SAN FRANCISCO — Despite experiencing one of the country’s largest outbreaks of monkeypox, San Francisco’s health department has pulled back on contact tracing – a standard public health practice in combating viral disease – for those who have been infected, this news organization has learned.
The revelation comes amid successive declarations of public emergencies over the monkeypox virus by the federal government, the state and San Francisco Mayor London Breed, whose director of public health announced at the end of July it was “imperative that we mobilize city resources rapidly” to curb its spread.
But San Francisco has never announced publicly whether it is tracing the contacts of infected residents in order to detect and control the spread of a monkeypox outbreak that has affected hundreds, and emails obtained by this news organization indicate that health department officials are reluctant to answer questions about their strategy. It turns out that for this city, contact tracing — a key endeavor during the early days of the COVID-19 pandemic, and an approach epidemiologists say should work well against monkeypox — plays only a small part.
While the department investigated every known case in the “early days of the outbreak,’’ many of the people interviewed were unwilling or unable to share the names of their partners, according to city health officials. The virus, health officials say, is spreading through skin-to-skin contact primarily during sexual intercourse.
“This made it difficult to contact trace all known cases,” the health department stated in an email. “We pivoted our strategy to focusing our case investigation effort to specific groups that might signal something new in the epidemiology. We are currently doing case investigations and contact tracing for youth under 18 years of age; any person who could become pregnant, and people who are pregnant, among others.”
The virus, however, is overwhelmingly affecting men having sex with other men. While San Francisco would not say what percentage of monkeypox infections it is tracing, its description of its new strategy suggests the answer is, just a sliver of them.
Some epidemiologists question that approach. “It’s critically important to let exposed people know who they’ve had an encounter with,” said Dr. Scott Roberts from the Yale School of Public Health.
The shift in strategy, San Francisco officials said, occurred about a month ago.
The department said that out of the 386 cases reported on Aug. 2, 72% of the affected individuals have been interviewed by health officials, and another 9% are awaiting interviews. But the agency did not provide numbers on how many potentially exposed contacts they’ve received – or reached – from those interviews. According to the department, it is now asking infected individuals to inform their sexual partners that they should receive medical attention, rather than trying to contact those partners itself. Those the department does contact are provided with resources to combat the virus and are given priority for vaccination.
By Sunday, the city had added 58 cases to their count, a total of 444 individuals.
Health departments in Santa Clara and Alameda counties – which are also facing sizable monkeypox outbreaks – both said in responses to this news organization that they were interviewing each person who tests positive for the virus to identify contacts who may have been exposed. Alameda included in its response that “it can be challenging to elicit information for exposed contacts for monkeypox because of the intimate nature in which exposures may occur.”
In their public pronouncements about fighting monkeypox, San Francisco officials have stated that they are trying to rapidly obtain a vaccine that is currently in short supply across the nation – and have emphasized that they’re working with the city’s LGBTQ community, which has been disproportionately affected by the virus.
But emails from mid-July obtained through a public records request show internal wrangling by top San Francisco health officials over how to shape the narrative on contact tracing.
“Please weigh in – don’t want to say too much, or beg more questions,” wrote Amy B. Garlin, medical director of the agency’s communicable disease control department, in a July 21 email asking her colleagues to review her response to this news organization. Shortly after, Health Officer Susan Philip approved the response, which stated “we are doing contact tracing for monkeypox,” without any indication that was true in only a fraction of cases.
Later that day, Stephanie Cohen, medical director of the San Francisco City Clinic, weighed in during the email exchanges. The city-run clinic specializes in sexually transmitted infections and is active in the agency’s response to monkeypox.
“I think this response over-emphasizes contact tracing,” she wrote. “We’re scaling back (case investigators) and encouraging people to self-refer partners, correct? I think the response should be more in line with our strategy … I don’t think we should say: ‘we are doing contact tracing for monkeypox.'”
Garlin did not respond to a request for comment asking about her communications with colleagues.
Epidemiologists said in interviews that contact tracing would be effective in stopping the virus’s spread but acknowledged its challenges.
UC Berkeley epidemiologist Dr. John Swartzberg said that because the incubation period of monkeypox is a couple of weeks, rather than COVID’s couple of days, cutting off the spread by identifying potentially infected individuals is easier. It is also easier to determine who may be at risk for catching monkeypox, which involves intimate contact between people, rather than COVID which spreads through the air and could infect multiple people in a public space.
However, Swartzberg agreed that contact tracing could be difficult in some cases because those infected with monkeypox may be hesitant to reveal their sexual partners to public health officials, some individuals may not know the actual identities of the people they are having sex with and public health departments already lack resources in light of the ongoing COVID pandemic.
Others, like Roberts from Yale School of Public Health, said monkeypox’s tricky symptoms make contact tracing all the more important.
“A problem with monkeypox is that you have flu-like symptoms,” he said. “The rash can be mistaken for other STIs like syphilis or herpes. So many may not know they were exposed.”
