Covid-19: The inside story of how the contact tracing system averted a Christmas collapse

A large number of social contacts of Covid-19 cases are still associated with funerals and weddings, the head of contact tracing and testing for the Health Service Executive (HSE) has warned.

Dr Stephanie O’Keeffe, the national director of strategic planning and transformation with the HSE, said that while the median number of close contacts of positive cases was 6.3 on December 29th, there were some individual cases, including people who had attended weddings and funerals, where there were 50 or 60 close contacts.

“There are still a large number of contacts associated with funerals and weddings. People are adhering to the limits on numbers, but in the evening time that changes as people get more casual,” she said, adding: “People were not adhering to guidelines.”

However, she pointed out that generally the latest wave of Covid-19 was very widespread, and evident everywhere in society. “It’s people who are getting it from family members, through social friendships, from work colleagues. Right across the country it is transmitting in every setting, formal and informal,” she said.

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She said that close contact numbers were now declining, and on the evidence of the falling close contact numbers, Dr O’Keeffe said she is hopeful we are now reaching the peak of the current surge.

“The feedback from contact tracing centres is that the median numbers of close contacts has fallen from 6.3 to 3.2 people [on January 5th],” she said.

Exceeded expectations

The massive upsurge in Covid-19 cases in late December exceeded by a long way the most pessimistic scenarios projected for the post-Christmas period, she said.

Dr O’Keeffe said recent confirmed daily numbers surpassed all projections in the modelling, as daily figures of new cases went from the low hundreds to more than 7,500 in the space of a few weeks.

“From a planning perspective, we have exceptionally good data underpinning our [projections]. All of those numbers were far exceeded by a long way, even the most pessimistic scenarios.

“We were planning for all hands on deck across Christmas but nobody was prepared for these levels of cases,” she said.

In an interview with The Irish Times, Dr O’Keeffe said the tracing service was meeting the extraordinary demands placed on it in the past fortnight but this has involved huge sacrifices from the 800 staff who have worked around the clock and all through Christmas, and has seen an extra 200 personnel drafted in to help with contact tracing. A radical change of approach to contact tracing was also required on December 30th that prevented the service from being overwhelmed by the volume of new cases.

During the first coronavirus lockdown, virus testing and contact tracing were largely done by staff and volunteers, seconded from other HSE departments and the wider public service. From last summer, the HSE began a system of recruiting a permanent team of people.

Three-call protocol

For contact tracing, the system had operated under a three-call protocol. When a case was first detected, the first call was made by a medical person, who informed the patient in question that they were Covid-positive and discussed the medical advice. The second call was made by a tracer, who collected a list of close contacts, and their phone numbers. A third series of calls were made to the close contacts, who were told to take a test and isolate.

Dr O’Keeffe said the service was always planning for a “peak surge”, but in the run-up to Christmas, the Covid-positive laboratory results coming in were “very high and very worrying”.

There was a bit of a reprieve on Christmas Day, when fewer people were tested and only 363 cases were detected. But the figures soared after that. On December 26th, there were 1,687 cases detected – and within a week daily cases tipped to record numbers of more than 2,000.

Meanwhile, the number of tests being carried out daily had also effectively trebled, from 8,000 before Christmas to a high of 26,000 on one day in early January. Positivity rates had also increased from about 9 per cent to 25 per cent.

At any one time 44 per cent of the 800 contact tracers are working in centres in Dublin, Cork and Limerick, with a satellite centre in UCD, run by Prof Mary Codd. In addition, 100 extra personnel were drafted in from the Defence Forces to help out, and 100 environmental health officers were also seconded.

“People were working night and day, and came in to work through Christmas Day. Laboratories were working at full throttle through night-time. Every enhancement has been implemented to cope with the level of demand,” said Dr O’Keeffe.

Problems with contacts

In addition to the huge uptick in cases, there was also the problem with close contacts. The median number of close contacts for each case at the end of December was 6.3. Some people had 50 or 60 close contacts.

It meant that for every case detected, at least an extra six calls had to be made. When the numbers of detected cases were at almost 2,000 on December 30th, the service made 11,600 calls to confirmed cases and their close contacts. It was clear the service was about to be overwhelmed.

On December 30th, Dr O’Keeffe knew an explosion in the number of cases was imminent. Given the harsh facts on the ground, Nphet agreed a new procedure to prevent a collapse of the tracing system.

Instead of a three-call protocol there would be one call. In that one call, the person would be informed of a positive test result, given medical advice, and would be asked for their close contacts. Contact tracers then texted the contacts telling them to isolate but not to present for a test unless they were symptomatic.

As it panned out, that change was essential. On New Year’s Day, there were more than 4,000 positive tests, and the number increased each day to a peak of more than 7,500 on January 4th. If all close contacts had had to be called, that would have involved up to 50,000 calls that day.