The expert National Contact Tracing Review: A report for Australia’s National Cabinet November 2020 comments
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.
Recommendations in the report are -
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.
The bigger picture
1. Continuous improvement
1.1 All jurisdictions should aspire to continuous improvement and reflect upon, evaluate and externally communicate their performance against the list of ‘Characteristics of an Optimal Contact Tracing and Outbreak Management System’.
2. Preventative public health measures
2.1 Maintain the focus on preventative public health measures, including those that were agreed by National Cabinet early in the course of the pandemic.
3. Workforce and training
3.1 Ensure ongoing investment in the medium to long term in accredited training programs for applied epidemiology and applied public health training.
3.2 The Commonwealth, states and territories should consider increasing the number of public health training positions in all jurisdictions.
3.3 All states and territories should continually invest in training surge workforces to be employed in a reserve capacity.
3.4 Ensure there is capacity for the Commonwealth to mobilise a trained contact tracing surge workforce through the Australian Public Service to assist states and territories with contact tracing should the need arise.
3.5 Continue funding rapid deployment capability to coordinate a standby pool of equipment (including personal protective equipment and transportable laboratory equipment) and senior clinical and public health experts for extreme situations requiring surge capacity anywhere in Australia.
3.6 Undertake forward planning for the pathology laboratory workforce, given the ongoing requirement for high volume testing in the near and medium term.
4. Stress tests
4.1 States and territories should undertake desktop and functional simulation exercises to verify the performance of their contact tracing and outbreak management systems.
4.2 Desktop and functional simulation exercises should be based on four new confirmed cases (not in quarantine) per day per million population (but no fewer than four per day per jurisdiction) for a week or more. This daily case number is consistent with the Framework for National Reopening adopted by National Cabinet.
4.3 Extreme stress testing should be based on up to ten times the standard stress testing numbers.
End to end contact tracing
5. Never fall behind
5.1 An effective contact tracing and case management system will cope with high case numbers. In extreme conditions, the jurisdiction should in the first instance recruit workforce assistance from other jurisdictions and the Commonwealth. If this proves insufficient, it is nevertheless essential to keep up with managing new cases. In order to never fall behind, the extent of contact tracing measures should be reduced on a risk minimisation basis.
5.2 COVID-19 testing resources and strategies
5.3 Continue to fund COVID-19 pathology tests through the Medicare Benefits Schedule and other funding arrangements.
5.4 Continue to ensure adequate supplies of testing reagents and build stockpiles during quiet times.
5.5 Ensure that pop-up test sites can be rapidly deployed, in under six hours in metropolitan locations, and in under 24 hours in regional locations.
5.6 Pathology laboratories should use diagnostic instruments from multiple vendors to ensure resilience during times of global shortages of reagents.
6. Support for maintaining national standards
6.1 Ensure Commonwealth epidemiological and public health expert support is provided to the Communicable Diseases Network Australia for ongoing work for COVID-19 and other notifiable diseases, including development and maintenance of the Series of National Guidelines.
7. Technical capability
7.1 Develop a ‘Data Exchange’ capability to facilitate contact tracing, through the exchange of data between states and territories, and access to contact tracing data from relevant government agencies.
7.2 Data should not be stored in the Data Exchange itself, thereby allowing a simplified, decentralised design with high levels of privacy and security.
7.3 The exchange of data would ideally be as near to real time as is practical and consistent with Commonwealth, state and territory security and privacy requirements.
8. Data sources
8.1 The Data Exchange would access a variety of data sources such as appropriate administrative databases, airline and shipping passenger contact tracing information, other relevant government agency databases, contact tracing databases from other states and territories, and COVID-19 diagnostic test result repositories.
8.2 Evaluate the possibility of the Data Exchange in the medium term accessing the Australian Immunisation Register for relevant vaccine status.
8.3 In all instances data requests must be restricted to data that are relevant to a public health response, such as phone numbers, addresses, case interviews and diagnostic test results.
8.4 Domestic airlines should supply accurate passenger contact tracing information on request, accessible by the Data Exchange. Accuracy would be improved by requiring photo ID checks for all domestic passengers.
8.5 Australian Border Force should work with international airlines and shipping companies, supported by bilateral travel agreements, to provide accurate passenger contact tracing information on request, accessible by the Data Exchange.
9.1 For efficiency in implementing the Data Exchange: – Limit the initial implementation to a pilot involving Victoria, NSW, ACT and the Commonwealth. – Development of the pilot should be based on an indicative scope of technical work developed by these jurisdictions and others that wish to contribute. – Deployment in other jurisdictions would proceed if an evaluation of this pilot implementation concludes that it is successful.
9.2 Implementation of the Data Exchange should not delay any existing plans for sharing of contact tracing data, such as may be provided by airlines and Australian Border Force.
10. Identify sources
10.1 At low case numbers, epidemiologists and other public health experts should strive to identify the source of infection for all confirmed cases. Where the source of infection is unknown, detailed upstream mapping of contacts to identify the source of infection should be undertaken.
11. Predictive analytics
11.1 Develop, evaluate and share advanced analytics software for outbreak analysis and predicting risks, to support existing expertise.
12. Pathology test technologies
12.1 Researchers and public pathology laboratories should continue to invest in developing and validating new COVID-19 specimen collection and diagnostic methods.
12.2 A framework should be developed on the role and use of rapid antigen tests, to support the public health response to COVID-19 and enable tracking of all positive and negative test results by public health authorities.
13. Automation and digital support
13.1 Fully digital and partially automated end to end systems should be implemented within each state and territory to support collection of case information, reporting of COVID-19 test results to the health department, allocation of confirmed cases, contact tracing, digitally issued quarantine directions, case management and outbreak management.
14. Attendance registration
14.1 Recording of contact tracing information of attendees should be a condition of entry to restaurants and other public venues, institutions and workplaces. Electronic data collection should be strongly encouraged, with pen and paper only being used if the former is unavailable.
14.2 Where attendance data are recorded for contact tracing, only the minimum information required for that purpose should be collected. Data collected for contact tracing should only be used for contact tracing purposes, kept securely and permanently deleted after 28 days.
14.3 Contact tracing information must be made available to health authorities in a timely manner, at most within 24 hours of request, to assist contact tracing.
14.4 Where smartphone apps are used, they should have simple “click and enter” functionality to encourage compliance.
14.5 To maximise participation, ensure effective communication of the benefits of attendance registration.
14.6 States and territories should consider using a single smartphone app within their jurisdiction, or require that all smartphone apps adhere to the above requirements.
15. Other technology solutions
15.1 Evaluate consent based systems that can download contact tracing information from smartphones.
15.2 The Commonwealth should lead the development of arrangements between states and territories and payment card providers so that contact tracers from the states and territories will be able to request contact details of persons who have made a transaction at a hotspot venue, noting that privacy rules will apply and in some jurisdictions legislative change may be required.
15.3 Develop, use and share proven web portals and smartphone apps for quarantine monitoring and tracking entry into high risk settings, such as residential aged care homes.
16. COVIDSafe app
16.1 The Commonwealth should continue to enhance the functionality of the COVIDSafe proximity app, particularly with respect to the duration for identifying contacts and enhancing notifications to users on the status and operation of the app.
16.2 The Commonwealth should consult with the states and territories on ways to optimise incorporation of COVIDSafe contact information early in the contact tracing process.
16.3 The Commonwealth should consult with the states and territories on the best means to report usage of the app in contact tracing.
17. Wastewater testing
17.1 The public health, clinical and wastewater sectors should build on existing research and field testing of wastewater detection to validate its role as an early signal of potential outbreaks.
17.2 Determine whether a goal of 50% coverage of the Australian population is practical and useful, with appropriate coverage of urban and rural areas. If so, aim to achieve this level of coverage in the medium term.
17.3 States and territories should publish results regularly.
A conversation with communities
18. Involve communication experts early and throughout
18.1 Integrate and embed communications and media experts in health, emergency, police, customer service and other relevant government departments to ensure that public health messages are pitched appropriately for state wide and local audiences, and vulnerable communities.
18.2 Work with community leaders to ensure that public health messages are culturally and linguistically tailored to each community, and understood and amplified through existing formal and informal networks.
19. Avoidance of confusion
19.1 All messages to affected communities, families and individuals should be evaluated to minimise any risk they could be misinterpreted.
19.2 Consistent messages should be given to all individuals in affected families, and consistent guidance provided to leaders and staff in affected settings, such as workplaces, schools, and places of worship.
19.3 Automated text and web messages provided to people in isolation and quarantine should be offered in their preferred language.
Earning community confidence
20. Reporting confirmed cases
20.1 Confirmed cases identified in quarantine are a sign of a well functioning system that is able to mitigate community exposure and transmission. Confirmed cases identified in the community are cases that are more complex and have to be actively traced and managed. States and territories should publicly report daily on: – New confirmed cases identified in the community. If zero cases, the number of days since the last confirmed community case. – New confirmed cases identified in quarantine. If zero cases, the number of days since the last confirmed case.
21. Performance metrics reporting
21.1 The Commonwealth, states and territories should agree and publicly report weekly national performance metrics, including: – The number of hours from collecting the COVID-19 specimen to notifying all people of their results, with the target being fewer than 24 hours at the 90th percentile. – The number of hours from collecting the patient’s COVID-19 specimen to notifying their close contacts that they must quarantine, with the target being fewer than 48 hours at the 90th percentile.
In discussing community communication the report states
Efficient contact tracing and outbreak management are necessary but not sufficient to successfully live with COVID-19. Preventative measures such as attention to personal hygiene, social distancing, early testing at the first sign of symptoms, and voluntary quarantine when symptomatic will continue to be essential components of the first line of defence against COVID-19.
People have a right to know what is expected of them and how the pandemic and the response is unfolding. Therefore, a substantial commitment to a broad spectrum of public communication activities is required across government. This messaging may need to be strengthened in times of adjustment, particularly when restrictions are tightened. It is important to have communications and media experts integrated and embedded in health, emergency, police, customer service (NSW) and other relevant government agencies to ensure public health messages are consistent and pitched appropriately for Australia wide, state wide and local audiences.
Ongoing strong, consistent and culturally accessible and appropriate messaging through community engagement is vital to building and maintaining public awareness, trust, acceptance and confidence. Regular and proactive communication and engagement with the public, specifically with at risk populations, can also help alleviate confusion and avoid misunderstandings.
Education is needed to improve community understanding and health literacy, particularly with regards to infection prevention and control. The community must be encouraged to take personal responsibility and understand the impacts of their behaviour.
It is important that as we move towards a COVID normal society the public remains vigilant. This is most likely if messages from the Commonwealth, state and territory public health and political leadership are consistent. Currently, there are inconsistencies in the messaging around getting tested between the jurisdictions. For example, the Commonwealth advice is “if you have cold or flu like symptoms you should seek medical advice about having a test for COVID-19”. However, in other jurisdictions the advice is that “anyone with mild COVID-19 symptoms should get tested”.
This inconsistency could create a barrier to some individuals getting tested, while also delaying the time it takes for an individual to get tested from symptom onset. Similarly, there is inconsistent advice about what people should do while awaiting test results and when they should resume usual activities.
There are also inconsistencies in key terms used by government and the media, including the use of the terms ‘community transmission’, ‘mystery cases’, ‘physical distancing’ and ‘social distancing’.
Where possible, states and territories should review their use of messaging around new cases, community transmission and mystery cases. There is currently not an agreed definition and these terms are being used differently in each state and territory. The review has adopted usage of terms to describe confirmed cases as ‘those identified in the community’ and ‘those identified in quarantine’. Further details can be found in Chapter 7 – Earning community confidence.
The term social distancing has become a commonly used term by governments and media and is used interchangeably with the term physical distancing. However, these terms can have different interpretations. Consistent use of ‘physical distancing of at least 1.5 meters’ would promote community understanding and practice.
When a person is notified of their COVID-19 test result, usually via a text message, it is important to clearly articulate the result to avoid confusion. Explicitly reporting detection of the virus, or no detection of the virus, in the test sample is preferred. The use of terms such as ‘positive’ and ‘negative’ can be misunderstood as a ‘good result’ or a ‘bad result’.
As part of contact tracing and case management, it is important consistent information and directions are given to all individuals in isolation and quarantine, including their immediate family and household. As part of an optimal end to end contact tracing and case management system this is optimised by allocating a single case manager to each household.
Consistency in messaging is vital across all community settings. During an outbreak clear, concise and consistent messages to affected settings such as workplaces, school and places of worship is important. This is optimised through ensuring communications and media experts are integrated and embedded in all government agencies, including health, emergency, police and, customer service (NSW), and ensuring all agencies are collaborating to present one voice.
In addition to consistency, it is important states and territories are checking to ensure public health messages are understood and not being misinterpreted. For example, South Australia has adapted their weekly state wide population health survey to include questions on understanding and adherence to COVID Safe messages. This includes questions on actions people are taking to protect against COVID-19 and reasons for not getting tested if symptomatic.
Working with community leaders
Australia has a diverse population, thus it is important that messaging is tailored for our various community groups, including people from culturally and linguistically diverse backgrounds.
Inclusion of community leaders in supporting and implementing public health measures is key to an effective response.
Working with community leaders has proved very important in states and territories with remote Aboriginal and Torres Strait Islander communities and also metropolitan areas with culturally and linguistically diverse communities. During the first wave, Aboriginal and Torres Strait Islander leaders called on governments to provide additional protection to remote communities, which was provided at a Commonwealth level through the Biosecurity Determination limiting travel to remote areas. States and territories with remote communities have invested extensive resources to assist communities and build trust and rapport to support them to protect and then reopen communities safely.
As an example, Queensland has committed to a co-ownership approach with local Aboriginal and Torres Strait Islander communities, drawing expertise from Aboriginal and Torres Strait Islander Community Controlled Health Organisations, the Queensland Department of Aboriginal and Torres Strait Islander Partnerships and the National Indigenous Australians Agency as well as working directly with mayors and CEOs of discrete and remote Aboriginal and Torres Strait Islander Communities. Through this approach, Queensland have provided support to communities, including targeted testing and targeted scenario planning for the unique circumstances of remote communities.
It is also important to engage with cultural and religious leaders in metropolitan areas, especially areas with large culturally and linguistically diverse populations. Community leaders in diverse cultural settings can help ensure key messages around physical distancing, hygiene, tightening restrictions and the importance of getting tested. In some communities there is stigma attached to contracting COVID-19 and getting tested. Cultural leaders can assist to break down these barriers. For example, in Melbourne cultural leaders helped to reduce stigma and bolster testing in underrepresented cultural groups.
Translation of key messages and resources
Ensuring all Australians can understand key messages around COVID-19 is vitally important in keeping the community safe by ensuring people adhere to public directions. With more than 300 different languages spoken in Australian homes, it is important that key messages are translated into appropriate languages and tailored to communities.
There are a number of translated materials on Commonwealth, state and territory designated COVID-19 webpages. The number and quality of these translated materials has improved greatly since March 2020, however it is an area that should undergo continued review and refinement.
It is imperative that translated messages are updated regularly to reflect any changes in the original English messages.
Further, the accuracy of the translations should be verified by reverse translation back into English to ensure the messages are concise and comprehensible.
As part of ongoing case management, most states are utilising automated daily text messages to monitor people in isolation and quarantine to remind about their obligations to remain in isolation or quarantine. Messages are generally sent in English, but contact tracing systems built on modern software applications can easily send these messages in preferred languages.
In addition, collecting information on language spoken at home alongside other contact details and symptom information at the point of COVID-19 specimen collection would enable the automated result notification to be sent in a person’s preferred language. This would help ensure people understand their test result, especially when COVID-19 virus is detected, to ensure the patient understands the need to isolate and await a case interview.