Stopping contact tracing in the UK in mid March was one of many mistakes made in the management of the covid-19 pandemic. WHO guidelines for the covid-19 outbreak recommend that cases are identified and advised to isolate, and that their contacts are traced, advised to quarantine, and then followed up to identify new cases.
In early April we sought to determine the feasibility of training volunteers to contact trace. We believed that volunteers could be recruited and trained on a scale to make a significant difference.
Further, both index cases and contacts are in need of support to isolate. Volunteers may be in a position to use local knowledge and networks to support people to remain isolated and prevent further spread of the virus.
Training materials were developed by members of a steering group, consisting of recently retired GPs and public health physicians in collaboration with a local community development organisation. Six volunteers were recruited and given five hours of training using videoconferencing, after which they were individually assessed, and all deemed sufficiently prepared. Cases were referred by a local general practice, which explained to them the nature of the pilot and sought their consent before referring them on.
Volunteers telephoned index cases, established consent, and recorded symptoms. Details of contacts of the case, defined according to the European Centre for Disease Prevention and Control criteria, after a date five days prior to first developing symptoms, were sought. Volunteers then phoned each of the contacts. After an introduction, establishing the contacts’ consent to participate, and enquiry about any symptoms, each contact was given advice to strictly self-isolate, according to current Government guidelines, as well as advice on what to do should they develop symptoms themselves. Index cases and contacts were offered a daily call from the volunteer for support. Index cases were followed up for seven days or until symptoms ceased. Contacts were followed up until 14 days after they had been in contact with the case.
13 cases were enrolled. Six worked for the NHS or care services. An average of 80 minutes was spent by volunteers with each case on the initial interview and follow ups. Two cases didn’t respond to phoning, until a letter was hand delivered, a strength of community organisation.
58 contacts were identified. 19 of these were named by the index cases, and themselves contacted. They were each given advice regarding self-isolation and were followed, either directly or with information provided by family members, until 14 days after their last contact with the index case. One of these became ill and was then followed up as an index case in their own right. Index cases were unable to or unwilling to give the names and details for 39 of the contacts.
29 contacts worked for carer provider agencies and ten were employed in other settings. Employers were phoned or emailed and advised regarding self-isolation for contact employees. Some said that they would pass on information to staff, but did not give further information to enable formal follow up, others refused to cooperate.
We demonstrated that it is feasible to train volunteers without previous experience of contact tracing to undertake it effectively. They were then able to go on to have constructive conversations with cases, identify contacts, and in turn speak to the contacts and give them relevant advice.
However a significant limitation of this model was also identified, namely that without formal authority there were limits both on the access that contact tracers could establish with contacts, and also the weight behind the advice that was given. Some employers were not willing to allow volunteers access to their contact employees, and some contacts who were advised to self isolate and therefore not go to work, were unwilling to do so. Without formal authority, volunteers were unable to take these conversations further.
Contact tracing for covid-19 is significantly more complex than contact for other diseases, where contacts can derive obvious benefit from being identified, in that they are likely offered treatment for the disease. For contacts of covid-19 cases, there was at the time of this pilot no offer of testing or treatment, only the prospect of self isolation, including not going to work, with the financial penalties that entails, for a period of 14 days. During the trial several people who had been contacts of a person with covid-19 found it hard to accept the label of “contact”, in particular those who were in employment and physically going to their workplace.
Although re-starting contact tracing has now become Government policy, it has only just started, and the NHSX contact tracing app may take months to be fully developed. We believe there is a potential role for volunteers to be trained as contact tracers, especially if they are given an official stamp of authority.
Jeremy Wight, former Director of Public Health (corresponding author)
Jack Czauderna, former general practitioner
Tom Heller, former general practitioner
Bing Jones, former associate specialist in Haematology
Joan Miller, former consultant in public health
Mike McCrave, community volunteer.
Paul Redgrave, former director of public health
Mike Tomson reinstated GP (Sheffield) and Associate postgraduate Dean (HEE)
Declarations of interest: All authors are members of the Sheffield Community Tracing Group of formerly retired Doctors and volunteers.
JC is Chair of Pioneer Health Foundation (Peckham Experiment legacy organisation), and Trustee of Darnall Wellbeing. JW is a non-executive director at Chesterfield Royal Hospital and a Trustee of Medact, though this is written in a personal capacity. MMcC and TH, JM, BJ, PR and MT have no interests to declare.