National Contact Tracing Review - Strengthen capacity, build confidence, avoid complacency
I’ve had a busy two months working on a national contact tracing review with Dr Tarun Weeramanthri and led by Australia’s Chief Scientist, Dr Alan Finkel. We’ve had a fascinating insight into how the States and Territories are managing their testing, tracing and isolation approaches. Overall, we were encouraged to see the commitment to of each state and territory health department to strengthening their COVID-19 response with continuous improvement in systems and processes.
I’m pleased that National Cabinet has endorsed all of our recommendations which you can view here. Delivering on these recommendations, including building a digital contact tracing data exchange, will keep Australia prepared for any future outbreaks.
A huge thanks to the taskforce who put in a massive amount of work to support the review – thanks to Allison Jones, Kaori Ikeda, Josh Montgomery and Emily Holt.
Our introduction to the review is below.
Strengthen capacity, build confidence, avoid complacency
We were tasked by National Cabinet with reviewing COVID-19 contact tracing and outbreak management systems in each state and territory to determine their ability to support an active economy by Christmas 2020. This includes systems for testing and tracing, quarantine and isolation, outbreak management, data exchange, and surge capacity. Although our remit was the current COVID-19 pandemic, we note that most of our recommendations may be relevant to managing future pandemics caused by other infectious diseases.
As we visited each jurisdiction in October 2020, it became clear to us that internal borders will only reopen and remain open if state and territory leaders have confidence in how their interstate counterparts are managing the pandemic. By the same token, the economy will only bounce back if Australians feel confident they can participate and travel safely. Many of our recommendations are aimed at building this confidence and ensuring it is well founded.
The states and territories have decision making authority for public health and will remain responsible for their own contact tracing and outbreak management systems. Our review acknowledges this autonomy while identifying areas where changes to processes, information sharing and technology will improve national capability.
Our remit was contact tracing and outbreak management. These systems must perform extremely well if we are to successfully live with COVID-19 until a vaccine or an effective therapeutic arrives, and perhaps longer. However, contact tracing and outbreak management are necessary but not sufficient components of an overall response and they are measures we would prefer never to have to activate. Crucially important in the first line of defence are measures relating to physical distancing, personal hygiene, staying away from work and gatherings if unwell, testing if symptomatic, mask wearing where required, limiting access to vulnerable communities where appropriate, COVID Safety Plans, attendance limits at public events, and quarantine for international travellers and others at risk of having been exposed.
Overall, we found very strong commitment to prevention and control measures across the country. All jurisdictions are committed to implementing effective COVID-19 contact tracing and outbreak management systems, have increased their investment and are training and preparing constantly. Across all states and territories the information technology systems used for contact tracing have improved significantly over recent months.
However, we found processes that can be improved. In some jurisdictions, interviews with contacts are recorded on paper before being entered into a database, causing delays and the potential for error. Contact information is inconsistently collected when people visit venues. Text messages to people with COVID-19 and contacts are not always in the preferred language of the person. Domestic airline passenger lists and contact details are not always accurate. Real time performance metrics are not sufficiently ambitious.
Our report sets out the characteristics of an optimal contact tracing and outbreak management system, and invites every jurisdiction to evaluate its performance against this blueprint.
We also recommend clear, measurable and transparent metrics that should be published by each state and territory to allow the public to track performance.
The two key performance metrics we recommend relate to fast testing and fast notifications to contacts. The currently agreed national target of 48 hours from reporting a positive test result to directing close contacts to quarantine is inadequate from the point of view of suppressing community transmission.
We recommend that test results should be available within 24 hours of a sample being taken, maximising the likelihood that people will isolate themselves while awaiting test results. We recognise this may be difficult in remote parts of Australia, but it is an important stretch goal and confirmation of our national capability. Further, we recommend no more than 48 hours in total from the time a test sample is first taken to the point at which close contacts of a confirmed case are notified to quarantine. Advice to us is that if this turnaround time is achieved, we can substantially reduce community transmission.
Across the jurisdictions we discovered quite different digital solutions for case management and contact tracing, developed in isolation. In some instances, the digital systems are built on similar underlying platforms, but they are heavily configured and require different training for users.
However, the panel does not recommend the creation of a single integrated national contact tracing system. The important thing is that information is shared efficiently, where necessary. States and territories must be able to access and transfer information about cases and contacts where people have crossed borders. Currently, such information is conveyed through phone calls or emails, a practice that would not withstand high case numbers.
For this reason, we recommend the development of a digital data exchange mechanism. Building this capability now would prepare the states and territories for coordinated contact tracing to more effectively manage future outbreaks.
The mechanism we suggest would allow the states and territories to share contact tracing data, and incorporate contact tracing data from sources such as airline and shipping passenger manifests, registries of test results and relevant government agency data stores. Only data relevant to contact tracing would be transferred, such as phone numbers, addresses, case interviews and diagnostic test results. No data would be held or stored in the data exchange. As such, we are confident the data exchange can be consistent with privacy requirements and community expectations.
We make a number of recommendations to improve the use of technology.
In that context, we recommend that the states and territories share information about new and emerging technologies, such as electronic venue and workplace attendance registration systems, smartphone apps to monitor self-quarantine, new diagnostic tests and wastewater surveillance. For example, the venue attendance app used in the ACT is as simple as “click and enter”, the only information shared is an email or phone number, no information is used for marketing and data are purged every 28 days.
Patient testing, contact tracing and case management should be fully digital end to end, starting at the point of testing. This includes collection of information, reporting of results, contact tracing, case management and outbreak management.
However, while a fully digital system dramatically improves the efficiency of contact tracing, it will never replace the need for well trained contact tracers and expert public health oversight, especially for difficult interviews, cluster analysis and outbreak responses. All states and territories should employ a permanent workforce for tracing and outbreak management, with senior public health leadership, and should have an additional surge workforce trained and at the ready. Digital case management and contact tracing systems should allow easy and secure onboarding of contact tracers from other states and territories and from the Commonwealth.
In the event of an outbreak, every effort should be made to go hard and go early. The driving principle for contact tracing must be to never fall behind, which means operating procedures should allow a risk based prioritisation of contact tracing practices that if the surge workforce becomes overwhelmed. These would include, for example, initial notification of close contacts by text instead of by phone.
Desktop exercises and field rehearsals should be run regularly to ensure the system can deal with a sustained surge of around four new cases per day per million population and be able to rapidly scale up should there be a further escalation.
As Australia takes steps to reopen, we emphasise that a national testing and contact tracing system is only as good as its weakest link. No jurisdiction can afford to let down its guard. Each must have a strong focus on continuous improvement, including regular stress testing, a highly trained workforce, high functioning technology, and a commitment to transparency on performance metrics. We must keep awareness high and the safety message front and centre if we are to avoid the complacency that can be a dangerous companion to low case numbers.
COVID-19 remains a complex and highly communicable disease. Even with the best systems in place, outbreaks are likely to be unavoidable. We are acutely aware of the lockdowns being imposed once again in many countries as the world struggles to find a way to live with the pandemic. However, we believe that Australia’s internal borders and economy can safely, confidently and successfully reopen, and the nation can manage an early cluster or outbreak and a moderate number of confirmed cases in the community without resorting to wide area lockdowns. To ensure this, each state and territory needs to be well aligned to the characteristics of an optimal contact tracing and outbreak management system as outlined in this report, alongside important measures to prevent transmission.
Dr Alan Finkel
Dr Tarun Weeramanthri
Link to the full report: