What goes on inside the contact-tracing ‘dungeon’

As Covid arrives in the regions, local contact-tracing efforts are being stepped up with whiteboards and sticky notes. Scott Yeoman spent an afternoon in the Tauranga command centre.

Dr Phil Shoemack is fast asleep in bed when his phone rings. It’s after 11pm, unusually late for the lab to be calling.

Shoemack is the on-call medical officer of health at Toi Te Ora, the public health unit covering Bay of Plenty and Lakes district health boards – a large area encompassing Tauranga, Rotorua, Whakata¯ne, and Taupo¯, from Waihı¯ Beach to Whangapara¯oa on the east coast, and inland to Tu¯ rangi.

Toi Te Ora serves a population of more than 375,000 people. The unexpected late-night call on Tuesday was to tell Shoemack that one of them had tested positive.

The case was in Waimana, a small rural community south of Whakata¯ ne, on the edge of Te Urewera. That’s why it was urgent.

‘‘That’s our first case of confirmed Covid-19 in the Eastern Bay of Plenty since April last year,’’ Shoemack later explained. ‘‘So obviously there’s a fair level of anxiety, not surprisingly, particularly in the small community that the individual’s from.’’

Not to mention the vaccination rate: the latest data from the Ministry of Health showed fewer than 70 per cent of the eligible population in the Waingarara-Waimana area had received at least one dose of the Covid-19 vaccine, and just 55 per cent were fully vaccinated.

Shoemack got out of bed on Tuesday night and started working on a response. He called Whakata¯ ne Hospital, where the Waimana case was tested. He passed on the news of the positive test, and got as much information about the case as he could. He then put together an email alerting Bay of Plenty DHB leadership, ‘‘with a note saying, ‘can one of you please let the mayor know in Whakata¯ ne’.’’

By about 6.30am the next morning, Shoemack had left home and was cycling to work when his phone started ringing again. It was the lab, with more positive test results to report.

New Zealand’s Delta outbreak began in Auckland in August and there has been no going back. Like many parts of the country, Bay of Plenty and the Lakes managed to stay Delta-free for almost three months – despite some close calls and false alarms – but the good run ended late on November 12, when a positive case was confirmed in Taupo¯ .

Cases in Rotorua soon followed, and before long the virus was also in the community in Tauranga. By November 24, when the Sunday Star-Times arrived at the Toi Te Ora office in central Tauranga, there were more than 50 positive cases across Bay of Plenty and the Lakes. That has since climbed to 70, with cases in several schools.

After showing our vaccine passes at the locked front door – and with masks on – we were given behind-the-scenes, realtime access to the local public health response to this pandemic.

We watched as Toi Te Ora staff traced new infections in the community and worked quickly to try to prevent further spread. We sat in on meetings as local health leaders and regional heads of government departments discussed the challenges facing them in the weeks and months ahead. The

Star-Times organised the visit to Toi Te Ora late last week but by Wednesday the local outbreak

had escalated further, and Shoemack warned on arrival ‘‘things are pretty hectic’’.

Each morning at 8.30am, Toi Te Ora tallies up the number of new cases in its patch during the past 24 hours. On Wednesday morning, there were 11 new cases – all of them in Bay of Plenty, including the one in Waimana.

By lunchtime, more cases had trickled in and would continue to throughout the afternoon.

Shoemack said almost all of Toi Te Ora’s capacity is dedicated to Covid-19 right now – up to 40 staff on any given day.

‘‘For a few months, we’ve been handling some cases on behalf of Auckland, but somehow it feels a bit different when you know the

person lives just down the road.’’

Most New Zealanders think of this Delta outbreak in terms of numbers because, most of the time that’s all we have to go by: How many new confirmed cases were reported today? Is that a daily record? What does that take our total to? How many are linked? How many close contacts?

When the numbers are growing by 10, 20, or 100 a day, it’s easy to forget that behind each new batch of cases is a group of individuals, each one of them needing to be contacted.

At Toi Te Ora, we were led downstairs to an area some staff call ‘‘the basement’’ or, as one of said with a laugh, ‘‘dungeon is another word that gets thrown

around’’. It is the engine room of this local contact-tracing effort, and it was humming.

A steady chorus of keyboards tapping as emails were hurriedly typed up. Small groups huddled together, voices muffled behind masks. Others on the phone, with snatches of conversation briefly audible as you walked past desks: ‘‘ . . . go home and isolate’’.

At the end of the room were two large whiteboards covered with brightly-coloured sticky notes, each a confirmed case. Between some notes, a dotted line had been drawn – signifying a potential link. Others were connected by a solid line – the link already confirmed.

The Bay of Plenty and Lakes Delta outbreak was recorded on two whiteboards, mapped out by hand, case by case.

Almost all the cases, at that stage, were grouped under four main clusters – Pa¯pa¯moa, Tauranga, Taupo¯ , and Rotorua – with a few outliers so-far unlinked.

‘‘We’ve got more whiteboards

‘‘We’ve got more whiteboards coming. We’ve talked about getting IT solutions, and collectively decided that this is so much more flexible. Give us another five years, and it could be different.’’ Dr Phil Shoemack

coming,’’ Shoemack said.

‘‘We’ve talked about getting IT solutions, and collectively decided that this is so much more flexible. Give us another five years, and it could be different.’’

Every Covid-19 swab in Bay of Plenty and the Lakes is tested at Pathlab in Tauranga. For each positive result, the lab’s first call is to notify the on-call medical officer of health at Toi Te Ora. Increasingly, there are a few new cases to report at a time.

The lab sends an email with further details to Toi Te Ora, where each confirmed case gets a contact-tracer, before being entered into a national database.

The first call or contact is key, and needs to be done as soon as possible if not too late at night.

Shoemack said contact-tracing relied on people being home or answering phones: ‘‘Sometimes people will be unresponsive for 24 hours, which is always a concern.’’

He said there was usually a good reason for it – dead battery, bad cell coverage – and no confirmed cases have disappeared completely, but some have been uncontactable for a few days.

In that first call, which can sometimes take up to an hour, the contact-tracer will inform the person they have tested positive for Covid-19 and tell them they have to stay at home and isolate.

They will ask what they can do to help the person stay home – do they need groceries, for example.

‘‘Our goal is to do what we can to prevent further spread, and one crucial part to that is to keep that person where they are, so they don’t keep mixing in the community,’’ Shoemack said.

The contact-tracer will then start to get into detail with an extensive set of questions about where the person has been, who they have been in contact with, and how many members of their household there are. This is to identify how the person became infected in the first place, how long they may have been infectious for, and who they might have passed the virus on to.

Each case and situation is different, some are complex. Sometimes that first phone call is actually two calls, or three. People might remember a location two days later.

Overall, Shoemack said most people were ‘‘incredibly thankful’’ and appreciative when Toi Te Ora contact them: ‘‘It’s encouraging how helpful people are. There’s always a few instances where someone gets angry ... you’re giving them bad news, and sometimes people react in interesting ways to bad news.’’

Toi Te Ora is working to open contact-tracing offices in Whakata¯ ne and Rotorua, to utilise local knowledge and provide back-up options in case a Tauranga staff member is infected.

Shoemack said one of the biggest challenges was having enough staff for the increasing workload, and they were constantly recruiting.

The team working away in ‘‘the basement’’ in Tauranga is made up of people from all different backgrounds. Some young doctors, nurses, and health staff have stepped out of their normal roles at the district health boards to help out.

Hannah Kelly, 34, usually works supporting businesses to implement health and wellbeing programmes. Now she is in the team working to identify exposure events, assessing infection risk at each location, whether there are likely to be close or casual contacts, and talking with businesses, workplaces or schools to set out the steps they need to follow: ‘‘It’s definitely upped the ante as far as pace goes,’’ she said.

For University of Otago health sciences student Tessa Dodson, 18, Wednesday was her first day at Toi Te Ora: ‘‘I just wanted to help out, and I saw an opportunity to. And it’s interesting . . . I’m excited to work.’’

It was also the first day for Jeannie Bruning, who is in her 60s. She worked as a nurse for more than 40 years and in September left her senior nursing role at Tauranga Hospital to have a break and consider her next step.

When she got a call asking if she would be interested in joining the Covid-19 response effort, her mind was suddenly made up: ‘‘If there’s any little thing I can do to make a difference in some person’s life, to me, it’s worth it.’’

Shoemack said modelling suggested the peak of the Delta outbreak could be in the second half of February – depending on variables like vaccination rates, there could be between 150 and 450 new cases a week across Bay of Plenty and Lakes.

Those numbers would put enormous pressure on the local contact-tracing effort, but Shoemack said they would continue the work for as long as they could, even if there were as many as 50 new cases a day.

‘‘It will depend on us retaining our existing workforce, not burning them out, and continuing to attract and train new ones.’’

The balance between workload and workforce was one of the main challenges discussed on Wednesday in meetings with local health leaders and regional heads of government departments. Another was coordinating the welfare needs of people who have to isolate, and working out which public service might help, providing everything from food to accommodation, phone credit to dog walking, while avoiding double-ups and people falling through the cracks.

‘‘It’s all about the people,’’ Shoemack said.

‘‘I just wanted to help out, and I saw an opportunity to. And it’s interesting . . . I’m excited to work.’’ Tessa Dodson