman Christopher Ave said.
In Boone County, there were anywhere between two to three, with one full time and others who chipped in part time, said Scott Clardy, assistant director of the Columbia/Boone County Department of Public Health and Human Services.
Based on Missouri's current caseloads, the state would need more than 25,800 contact tracers to clear all of its cases in one week, according to a contact tracing workforce estimator developed by the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University.
Public health departments have had to quickly hire and train more staff in order to bolster their workforce. And for many, that has been paid for by funds allocated in the Coronavirus Aid, Relief and Economic Security Act, or CARES Act - an aid package approved by Congress in March that has a Dec. 30 deadline to spend the money before unused funds must be returned to the federal government.
Missouri's state health department has deployed 235 staff members who normally work on other public health functions to 18 jurisdictions to help with contact tracing, Lisa Cox, a Department of Health and Senior Services spokeswoman wrote in an email last Monday.
In the last two months, the state has also contracted with 33 private companies that are available for local health departments to hire additional contract tracers through.
Despite some contractors offering discounts - like 1 percent off monthly billed hours for every 1,000 cases received - some local health departments said they don't have extra money to spend.
"We have who we're going to have through the end of the year," Ave said. "Then in the new year, if the state can provide some help - that we don't have to pay for - we would welcome it. But we do not have the money to pay for this additional personnel that the state is offering."
The Springfield-Greene County Health Department has added an additional 48 people through February with a contract with Maximus Federal Services Inc., which has allowed internal staff to refocus on case investigation, said Katie Towns, an assistant director for the department.
An additional 15 contact tracers are expected to start in the coming weeks with the Jackson County Health Department through a purchasing agreement with the Mid-America Regional Council, spokeswoman Kayla Parker said.
"This is a short-term solution," Parker said of closing the clinic to shift nursing staff to contact trace.
When the funding runs out
With a little more than a month before the spending deadline, health departments are planning how to keep paying for extra staff brought on in the last nine months in order to tackle a pandemic that is now reaching all-time highs.
"This is here for a while," Phillips said. "It doesn't magically disappear Jan. 1."
With more than 48,000 positive tests since March, St. Louis County has seen the most cases out of anywhere in the state. Between 200-300 people are helping call cases each day, through a combination of new staff, volunteers and partnerships, like with Saint Louis University, Ave said.
For the fiscal year which begins Jan. 1, the St. Louis County Department of Public Health is requesting about $74,028,500 for its health fund - about 25 percent more than the fund's appropriation this year.
The budget proposal calls for adding 90 new positions dedicated to responding to the pandemic, many of whom will work in case investigation and contact tracing, Ave said.
In Boone County, about $312,570 in CARES Act funds have gone toward additional staff through the end of October, Clardy said. That's helped boost the county's contact tracing staff to 13 and its case investigations staff to 20-25.
The hope is that a variety of funds will help keep staff running past Dec. 30, like reimbursements through the CARES Act for previous expenses and extra funds the state has made available.
"We're trying to attack this from multiple angles," Clardy said.
Others are having to make do with what's on hand.
Some public health departments, like Shelby County's, have struggled to obtain CARES Act funds from their county commissioners.
Gough, administrator of the Shelby County Health Department, has only received about $9,000 out of the more than $30,000 she's requested - and that's been primarily to reimburse her staff for hours they've worked overtime.
Without extra funds, she's put her five nurses toward case investigations and contact tracing. They've been "slammed" with new cases, but they're managing. It can be time-consuming work with a case in a school requiring them to comb through seating charts and watch game footage to see who a student may have come in contact with.
And even if she had the extra funds to spend, having her staff make those calls - rather than outside contractors - ensures they can help the community they know best, like getting groceries to a resident that may need to isolate at home.
"Most of them are expecting a call from us," Gough said. "And then to hear a voice on the other end that they can relate to and put a name and a face to, builds that trust."
Health departments have seen their fair share of people refusing to share names of those they've been with or express worries they may be getting someone in trouble by talking. And there's those they can't reach at all.
"They are completely worn out," Larry Jones, the executive director for the Missouri Center for Public Health Excellence, said of health departments. "They have been working seven days a week since March. They have been cussed at, they have been called everything under the sun."
To continue to combat a pandemic they anticipate will only worsen until a vaccine is widely distributed, health departments echoed their most dire needs: more direct funding and for people to follow best practices.
"At what point do you have this diminishing returns," Clardy said, "where you put more and more money into trying to control a disease that more and more people don't seem to want to control?"
The Missouri Independent is a nonprofit, nonpartisan news organization covering state government and its impact on Missourians.