The recent rise in the numbers of positive test results for Covid-19 has put the challenge of containing its spread at the forefront of our minds once again. We are constantly being reassured by the Government that we have the required testing and tracing capacity to rapidly respond to a resurgence of the virus in the community.
Testing regimes have advanced considerably since the early days of the pandemic and referral-to-results time has fallen from seven to 10 days to a median of 3.1 days from referral to completion of contact tracing (according to Minister for Health Stephen Donnelly on Morning Ireland, August 12th). Though this is indeed a substantial improvement, it is far short of what is required to contain the spread of the pandemic.
We must recognise that we are in a different phase of the pandemic now, where most infections are occurring among the age groups who are working and socialising. The potential for rapid spread is much greater than when the nucleus of the pandemic was older and more vulnerable people and the population was in lockdown or partial lockdown.
Coupled with this is the fact that the majority of those testing positive over the past few weeks have been asymptomatic. An asymptomatic twentysomething is likely to come into close contact with far more people in those 3.1 days than a nursing home resident who is symptomatic and most likely has been isolated since the onset of his or her symptoms.
More than 1,500 individuals were trained as contact tracers and many of these were on call to volunteer for shifts as the need arose
If we are to effectively deal with this changed scenario, we need to repurpose our contact tracing system to deliver far more rapid results, so that the Covid-19-positive person is self-isolating and all contacts are being tested within hours of the person receiving a positive result. This is critical to containing the spread of the virus in the community.
Academic volunteers
First, there is the question of what we can learn from our contact tracing efforts to date. According to the Government website, there were eight contact tracing centres established to respond to the pandemic, with five of these located in universities. More than 1,500 individuals were trained as contact tracers and many of these were on call to volunteer for shifts in the contact tracing centres as the need arose, based on the volume of test results in any one day. Many were university staff, who had some free time due to the universities moving to online learning and/or were willing to give their weekends to help deal with the volume of work.
It would, however, be a mistake to assume that the contact tracing system that was rapidly put in place in the early stages of the pandemic is fit for purpose now, given the changing priorities and demands. Indeed, the recent rise in the number of positive test results demonstrated this. Volunteer workforces are often difficult to sustain and tend to be transitory in nature. University staff are burdened with the increased workload of organising lecture spaces and timetables to comply with social distancing and infection control, preparing materials for online delivery, reorganising their work practices for continued remote working etc. They are unlikely to have the time to volunteer, or at least not in the large numbers they previously did.
What is needed now is a more sustainable, trained and paid workforce, employed for the specific purpose of contact tracing. With the current high unemployment levels, this would be a welcome opportunity for many.
Second, we need to rethink the purpose of the contact tracing calls. In his interview on Morning Ireland, Donnelly repeatedly referred to the tracing calls as “clinical calls” and made reference to the difficulty of “pulling people off clinical work”. At the height of the pandemic, one could see the value of having clinical staff as the primary contact tracers, as least when informing the Covid-positive patient of their results.
Repurposed system
At that time, most positive cases were in the older age group and results were being delivered over the phone to patients in hospital and residents in nursing homes. Many of these people may have had other conditions and/or cognitive impairment and reassurance and guidance was a key focus of the calls. Given that the majority of those testing positive are either asymptomatic or experience only mild symptoms, there is not the same need for clinical expertise. Isn’t it time to repurpose our contact tracing system to focus on getting results delivered and close contacts informed of their risk in the most efficient manner possible? It takes less than three hours to train a contact tracer. Having a trained workforce that is fully available to respond to unexpected spikes in the number of cases would mean less reliance on taking clinical staff away from their usual clinical work. For those cases that are more complex, a smaller on-call clinical team could be available for follow-up calls to people who need this advice.
The launch of the Covid Tracker is a welcome support to contact tracing. However evidence from Singapore (one of the first countries to introduce a tracing app) and a mathematical modelling study conducted by Oxford University, suggests a 60-75 per cent minimum adoption rate per population is needed to achieve the desired efficiency. Although Ireland has been hailed as the country with one of the highest adoption rates for the tracer app, we currently stand at approximately 33 per cent adoption rate.
Of course, the app is not the whole solution. What is required is a combination of human tracing and the app, to ensure that those who could be more vulnerable to infection but are less likely to have a smartphone, such as elderly or disabled persons, are not disadvantaged. Though contact-tracing apps are an important part of the effort in the fight against Covid-19, the apps alone cannot reduce its spread.
It is necessary that we now establish a robust Covid-19 testing and tracing infrastructure that is at the ready for whatever challenges the next stage brings, and one that can be sustained for the long haul.
Eilish McAuliffe is professor of health systems and director of the UCD Iris centre