Experience from Sheffield suggests that locally led initiatives can support rapid scale up of contact tracing
Matt Hancock, the UK Secretary of State for Health, announced on 17 April 2020 that thousands of people would be trained to do contact tracing as a component of a “test, trace and isolate” strategy to exit the coronavirus lockdown. However, the implementation details and timescales of this programme are still awaited. Extensive contact tracing is something which has been called for repeatedly by many public health experts, and the World Health Organisation (WHO) since the start of the epidemic. Tracing contacts of known cases is a fundamental part of all outbreak management, alongside testing, case finding, isolation and quarantine, and formed a core component of the “containment phase” of the UK’s response to covid-19. The UK stopped contact tracing for covid-19 on 12 March as part of the move into the “delay” phase of its coronavirus strategy. This was widely questioned particularly given that coronavirus infection rates varied widely across the UK. For example, while infection was already spreading rapidly in London at that time, in Yorkshire there were fewer than 10 cases per 300,000-400,000 people when tracing was halted.
If contact tracing systems with trained personnel are not in place prior to removal of lockdown in the UK, we risk a second peak of covid-19 with potentially serious consequences, both in terms of deaths from covid-19 and even more drastic economic consequences as a result of repeated cycles of lockdown and release. China has demonstrated the possibilities of large-scale contact tracing, where in Wuhan alone it was reported that at total of 9000 epidemiologists traced tens of thousands of contacts per day in a city of 11 million people. In order for the UK to achieve sufficient scale of contact tracing, it needs significant workforce availability. At the peak of activity before 12 March, only 290 individuals were contact tracing for Public Health England health protection teams. Germany rapidly trained up volunteers and effectively implemented contact tracing this way.
Mobile applications, such as one anticipated from NHSX, have been touted as a potential way-out of lockdown and a way to simplify contact tracing in the UK. However, there are concerns about privacy, acceptability, and whether individuals can legitimately be mandated to use an app to achieve adequate coverage. In Singapore, for example, only 17% of people have downloaded the official contact tracing app. Importantly, modelling studies suggest that a UK app will only be effective if 80% of the population who own a smartphone download and use it, meaning that it would have to be used in conjunction with the more established contact tracing methods we have discussed. In addition, a smart phone based solution will struggle to reach populations who are more likely to be severely affected by covid-19; the elderly, the isolated, those who are homeless or undocumented, and the poor, where smartphone ownership and usage is lower.
Locally led initiatives are essential in order to ensure rapid scale up of contact tracing. Sheffield is pioneering this with an initiative set up by retired doctors. This initiative, Community Contact Tracers, has trained local volunteers to trace through 5 hours of virtual training with supervision. Patients identified by a local GP practice are referred to a retired GP and then on to the volunteers. Index cases are supported and quarantine arrangements discussed in detail. The contacts of the cases are spoken to, encouraged to isolate, and provided with support. The initiative collaborates with a local development trust to ensure good social and organisational support and includes daily phone calls to monitor changes in symptoms, support the challenges of greater isolation, and provide practical support. Initial feedback from volunteers and recipients has been very positive.
To augment government plans, and for those who do not wish to disclose their contacts to a third party, local communities can start this process from the grassroots while waiting for formal structures to be in place for contact tracing. Why not promote the concept of contact tracing by encouraging those with probable (symptomatic) or confirmed coronavirus infection to get in touch with all of the people they have been in contact with for the last three days before the start of symptoms (if they are known to them)? This would be an act of good citizenship. They could make these individuals aware that they have potentially been exposed to the virus. We suggest urgent mobilisation of health, care and voluntary-sector organisations to support individuals who require help doing this as has been demonstrated through the Sheffield experience. Contacts can then self-isolate, if economically viable for them, for a period consistent with the national self-isolation advice. By promoting this concept, we may be able to increase acceptability, feasibility, and effectiveness of more structured contact tracing procedures that come into place later when the country moves to a more targeted covid-19 case-finding and isolation approach.
Competing interests: None declared