San Francisco has demanded more vaccines and treatment options for its escalating cases of monkeypox — but the city has all but abandoned a time-honored method of containing outbreaks: contact tracing.U.S. health officials declared monkeypox a national health emergency last week, as did California and San Francisco city officials, and although it’s typically non-fatal, no one wants to become infected by the smallpox relative, with its painful lesions that can lead to scarring.
With 472 cases — 36% of the state’s 1,310 cases — city public health officials believe San Francisco has the nation’s highest per-capita rate.
At first, the practice of tracing people exposed to a fast-spreading disease, then isolating or treating them, seemed like a good idea. Health officials relied on it in the early days of the COVID-19 pandemic as cases climbed.
But San Francisco public health officials said that when they tried to trace every person exposed to monkeypox — mostly men who have sex with men — it didn’t work.
“Many individuals were not willing or were unable to share the names and contact information of partners,” health officials said in a statement.
So about a month ago, health officials changed tactics and began urging people with monkeypox to do their own contact tracing. The city’s health department hastens to say that it still does monkeypox contact tracing — but said that it’s limited mostly to kids under 18 and pregnant women.
By contrast, a survey of several Bay Area counties — Alameda, Santa Clara, San Mateo, Contra Costa and Marin — found that all are continuing to do contact tracing with everyone who tests positive for monkeypox.
But case counts there are in the single or double digits, compared with hundreds in San Francisco.
Marin County is up to seven cases — yet only about half were willing to reveal the identity of any partners, no matter how gently public health officials asked or how adamantly they explained that they would keep the information private, said Dr. Matt Willis, the county Department of Public Health’s top official.
“This is always true for contact tracing sexually transmitted diseases,” Willis told The Chronicle. “ “We’re asking questions about sex and the kind of sex they’re having.”
Willis said that people are often willing to talk about their most intimate moments. “But when it comes to actually naming their partners, there’s often a moment where it’s clear they’re ambivalent about having any more conversation,” he said.
One common approach to make people more comfortable involves role-playing the conversation that health officials would like to have with the infected person’s partner or partners — and that can work. But not always, Willis said, and usually people just say they’d prefer to contact their partners themselves.
Yet contact tracers are better able to help the partners they do reach, because they can provide appointments and information, if not treatment. A smallpox antiviral can sometimes be used for people who are already sick, and others can get vaccinated. But drugs are in short supply.
Arnab Mukherjea, a public health expert at Cal State East Bay, expressed surprise that San Francisco would put the breaks on contact tracing no matter how low the yield.
“If someone refuses to divulge the name of another person, you can’t force that,” Mukherjea said. “But if good contact tracing nets you five contacts instead of 15, it’s better than letting it go unfettered.”
He said contact tracing can be more effective with monkeypox than with COVID, which is transmitted by air droplets. People can’t be sure who they got the coronavirus from, unlike monkeypox, which is commonly transmitted by skin-to-skin contact.
Nevertheless, tracing all partners of a person infected with monkeypox can take hours — especially if they don’t pick up their phone, said Willis.
“So I could imagine that if, like San Francisco, you have almost 500 cases — and you’re not getting a high yield anyway — I can see how resources be better placed elsewhere,” he said.
Even so, the fact that the San Francisco Department of Public Health had largely given up on contact tracing was not something officials easily admitted, according to an East Bay Times story this week. The newspaper obtained internal emails revealing that they waffled about telling the public the full story.
According to the paper, Susan Philip, San Francisco’s health officer, approved of a public response that said: “We are doing contact tracing for monkeypox” — but not saying how little of it they were doing. Stephanie Cohen, medical director of the San Francisco City Clinic, disagreed, saying that response “over-emphasizes contact tracing,” the emails cited by the paper showed.
The statement that S.F. officials sent The Chronicle on Monday acknowledged that they were focusing on younger people and pregnant people.