An overview of the establishment of a national contact tracing programme: a quality improvement approach in a time of pandemic

Introduction

The coronavirus disease 2019 (COVID-19) pandemic is a global health emergency and has placed unprecedented pressures on healthcare systems around the world. As of 20^th December 2021, there are 273,900,334 confirmed cases of COVID-19, including 5,351,812 deaths worldwide¹. Ireland has also suffered a loss of 5,835 lives and a total of 656,600 confirmed cases of COVID-19 as of 20^th December 2021² highlighting the magnitude of the problem. Contact tracing is a core component in the management of infectious disease outbreaks and has been a part of the strategies of various countries to battle the COVID-19 pandemic³. To stop the spread of COVID‑19, the World Health Organization (WHO) recommends finding and testing all suspected cases, isolating, and treating confirmed cases and identifying close contacts of the confirmed cases for quarantine and observation⁴. Countries should implement measures suited to their epidemiological conditions and system capacities while learning from success stories including China, Singapore, and South Korea who have demonstrated that identification and management of cases and their close contacts are effective practices⁵.

Studies have shown that reducing tracing delays by shortening the time to trace contacts and prompt testing and isolation of positive cases can enhance contact tracing effectiveness while also reducing reproduction numbers⁶. In most situations, efficient contact tracing and case isolation can significantly control a new outbreak of COVID-19 within 3 months⁷. In addition to this, digital contact tracing through apps allows for instant notifications and has the potential to reduce the number of cases using finite resources⁸.

There are eight regional Departments of Public Health in Ireland and under normal circumstances, each region manages and contact traces infectious diseases (IDs). The Health Protection Surveillance Centre (HPSC) coordinates nationwide outbreaks in collaboration with the eight regional Medical Officers of Health (MoH)/Departments of Public Health and Northern Irish authorities as required. However due to the rapid spread of COVID-19, coordination between the Departments of Public Health became challenging. Contact tracing services in departments with small numbers of staff and large urban populations became overwhelmed. There was a need for a contact tracing and management intervention at a national level to undertake high volume, low complexity contact tracing in Ireland. Members of the National Quality Improvement (QI) team, who also had expertise in public health, identified an opportunity to apply a QI approach to design and implement a national Contact Management Programme (CMP) at pace and scale.

The aims of the CMP are to rapidly identify and close chains of transmission of COVID-19 and collect essential surveillance data, thereby slowing COVID-19 transmission in Ireland and lessening the impact on health system capacity, in addition to freeing-up the Departments of Public Health to focus on complex public health issues. The aim of the paper is to describe the establishment of the CMP, its core components, outcomes on key measures (coverage, timeliness, and training) and learnings from the process since its establishment up till its first year of operations (May 2021).

Methods

Context

This study is reported using Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines⁹. On 11th March 2020, the Chief Executive Officer (CEO) of the Health Service Executive (HSE) Ireland directed the Chief Clinical Officer (CCO) to establish national level contact tracing. A team with expertise in QI (National Quality Improvement Team), programme development (National Women and Infants Programme) and public health infectious disease management was established. The CMP design was based on the Model for Improvement¹⁰, a QI method which centres around the development of improvement ideas with a clear aim, measures to know whether the aim has been achieved and small tests of change using PDSA (Plan Do Study Act) iterative cycles. The design of the CMP was an iterative process based on international best practices¹¹. Although the CMP closely mirrors these guidelines, the implementation using QI approaches in the Irish context is novel. Figure 1 maps CMP design onto the Model for Improvement. The four-step process blueprint of CMP was created using process flow mapping, a lean methodology tool¹². The national framework for improving quality in HSE guided the implementation of the QI approach for the CMP¹³.

Figure 1. Design of the Irish Contact Management Programme (CMP).

CMP design based on the Model for Improvement. COVID-19=coronavirus disease 2019.

Results

In total, 246,666 positive cases have been recorded on the CCT between 17^th March 2020 and 30^th April 2021, with contact tracing successfully completed for 237,759 cases, representing 99% and 96%, respectively, of the 248,529 cases notified in Ireland up to the 30^th April 2021. The other cases were managed by Departments of Public Health or Occupational Health Departments, outside the CMP process. There were 681,904 close contacts captured on the system between 17^th March 2020 and 30^th April 2021. The CCT also recorded 86,717 complex contacts or settings which were referred to Departments of Public Health for management. The busiest day for the CMP was 4^th January 2021, with 7,518 calls made to cases to inform them of their diagnosis and collect details of their contacts (combined call 1&2). CMP coverage outcomes are presented in Figure 2. Timeliness outcomes are summarised in Figure 3. The average time taken to complete ‘call 1’ was 14.9 hours (95% confidence Interval [CI] 14.8, 15.0) and the median time was 5.9 hours (approximate 95% CI 5.6, 6.3). The average time taken to complete ‘call 2’ was 4.9 hours (95% CI 4.7, 5.1) and the median was 0.8 hours (approximate 95% CI 0.6, 0.9). The average time to complete ‘call 3’ was 6.9 hours (95% CI 6.8, 6.9) and the median was 1.0 hours (approximate 95% CI 0.9, 1.1). The average time taken for contact tracing to be completed was 29.4 hours (95% CI 28.9, 29.9) and the median was 16.8 hours (approximate 95% CI 15.9, 17.7). The difference in mean and median is largely impacted by cases entering the system at night-time when CTCs were not working.

Figure 2. Contact Management Programme (CMP) coverage (March 2020 - May 2021).

Number of cases and close contacts managed through CMP.

Figure 3. Timeliness of the Contact Management Programme (CMP) (April 2020 - April 2021).

Mean length of time take to complete calls 1, 2 and 3 and the mean length of time to complete contact tracing.

The length of time taken to complete calls decreased during the first five months of the CCT’s lifespan as CMP efficiency increased and the number of cases and contacts decreased in line with the implementation of national restrictions. The rise in case and contacts numbers during the second surge in September and October was associated with an increase in time taken to complete calls. At the end of December 2020, Ireland experienced its third and by far largest wave with case numbers increasing tenfold in less than 2 weeks. Using the lessons learned from the second surge, the contact tracing process was rapidly adjusted. Call 1 and 2 were combined into one call and the Request a Test portal replaced call 3, until the point at which testing of close contacts had to be paused due to testing capacity. Throughout this surge, phone calls to cases, identification of contacts and communication via SMS of contact status was maintained.

A total number of 3,834 contact tracers were trained between March 2020 to March 2021. This excludes contact tracers who returned for refresher training. Initially the training was delivered face to face during the first phase of CMP induction (16th March 2020– 19th April 2020). Later, these sessions were offered remotely. Evaluation found that the contact tracers found the content, delivery, and design of the training informative, comprehensive, and beneficial. Majority of those trained found the programme to meet their expectations and felt well prepared to work in a CTC. The results are summarised in Figure 4. With the increasing complexity of calls, the education and training team now offer discussion sessions to contact tracers to consolidate learning and build confidence in the contact tracing workforce.

Figure 4. Training of contact tracers within the Contact Management Programme (CMP).

Number of new contact tracers trained in then CMP.

The demonstrate that the establishment of the CMP led to a drastic increase in the number and proportion of all cases of COVID-19 being managed centrally. This intervention enabled contact tracing to be undertaken by people with no previous experience in public health. Given the very small number of public health experts in Ireland prior to the pandemic, the CMP was responsible for allowing contact tracing to continue throughout the pandemic. In addition, CMP freed up the specialised experts within Departments of Public Health to undertake other complex COVID work. The PDSA approach has made the process scalable and to date, there have been 16 releases adding enhancements to improve the CMP process. Some other major enhancements include the introduction of a self-service booking portal and plans to introduce source investigation to identify and manage outbreaks more efficiently.

Discussion

This paper describes the establishment of the CMP, its core components, outcomes on key measures and learnings from the process. Across the world, government policies towards contact tracing vary greatly. Country responses to contact tracing can be categorised as no tracing, limited tracing, and comprehensive tracing¹⁴. Ireland along with a few other countries such as China, Australia, Japan, conducted comprehensive contact tracing¹⁴. The testing and tracing strategy of the Irish health system has proved successful in identifying cases of COVID-19¹⁵. Through the application of a QI approach, a scalable contact tracing system was rapidly developed. In close collaboration with regional Departments of Public Health, the Contact Management Programme ensured that cases and contacts were appropriately managed in a streamlined and sustainable process. The work was fast paced with new structures, services and initiatives often introduced in a matter of days. Leadership and coordination were provided by National QI Team and National Women and Infants Health Programme, working with colleagues in Public Health and across the HSE and other agencies.

In the absence of collaboration and coordination with other areas, contact tracing efforts of public health alone may quickly overwhelm the team's capacity¹⁶. Collaboration across departments and coordination at the national level was an important aspect of this approach as well. Decisive leadership, a rapid response, good coordination, understanding the socioeconomic and health dimensions of the population emerged as a key factor in determining success of COVID-19 pandemic response¹⁷. The learning from the CMP aligns with this evidence as leadership and governance enabled rapid mobilisation of resources and empowered the teams.

For a meaningful impact, contact tracers need to be trained in not only script-based guidelines, clarifying signs, symptoms and public health advice but also soft skills such as patience and empathy¹⁸. The CMP education and training team quickly trained a large number of contact tracers to assume this responsibility. Person engagement through different forums also contributed to the iterative improvement of scripts. This also supports the current evidence that suggests community engagement can be an important bottom-up approach in the COVID-19 response and its improvement¹⁹. Optimising the coverage of testing, timeliness of tracing coverage, reducing tracing delays by using app-based technologies has a potential of preventing up to 80% of all transmission and enhances the effectiveness of contact tracing⁶. The outcomes of the CMP show that CMP managed 96% of the contacts centrally and combined with other public health preventative measures, played a leading role in curbing transmission.

For contact tracing to be a valuable public health measure, the majority of the secondary cases need to be detected and isolated before they become infectious along with other public health control measures²⁰. The use of technology can facilitate the achievement of this target. Evidence suggests that countries more successful in managing the disease burden of COVID-19 quickly developed and deployed digital technologies to support pandemic management²¹. In Asian countries including China, Taiwan, and South Korea, contact tracing apps proved to be effective in supporting the contact tracing processes²². This was observed in the CMP as well where the CovidCare Tracker app served as an effective and scalable tool to connect the public with the CMP, greatly enhancing the capacity and speed of contact tracing. However, high-tech tools and digital contact tracing are not a replacement for contact tracing done by trained contact tracers²³. CMP also reflects this and is centred around the importance of trained contact tracers. This human aspect of the process has proved to be critical in ensuring people understand public health advice and gathering important feedback for process improvement. However, an implication of this human element of the contact tracing process is its resource intensiveness. One study predicts that every new case requires an average of 36 individuals to be traced which places huge burdens on public health departments²⁰.

The pandemic response to contact tracing has highlighted the efficacy of the QI approach in enabling rapid testing, measurement and multiple PDSAs leading to a more efficient ways of working²⁴. Using the QI approach strengthened the CMP by making it easily scalable, with each change being tested and evaluated and the learning assimilated in the process. The modelling of CMP on QI principles is a unique approach to pandemic management and may have potential for transferability to future pandemic planning.

Current evidence on the COVID-19 outbreak has established the importance of contact tracing in containing the virus and curtailing widespread transmission and it is expected to play an important role in avoiding an increase in transmission when public health measures are deescalated²⁵. CMP along with complementary public health measures has proven to be critical in achieving and maintaining epidemic control in Ireland and will also inform the knowledge base and preparedness for responding to any emergencies in future.

Conclusion

Ireland is one of few countries to continue comprehensive contact tracing throughout the pandemic. Using the QI approach, the HSE successfully established and scaled up a Contact Management Programme that rapidly notified results to people and traced their close contacts. The integration between the CovidCare Tracker, the COVID Tracker Ireland app, Self-Service Portals and automated SMS has led to further optimisation of contact tracing. CMP contributed to the success of the Irish health service in containing the three waves of the COVID-19 pandemic. A bespoke IT system and standardised training and support allowed for non-public health staff across the country to effectively undertake a task here to fore undertaken by public health staff under direct Public Health Physician supervision. The approach, processes and tools used in this national programme can provide direction to other countries wishing to implement a similar programme.

Data availability

The data used in this study cannot be shared publicly due to data protection concerns. Even after de-identification, some data may still be identifiable particularly during periods with low case numbers. However, the data can be accessed directly through the Central Statistics Office’s (CSO's) COVID-19 Data Research Hub. The researchers requesting data should contact the CSO researcher liaison contact via email (c19researchinfo@cso.ie). More details on the process are available here.