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Contact tracing complex cases through NHS Test and Trace

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People who test positive for COVID-19 are contacted by NHS Test and Trace by email, text message or phone call, and will get advice via the Test and Trace website or from a contact tracer over the phone.

But there are cases such as those linked to care homes, prisons, homeless hostels or schools, that are more complex to contact trace and are referred to PHE health protection teams, often working in partnership with local government.

In this blog Dr Anita Bell and Charlotte Flynn, both health protection experts based in London, discuss their role.

Who are the London health protection teams working as part of NHS Test and Trace?

Public Health England’s Health Protection Teams respond to cases and outbreaks of infectious diseases, chemical and radiation hazards and other emergencies by providing specialist advice and support to prevent and reduce their impact on health.

Health Protection Teams are highly skilled at carrying out risk assessments and working with organisations to put in place tailored action plans, including how to best manage the isolation of cases, what other control measures to put in place, and how to warn and inform other people that might be at risk.  Even in the midst of a pandemic our work continues on these other issues alongside our vital work on COVID-19.

In London, the Health Protection Teams are working as part of a response cell to deal with COVID-19 cases in complex settings. This cell – the London Coronavirus Response Cell (LCRC) – has been working on COVID-19 related cases and situations since February 2020.

We are a multi-disciplinary team of public health specialists including doctors, nurses, scientists, specialists in health protection, disease surveillance and environmental health, as well as administration and operations support. Additional contact tracing specialists have been recruited as part of our response to the pandemic.

The cell is open from 9am-8pm every day of the week but we can be contacted 24/7 in emergencies.

How are cases referred to you and what happens?

When someone tests positive for COVID-19 they will be contacted by NHS Test and Trace – either online, by text or over the phone – and be asked to provide information on where they’ve been and who they have seen to inform what contact tracing is required.

If the positive case works in, lives in or has visited a setting such as a school, hospital, care home or work place – where establishing the level of contact tracing and self-isolation advice can be more complex or may involve vulnerable people – then they will be referred to LCRC. We will ensure that the appropriate advice is given to prevent onward spread of the virus.

We receive regular notifications from NHS Test and Trace on cases and settings that require further investigation from us.

Based on this information, we will contact positive cases to gather more information on where they were within a setting while they may have been infectious, and who they were in close contact with.

We will work directly with an institution, such as liaising with a care home or homeless hostel manager to carry out a risk assessment.

Each of these cases and settings are unique, requiring bespoke professional advice and support on how to contain transmission and reduce risk.

If the case was a primary school teacher, for example, we might contact the headteacher to gather information and go through our advice. As part of this we ascertain whether any staff members and/or pupils need to self-isolate, or whether parts of the school building need to be deep cleaned. Our team is responsible for following up directly with any close contacts identified to find out if they have had any symptoms and to offer self-isolation advice.

We then provide the school with a range of communication materials, such as letters, emails and Q&As, that they can use to update parents and staff on the situation and what they need to do, based on the advice that we have given.

We work with settings to tailor these communications as much as possible and always include our contact information so that people can ask questions if they’re unclear on the information that’s been given.

Throughout this process we keep regular contact with local Directors of Public Health and Local Authorities, sending daily reports with the latest information on what’s happening in their community.

For situations that are particularly complex, for example an outbreak (defined as two or more linked cases in a setting) or where the setting poses challenges for contact tracing and isolation, we may hold an outbreak control meeting. We invite representatives from the setting, other local stakeholders such as the Local Authority, local NHS and communications teams to these meetings and agree what the response should be to investigate the outbreak further and prevent onward spread.

We may also identify clusters of cases in a particular community or area through our surveillance work, or through information from a Local Authority. We need to investigate these to see if there is any link between the cases, and whether control measures are needed to prevent further transmission, as we would for other infectious diseases.

What are some of the challenges involved with this work?

The COVID-19 pandemic is unprecedented in its scale and impact, and we have had to rise to the challenges it has brought. However, we usually find that people are very pleased to receive our support. Health Protection Teams have lots of experience in managing complex outbreaks, so we’re used to providing information and managing concerns around sensitive situations.

We take a tried and tested approach regardless of the nature of the outbreak. The most important element of our response is providing clear and consistent advice, and that any communications being sent out are easily understood. It’s important to listen to what the specific needs of the setting are and adapt to this, especially in larger cities like London where many won’t have English as a first language.

While we lead the response to an incident, it’s very much a group effort working with relevant stakeholders to deliver the right advice at the right time. Depending on the nature of the case and the setting, we provide continued support as required.

How do you make decisions on what action is needed?

Every case is different. It is important to gather as much information as possible and use this to inform our risk assessment, before deciding on the right course of action to take.

Factors such as who the case is, where they live, what type of setting they have had contact with and how that setting is operating are all important.

Self-isolation advice would depend on where we believe transmission took place and who then meets the contact definition. It’s about unpicking the detail with each case to decide on who should be isolated.If multiple cases are reported in a school, for instance, we need to consider whether these cases were infected in the community and happened to be in school at the same time or whether there is evidence of transmission happening within the school.

For certain complex settings we may decide that we need to test others in the setting to find out whether transmission is happening. We can organise this ourselves by sending swabs to the setting or to people’s houses, or we can arrange testing through mobile testing arrangements.

You have to be pragmatic and ensure that any advice is proportionate to the risk. For example, if one person in a workplace was confirmed positive, it wouldn’t necessarily require the whole workplace to close and instead require only certain people to self-isolate if they had had close contact, whereas if there were multiple cases then more serious action or even closures might be necessary.

While there is guidance available online, we’re often contacted by settings who are concerned about possible cases and we are able to point them to the relevant guidance and help them take the right course of action.

This might involve offering advice for workplaces on how to operate a COVID secure workplace and minimise the risk of COVID-19 through social distancing, changing working patterns and good hygiene practices. If the advice is followed, then onward transmission should be minimal if a worker tests positive for COVID-19.

In several settings where we’ve seen a positive case following a risk assessment, we haven’t needed to advise anyone to self-isolate, as the correct social distancing guidance has been followed.

5 facts about the work of health protection teams

  1. Now operating in conjunction with the new NHS Test and Trace service, PHE’s health protection teams work alongside a new workforce of contact tracers. This ensures anyone who tests positive for COVID-19 can share details of their contacts, with the contacts followed up promptly and offered advice online or over the phone. The NHS Test and Trace service escalates all complex cases to local PHE experts
  2. Some cases involving an institution or setting can be more complex to contact trace so advice is issued to the institution rather than speaking individually to all contacts identified
  3. Health protection experts are trained to work with a setting like a care home, prison, school or workplace and carry out a risk assessment, which includes ascertaining how many people may be at risk and need to receive advice on self-isolation
  4. As well as identifying contacts who may be at risk of being exposed to an infection, health protection teams provide advice on issues like personal protective equipment and infection prevention and control
  5. Outbreak management is a long-established part of the day-job for health protection teams who are experienced in controlling community outbreaks of infections from meningitis to measles.

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