CASE NOTES

Tracing During the 2021 COVID-19 Pandemic

Megan Davies, District Veterinarian and Emergency Management Coordinator, North West Local Land Services, Narrabri

Posted Flock & Herd May 2022

Introduction

In June 2021, the number of cases of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2, COVID-19) in NSW began to increase, due to a Delta Variant outbreak.

In response to the increasing number of cases, NSW Health requested assistance from the Department of Primary Industries (DPI) to supply and coordinate contact tracing staff for the COVID-19 Response.

80 staff from Local Land Services (LLS) assisted with the COVID-19 tracing response, alongside staff from DPI and other regional NSW staff (1). Work on contact tracing continued until late September 2021, when a leadership change in the NSW State Government resulted in a shift in the COVID-19 control priorities, and a reduction in contact tracing.

Overview of tracing process

Purpose

The primary role of the LLS staff working with NSW Health was to communicate via phone calls with people who had been identified as contacts of a positive COVID-19 case. Contacts were classified as "close contacts" or "casual contacts" based on NSW Health criteria, including time spent in close proximity to the positive case.

The phone calls served several purposes: to ensure that people were aware of their status as a contact, to provide information about isolation and testing requirements, and to gather demographic and risk data from contacts.

Communicating with positive cases

When a positive COVID-19 case was identified by NSW Health, NSW Health staff would liaise with the positive case and gather information about their movements during their infectious period. NSW Health would access data collected by the Service NSW App, which people were required to use to check-in and check-out of venues. These data, along with information provided by the positive case, was used to populate live spreadsheets with information about people who may have been in contact with the positive case during their infectious period.

For example, if the positive case had attended a supermarket during their infectious period, a spreadsheet for that supermarket was established, listing all people who had checked into that supermarket during the period that the positive case was present at the venue.

If the positive case had attended a workplace, the workplace provided information to NSW Health about staff and any other people who entered the premises or had contact with the positive case on that day. This data was all added to the spreadsheets.

Contact tracing teams

LLS staff were organised into small teams, each with a team leader and a NSW health supervisor. Communication within teams was via the Microsoft Teams and SharePoint programs, which allowed videoconferencing and sharing of files. Tracing shifts were from 10am-6pm daily. Rosters were organised by the DPI Emergency Management Unit in response to Expressions of Interest submitted by staff members.

The day would start with a team leader briefing, followed by an all-staff meeting. This meeting would update participants on the spreadsheets that were to be used, any overnight changes to public health orders, and any changes to the scripts and information to be given to contacts. Training for new staff was conducted each morning via the Teams platform.

After the morning meeting, each team member would each select a number of rows in the designated spreadsheet to begin calling contacts. Team members used mobile phones, set on "private number". Each phone call tended to take between 10-20 minutes. Information collected from each phone call was entered into the live spreadsheet and any issues that required addressing were escalated.

Prior to receiving the phone call, contacts were meant to have received a text message from NSW health informing them of their status as a contact. This communication prior to the phone call meant that in most cases, the phone call was not a surprise - however in some cases, the text messages had not been received. Some contacts had also already been informed by their workplaces, schools or friends that they were a close contact.

The most common locations contacts had attended resulting in their "contact" classification were: supermarkets, schools, childcare facilities, medical centres and hospitals. Many police officers policing the lockdowns were deemed close contacts by visiting these locations as part of compliance activities.

Scripts

NSW Health provided thorough scripts for the phone calls, and these were updated daily to reflect any changes in public health orders. The scripts included:

Confirming identify of the contact, confirming their attendance at the venue of concern and notifying of contact status.
Questions about basic demographic information.
Questions about vaccination status - any COVID-19 vaccines received, brand and date given.
Gathering work information - have they attended work in high-risk settings such as health care facilities, schools, emergency services, meat processing facilities etc.
Requirement for getting COVID-19 PCR tests, and the frequency and dates these tests were required.
Common symptoms of COVID-19 and what to do if experiencing symptoms.
Questions about welfare - do the contacts have enough food and medication, do they have somewhere safe to isolate?
Information about how to safely isolate, and how to manage family members / housemates etc.
Questions about the location at which they intended to isolate.
Information about follow up phone calls and text messages from NSW Health, and provision of a phone number for any further questions they may have.

Escalating issues

Any issues that were identified during the phone calls were escalated via Team Leaders to a designated NSW Health supervisor. Issues included contacts who were or had been working in high-risk settings (health care facilities, schoolsetc.), contacts who had welfare issues such as insufficient food, and contacts who were non-compliant. Any contacts who were openly defiant and stated that they would be non-compliant, along with any that were reasonably suspected to be non-compliant, were referred to NSW Police.

There were processes for leaving messages for people who did not answer their phones - each person was attempted to be contacted three times before their number was escalated for follow up by NSW Health.

Issues encountered

Broadly speaking, the process of making phone calls and the organisation of the teams was well coordinated and efficiently executed. Changes were made as needed to make the whole process run as smoothly as possible. Some issues included:

Fear / frustration / confusion

Many people contact tracers spoke to were, understandably, in a heightened emotional state. The outcome was that some phone calls were challenging and difficult for staff. Many contacts were worried for their health and that of their families. Others were frustrated with the constant changes in public health orders and restrictions. Others had genuine concerns about how they were going to manage isolating, often in cramped accommodation, often with families.

Team Leaders were aware of the challenging nature of the phone calls and kept a close eye on staff throughout the response, assisting with difficult calls and providing debriefs after challenging calls.

Data duplication

There was a large amount of data duplication in the spreadsheets provided. Due to gathering data from various sources to populate the spreadsheets, some people would be entered multiple times. Unless this duplication was identified early, these people would receive multiple phone calls from contact tracers.

Many people have multiple names (e.g. an English name and a non-English name, or a nickname, or a surname put in place of a first name), and so were often duplicated within the spreadsheet.

Efforts were made to minimise duplication, but it still occurred, resulting in inefficiencies and repeat phone calls to the same people - with consequences for public perception of the competence of the response. Some people also entered fake names and phone numbers into the Service NSW app.

Language

Language barriers were significant. Telephone translation services were used effectively using a NSW Health account, however sometimes it was difficult to determine what language translator was needed, and sometimes it was difficult to convey and receive all the required information via a translator. An example is that if a person does not know the English alphabet, they are unable to spell out street names to provide their address. Text messages helped with language barriers, as online translation apps were used by many people to translate the content of text messages from NSW Health.

Compliance

Most people were largely compliant with all instructions given, and freely provided answers to questions asked. Some people did not trust that we were calling from NSW Health - as our calls came from Private numbers - and refused to provide personal information. A very small percentage of people were openly aggressive, rude, and indicated that they would not comply - these were all referred to NSW Police via NSW Health.

Staff Fatigue

The nature of the work meant that it was emotionally draining for staff. After the first few weeks of the response, a rule was brought in that staff were limited to three sequential days of contact tracing. This rule was put in place to manage fatigue. Further rules were brought in to prohibit staff from completing business-as-usual work at the same time as working on the response as some staff were managing double workloads during the response. Employee Assistance services were provided to all staff participating in the response to allow any staff requiring support to be able to access help as required.

Delays / Hurry up and wait

When an issue was identified with a particular spreadsheet or script, staff were instructed to halt work on that spreadsheet until the issue could be rectified. This instruction resulted in many staff hours spent unproductively waiting. Some staff found this particularly frustrating, while others appreciated the break in workload.

The immensity of the response also led to delays in communicating with contacts. In some cases, our staff were calling contacts on the final day of the 14-day period in which they were meant to be isolating, only to find they were unaware that they were a contact. Some spreadsheets, particularly those for large supermarkets, contained over 5000 contacts to be called - a process that took many days. The delays led to frustration amongst both contacts and contact tracers, many of whom despaired that we might never get on top of the outbreak.

Internet accessibility / systems issues

Good quality internet connections were required to enable access to the live spreadsheets and the Microsoft Teams platform. The size of the spreadsheets made them difficult to navigate, particularly on small screens. The size and seeming complexity of the spreadsheets was also daunting for some staff and put them off participating in the response.

Lessons learned and application for future responses

Tracing is hard

The immensity of the tracing task cannot be underestimated. Having expert data managers to handle the huge volumes of data is essential, as is having staff who are competent with basic data management programs such as Excel spreadsheets. Tracing is also very time consuming - the disease continues to spread as tracers scramble to keep up and contact people to help minimise future spread. The resources required, in terms of staffing, are significant.

Technology helps

The ability to work remotely in this response allowed many more people to participate than if travel to a central location had been required. The use of apps such as the Service NSW QR code check-in app significantly helped with gathering tracing data - but that data is only as accurate as the information people enter and is only useful if able to be accessed, interpreted and acted on in a timely manner.

Long responses require active fatigue management

Fatigue management for staff involved in contact tracing was quickly identified as an issue with this response. Long days of making difficult phone calls took its toll on staff who were also often significantly impacted by the pandemic on a personal level - through lockdowns, home schooling and other pandemic-related challenges. The pressure to complete business-as-usual work for staff was also present, particularly those with people-management responsibilities. The challenge of finding staff to continue to contribute to prolonged responses will be difficult.

A pandemic does not prevent other emergency responses

Business as usual for many LLS roles is required to continue, even in the presence of pandemic restrictions and an active pandemic response, particularly in the emergency management space. Having LLS staff participating in major responses is a valuable learning opportunity and enables them to gain real-world experience. However, it does potentially leave staff either fatigued or unavailable for concurrent or subsequent responses. The challenge of managing multiple responses either with short time frames, or concurrently with other emergency management programs, is one that LLS will continue to face into the future.

Conclusion

Participation in a large, multi-agency disease outbreak response was a valuable experience for all LLS staff. It provided firsthand, practical experience and insight into how such responses are managed and provided many learning opportunities. Such learnings should be shared with colleagues to improve preparedness for biosecurity emergency responses along with ongoing training in all aspects of biosecurity emergency responses.

Acknowledgements

With thanks to NSW Health for their continued efforts to contain the COVID-19 Pandemic, DPI Emergency Management Unit for the coordination of the COVID-19 tracing response, and all LLS and DPI staff who contributed to the response.

References

Regional NSW. Support to NSW Health in COVID-19 response, June to November 2021. Published November 2021. Department Reference Number: INT21/172741