In the HSE’s national contract tracing centre in Galway, they are known by their shorthand “Call 1” and they are tough phone calls to make.
Nobody wants to hear – or to tell someone – they have Covid-19, but these calls are essential in the effort to break growing webs of infections, stop the virus spreading and ultimately suppress it.
The contact tracer must get the names of the people the infected person has been in close contact with over the previous 48 hours, as they might be infected too and they need to get tested before they spread it.
"We have rung people and they may have lost a parent or a spouse to Covid-19 and then you are telling them that they have it," says Niamh Kelly, a "shift lead" and one of about 30 people working at the Galway centre.
“That’s a very difficult thing to hear because they have experienced the true reality of what it means. I have rung single parents who are concerned about their children. I have rung people on their own who are concerned about how they get their shopping, who don’t have family support.”
It is not easy to admit you have been to a house party or on a bus or in gatherings where you are now going to have to name 40 or 50 people
Kelly says it is important not to rush the call. “No call is the same but we take our time.” They know they have to be empathetic and listen. Some people are ill and coughing when they call and need medical attention. Others may be reluctant to admit they ignored public health advice.
“Nobody is attributing blame to them for being Covid-19 positive. It is not easy to admit you have been to a house party or on a bus or in gatherings where you are now going to have to name 40 or 50 people who will have to go through this testing and restrict their movements,” she says.
Before the pandemic Kelly was an environmental health officer. She and her colleagues are now essentially investigators – Covid-19 detectives – on the trail of the virus and where it might be hiding.
“It does feel like we are investigating sometimes because we are trying to draw information out of people: ‘Where have you been; what have you done?’ ” says Kelly.
On a given day there can be up to 30 calls to new confirmed cases. Worryingly, the number of close contacts of each of those cases has risen 55 per cent in the past week. The average is just over five, so that’s five calls to make for every confirmed case.
House party
A concerning trend that has emerged since the country reopened further at the end of June is the very large number of close contacts of new cases, mostly young working adults.
They can be groups of 30, 40 or 50 who were at a house party or a casual get-together, or at work, or a group of friends who rented a house in the west or a running group who stopped being as careful as they were with physical distancing when they were exercising.
“Things might be just slipping a little in people’s minds and they are seeing more normality out there and letting their guards down a little, where it is important to keep that guard up,” says Kelly.
And then there are international flights. Here, the tracing centre becomes an early detection and warning system, tracing clusters back to one source by linking two cases in different parts of the country to the same incoming flight.
“We need to get that information. It is absolutely essential for us to do our jobs, like investigators or detectives, to draw that information out of people so that we can use it to get everybody tested and get them to restrict their movements.”
Confirmed cases have fallen from several hundred a day. Initially, there were 1,700 contact tracers, including Army cadets, in nine centres during the peak in April. This has now fallen to a handful of staff in one centre, but it has brought benefits, as the small team can share intelligence and spot trends more quickly.
"The disease is, largely speaking, in clusters now. That is where you are seeing slightly higher positives now"
“They can connect a cluster you might see in one part of the country to another which might sit under different public health departments,” says Niamh O’Beirne, the HSE’s national lead for testing and tracing, who oversees the Galway operation.
“Having them all in Galway, they can hear stories from each other – how that case came off that flight and another says, ‘Actually, so did the case I have,’ so that is two outbreaks and then here is a third. They can connect them all together.”
O’Beirne says the “whole trick” of contract tracing is how fast the team can get to newly infected people and their close contacts and get them all tested and self-isolating.
“The disease is, largely speaking, in clusters now. That is where you are seeing slightly higher positives now: where the virus got in somewhere and just took hold,” she says, using the construction site cluster in Dublin this week as an example.
The average testing and tracing turnaround time is 1.8 days.
“Time is critical. Every day that passes is the possibility of having someone out in the community who should be self-isolating or restricting their movements,” says Kelly.
The team feel a sense of achievement when they “join those dots” and they have “spotted something that could prevent something bigger happening,” she says.
Tracing app
The HSE’s new contact tracing app, downloaded more than 1.3 million times since its launch just over two weeks ago, has thrown up about 100 contacts of confirmed cases in the past two weeks. About half of those detected were people not mentioned as a close contact by a “Call 1”.
These can be “people they met and didn’t really know,” says O’Beirne.
“It is another way of closing out the spread of this,” Kelly says of the app. “In general – and I personally made calls to those people – they have been quite receptive, surprised maybe,” she says of the close contacts detected by the technology.
All the contact tracer can say is the date they came in contact with the infected person.
“They might be curious. I am sure they are thinking: ‘Where was I that day and how did I get it?’ ” said Kelly.
"I find it hard to understand why people are reluctant to go for a test. Some people say they don't want to know"
This week HSE chief executive Paul Reid raised significant, worrying trends: contact tracers spending longer trying to persuade close contacts to go and get tested; up to 25 per cent no-shows for the first "day zero" test and up to 50 per cent for the seven-day test – key moments when the virus may be detected in asymptomatic carriers and prevent them from unknowingly spreading it.
“I find it hard to understand why people are reluctant to go for a test. Some people say they don’t want to know. They may argue about whether they were a close contact or not. There could be a bit of a denial and ‘I couldn’t possibly have it’,” says Kelly.
“You ask close contacts whether they have symptoms: sometimes it is only when you speak to them that they realise that maybe I have had a cough.”
Contact tracers assure them that the test will be quick and will provide certainty, and that they may be protecting vulnerable people in their family or community.
Hostile calls are “few and far between”, says Kelly.
‘Upset and angry’
O’Beirne says younger people can “very upset and very angry” because they cannot go to work or are concerned their employer will know or unsure of how to tell friends and family.
Calling in public health inspectors or even the Garda, or using public health enforcement to ensure close contacts start showing up to be tested is a non-starter, Reid says; contact tracing and testing has to be a voluntary process and relies on goodwill.
“If you lose that, you lose it. That is a very fundamental line for health systems. If you get into surveillance, particularly for a health system, it is a very dangerous line to cross,” he says.
Reid has about 400 trained people available to bring into the contact tracing operation should cases rise. The Galway centre right now has capacity to manage calls for 150 positive cases a day, says O’Beirne. The trigger to start scaling up is if there are three consecutive days of 100 new cases.
“We would know we were heading that way,” she says.
What keeps a contact tracer awake at night? “Unrestricted crowds where everybody is unable to keep a physical distance or forgetting to after being out and about for a while. That is frightening for a contact tracer,” she says.
"That is our ultimate goal: to see this shrink and shrink and ultimately not be required"
“At the moment we are dealing with 30 people. Can you imagine dealing with a hundred or hundreds, trying to contact trace? It is unimaginable really how we would manage that.”
Kelly says a “dream day” for her and her colleagues is a “quiet day”.
“It’s not because we enjoying drinking coffee. It is because there aren’t cases to inform or contacts to follow up,” she says.
“That is our ultimate goal: to see this shrink and shrink and ultimately not be required. We will always be there in case we are needed, but a quiet day is a fantastic day.”
