As COVID-19 cases and hospitalizations soar in Maine, state public health authorities have scaled back the scope of their case investigations so contact tracing staff can keep pace with the disease, but for now the situation remains markedly better than other states.

The Maine Center for Disease Control and Prevention announced Monday that it was eliminating periodic check-in calls to people who had tested positive so it could redeploy employees to protect vulnerable populations. This followed an announcement last week that the agency would no longer investigate symptomatic people who’ve had contact with an infected person unless they test positive themselves, and may no longer contact those with the disease within 24 hours of receiving their results.

“We had to make some difficult decisions yesterday to focus on folks who are sickest or who have the most number of days left in their quarantine,” Maine CDC Director Dr. Nirav Shah told the Press Herald on Tuesday. “We have been studying what has been happening in other states very closely, and we are not immune from those forces, so it is a possibility that we may have to move to some very challenging triage decisions.”

The changes so far have been marginal, but if the situation continues to worsen, the department could be forced to retreat, ceding ground to the disease that will likely be difficult to recover until a vaccine is widely distributed months from now.

Over the past month, the number of active COVID-19 cases in Maine has more than tripled from a seven-day rolling average of 647 on Oct. 24 to 2,266 on Tuesday, while hospitalizations have broken a record every single day starting Nov. 12. The Maine CDC has identified more than 20 new outbreaks since Friday.

Yet the situation in the United States as a whole is so bad that Maine still has the second-lowest prevalence of the disease in the country after Hawaii, according to the New York Times tracker, and better than Vermont (48^th) and New Hampshire (42^nd).

The worst-affected state, North Dakota, has a seven-day per capita new case average that’s 10 times that of Maine. On Oct. 20, it told its citizens to do their own contact tracing after public health authorities became overwhelmed by the caseload. The state, which now has the highest COVID-19 death rate in the world, didn’t adopt a mask mandate until Nov 14.

New Hampshire, which now has twice Maine’s per capita new case average, announced on Nov. 13 that it would no longer investigate each person diagnosed with the disease and would reallocate its resources to do so for people at high risk of dying from the disease or spreading it. “Due to the rapid pandemic surge and widespread community transmission, containment is no longer possible,” the state’s public health department explained in a news release.

Contact tracing is one of the most effective weapons societies have to counter the spread of the pandemic. Public health authorities seek to promptly contact anyone who has been exposed to the disease so they can be isolated and, if they appear to have the disease, identify anyone they came in close contact with. But on Monday, the U.S. Centers for Disease Control and Prevention issued new guidance for health departments that have been overwhelmed by the disease, directing them to prioritize the household contacts of people who had recently tested positive for the disease or who worked or lived in congregant settings.

New Hampshire and Vermont, which has a slightly higher prevalence than Maine, have both directed schools to do their own contact tracing. “Schools already have well-worked systems in place to communicate with families, and families are likely to be more responsive to these messages from the school than to messages from the Health Department via unrecognized phone numbers,” Vermont Education Secretary Daniel French wrote in a Nov. 13 memo.

“Too few public health departments around the country took advantage of the downturn in cases earlier to get ready for this surge,” said Jeremy Youde, who studies the intersection of health and public administration at the University of Minnesota-Duluth. “We want trained people to do this work, not people who are trying to fight off a disease.”

Maine hasn’t abandoned hope to contain the disease, Shah said Tuesday. “We’re not where New Hampshire is yet,” he said. “We’re not at the ‘trace outbreaks only’ stage.”

The state had been ramping up for the expected surge, including by training staff in contact tracing so they could be redeployed to those duties if need be and by reaching out to the National Guard to identify medics and others with the necessary training, he said. The agency had 142 case investigators and contact tracers as of Monday, he said; about the same number as New Hampshire, which has roughly the same population.

“Our primary aim is staffing up even more,” Shah said. “We are dialing things up.”

Public health nurses are often on the front lines of contact tracing and vaccination delivery, but under Republican Gov. Paul LePage, the Maine CDC went from about 50 of them to fewer than 25, even though the Legislature had allocated funding for 48 of them. In early 2019, Democratic Gov. Janet Mills’ administration sought to dismiss a lawsuit that sought to force the state to hire the full 48 because complying was already its top priority. But a year and a half later there are still only 30.

Outgoing state Sen. Brownie Carson, D-Harpswell, was one of those who brought the lawsuit. He expresses frustration with the Mills administration’s failure to restore the personnel who are essential to contact tracing and other pandemic related duties. “These positions are funded, and not only are they not being filled, whenever we have reached out to (Department of Health and Human Services) Commissioner (Jeanne) Lambrew to offer help with recruiting, outreach and hiring, we were ignored or rebuffed.”

“I just don’t think Lambrew has made filling the ranks of Maine’s public health nurses a priority,” Carson said.

Lambrew’s spokesperson, Jackie Farwell, said via email that DHHS has “aggressively recruited” for the positions, including with radio ads in Presque Isle and Bangor, an open house for candidates in Machias, and job listings on websites and in the American Nursing Association’s journal.

“Maine DHHS has engaged in multiple conversations with Sen. Carson and consistently responded to his requests for information about our work to reinvigorate the PHN program,” she said. “We recognize that work remains to be done to achieve our shared goal of rebuilding the program and remain committed even in the face of the significant challenges posed by the pandemic and Maine’s health care workforce landscape.”

Shah said his agency, which is part of DHHS, had been working diligently to fill the ranks. “We do not have all the public health nurses that we wish we did, and that’s despite really aggressive recruiting,” he said. “We’ve interviewed a lot of candidates and made a number of offers, but in certain parts of the state including Down East, this has been challenging.”

Dr. Dora Anne Mills, a former Maine CDC director who is the chief health improvement officer at the MaineHealth network of hospitals, said it isn’t surprising that as the fall surge has hit, states have had to dial back on the level of contact tracing they do. “Contact tracing is like dousing a fire with a bucket,” said Mills, sister of the governor. “It works well when each fire is small, but as the fire expands, the buckets become less effective.”

Youde said any scaling back is unfortunate.

“This sort of shoe-leather health detective work is among the most useful and beneficial strategies for identifying and stopping the spread of an infectious disease outbreak,” he said. “To some degree, the decision by the Maine CDC makes sense – you’ve got limited resources and no expectation of money coming from the feds, so you have to prioritize which efforts you can support. But it’s going to make it that much harder to get the outbreak under control and is a pretty big indictment of the federal government’s disengagement from the real nuts-and-bolts work necessary to stop this pandemic.”