Brett Sutton looked relaxed but authoritative as he addressed doctors at Royal Melbourne Hospital via video conference on Thursday, September 3. Hundreds of physicians had dialled in to hear Victoria’s chief health officer speak, just days before the state government was due to announce its road map out of restrictions.
The CHO acknowledged the “hard choices” facing the government. The goal, he said, was to “get down to a point of such low transmission that either it ends community transmission or that we can manage it with robust surveillance, robust contact tracing and case follow-up”.
But in response to a question about the criticism of Victoria’s tracing system, Professor Sutton broke with public comments: “It was totally challenged. No question there. Even at lower numbers, there were some intrinsic challenges with contact tracing.”
He went on to describe in detail the hurdles Victoria’s contact tracing system had faced.
“We had some old systems, and when we wanted to have surge support from all other jurisdictions, we had to go to a paper-based system,” he said on the call, a tape of which has been obtained by The Saturday Paper.
Sutton said the recent decision by the state government to upgrade the technology powering the tracing effort “should have been part and parcel of our response for years”.
To underscore this, he said: “We still get notified of cases by fax.”
Some doctors on the call told The Saturday Paper they were relieved to hear problems with contact tracing were finally being acknowledged, albeit in a private setting.
But Sutton made another comment during the briefing that alluded to much deeper, structural flaws with the state’s contact tracing team, and the Victorian health department’s response to Covid-19 more broadly.
“We’ve learnt that the pathology system is a hotchpotch of public and private providers that are not able to be stewarded centrally,” he said. “The turnaround time for test results has been challenged.”
Five days later, during one of his daily press conferences, Premier Daniel Andrews expressed the opposite view. “I don’t accept that. I don’t accept that at all,” he responded when asked if a more efficient tracing system could have prevented the severity of the second wave. “… With the amount of cases that we had, a more centralised model worked and that’s not a matter of my opinion.”
This week, Andrews changed tack again, announcing Victoria will move away from a centrally controlled model to something more in line with New South Wales – where tracing units operate in devolved hubs, each with a focus on one community. Five regional tracing hubs are now up and running in Victoria, and new suburban tracing hubs have been announced.
But there is another key difference between the approach in NSW and Victoria: the degree to which each response has been outsourced to the private sector.
Since March, when the first wave of the pandemic hit Australia, Victoria has issued 85 contracts related to Covid-19 to private companies at a total cost of $116 million.
More than half of this – $64 million – has been spent on outsourcing basic contact tracing work, including on call centres, data analytics and management consultants.
Victoria’s reliance on outsourcing stands in contrast with other states, particularly NSW, which has conducted its contact tracing in-house, using public servants with support from the Australian Defence Force.
According to doctors and epidemiologists, Victoria’s reliance on outsourcing reflects how under-resourced the Victorian public health unit has been – even before the pandemic.
“The running into the ground of the public health response in the state of Victoria has led to a situation where the public health response could not match what was needed,” says Dr Mukesh Haikerwal, a GP who manages a testing clinic in one of Melbourne’s suburban hotspots and is chair of the Australian Medical Association’s Victorian taskforce on Covid-19.
When Covid-19 hit, Haikerwal says, the public health unit was “hammered”.
Brett Sutton, in his presentation to doctors at Royal Melbourne Hospital, similarly acknowledged that the unit, currently funded at a level of $80 million a year, needed to be “beefed up”.
When the pandemic began in March, Victoria’s contact tracing team consisted of just 14 people. According to the state’s Department of Health and Human Services (DHHS), there are now more than 2600 people supporting the public health response. However, the department would not provide a detailed breakdown of how many were outsourced workers.
Early on, Victoria rebuffed an offer by American tech giant Salesforce to utilise its technology – used in Western Australia, South Australia and New Zealand – for an integrated approach to contact tracing and communication.
Instead, DHHS gave a contract – worth $948,000 – to a company named Whispir to send text messages to positive cases and contacts. This week, the Andrews government announced it had engaged Salesforce to give contact tracing a “digital reset”.
At the end of March, DHHS awarded management consultants EY (formerly Ernst and Young) contracts worth a combined $5.3 million to provide specialist advice and operational planning on Covid-19 matters.
Travel agency Helloworld was awarded its first contract worth $3.6 million to staff the government’s Covid-19 hotline at the end of March. The company’s staff were responsible for contacting positive cases and their close contacts, after being trained by DHHS.
In April, a private health company, Torrens Health, was awarded $3.4 million to manage the deployment of key health personnel across the state.
On June 17, Victoria recorded its first day of more than 10 local cases during its second wave. A week later, testing had tripled to more than 20,000 tests a day. That boost, and the associated increase in positive cases, appears to have overwhelmed tracers.
By the end of June, the number of cases under investigation had ballooned to more than 100. On August 5, it peaked at just under 4000.
In NSW, meanwhile, the number of cases under investigation in its second wave has never exceeded four, according to analysis conducted by Anthony Macali, a data and analytics specialist who maintains the data website Covid Live. This held even when NSW saw a stretch of 11 days in a row with double-digit case numbers.
“A positive test result took forever to get anywhere,” Haikerwal said of Victoria’s tracing efforts. “And that was with very low numbers of tests.
“So, when this exploded it was an absolute disaster. Results were taking seven days, 10 days to come back. And if you did a positive test, in July, you’d have to spend 30, 40, 50 minutes to an hour waiting on the phone.”
The delay meant some positive cases had already transmitted the virus to close contacts, who in turn were spreading it to their close contacts, sometimes for days, before they were even first contacted by DHHS.
In July, DHHS spending on outsourced contact tracing ramped up again dramatically.
Quantium Health, a private health data company, was awarded a contract worth $2.7 million to produce dashboards for reporting Covid-19 data, and Helloworld was granted another $7.6 million to run an outbound call centre. Another company, Stellar, was awarded $9 million to help with call centre efforts.
Victoria’s contact tracing system is now based on a complicated patchwork of private sector providers, front-line health services and DHHS staff. It is a bolted-together system that simply could not handle the caseload in the state’s second wave.
At its worst, wait times blew out to two weeks before some close contacts were notified of their risk of exposure.
“The failure of DHHS to contact trace is why the second wave got out of control,” said one doctor, who manages a testing clinic but did not want to be named because she works closely with the department.
“In the beginning we had a pen and paper system,” she said. “In Victoria, you could notify for a gonorrhoea case online but for Covid it had to be by fax or by phone.”
Patients would be tested at community health clinics or by GPs. The test would then be taken to a private laboratory. The next day, doctors would receive the result and either fax it in to DHHS or phone a hotline.
The person on the other end of the call, likely an outsourced call centre operator, would write down the notification from the GP and pass it on to another staffer who would input the information into the database.
The slow paper-based tracing system meant mobile phone numbers weren’t being transcribed correctly and names were being mixed up. Call centre operators weren’t familiar with local areas and didn’t know how to spell suburb names.
The entire tracing process, from testing to data analysis, could involve the efforts of six or seven entities, most of them private sector organisations.
Two weeks ago, the system was finally upgraded to allow doctors to input positive results via an online portal, significantly reducing wait times.
Also in August, IBM was awarded a contract worth $4.2 million. The original tender document said the contract was to assist with a health tracing platform to “identify connections between different Covid cases”, which the tender initially said was not currently being done.
The document has since been amended, and The Saturday Paper understands that current tools are linking Covid-19 cases, but the new IBM software will be able to read the notes made by contact tracers to provide quicker analysis to identify links between cases and report on emerging trends in geographic areas or workplaces.
But because there are times when DHHS is only notified of a positive case 24 hours after they are symptomatic and tested – and close contacts are only notified within two days of the initial interview – it can still be several days before those at risk are reached.
One doctor told The Saturday Paper that, even with the online portal, they worked on a case where the housemate of a confirmed patient was only contacted by DHHS five days after the test was returned positive.
According to DHHS, more than 90 per cent of positive Covid-19 cases are being interviewed by tracers within 24 hours of the department receiving notification of their case, and 99 per cent of close contacts are notified within 48 hours of being identified.
But another doctor said the metrics used by the department include only people who actually answer the phone. With the bulk of calls being made by subcontracted call centres, close contacts are regularly not picking up calls from unknown numbers. The voicemails left by tracers don’t offer a return number.
The next focus in Victoria will be the “tail” of the second wave, which persists in healthcare settings and aged care. Those sectors need to remain open, and so even strict lockdowns may not be enough to snuff out the virus completely.
According to Dr Sarah Whitelaw, who represents emergency physicians to the Australian Medical Association, the inability of DHHS to properly trace the source of infection for healthcare workers has led some hospitals to run their own genomic testing.
She says the absence of universal genomic testing is a problem. “We need to be throwing every single thing, every tool that we’ve got in the kit, at reducing healthcare worker infections. Because if we don’t, we’re keeping the entire community in an extended lockdown without doing everything we can to address the areas where the infection transmission is still really high. And that just doesn’t make sense.”
Regardless of how long it takes Victoria to emerge from the current crisis, the desperate need for public health investment won’t dissipate.
As Brett Sutton told the doctors at Royal Melbourne Hospital: “I think we need to design a system that can respond to pandemics early and robustly because they are going to be part and parcel of our lives going forward.
“It won’t just be coronavirus. It’ll be the next flu pandemic. It’ll be the next fire season. It’ll be floods and droughts and food-borne illness and all of the corollaries of climate change that are going to be more and more significant threats into the future.”
This article was first published in the print edition of The Saturday Paper on September 12, 2020 as "Leaked Sutton call reveals failures in contact tracing".
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