A positive test result for COVID-19 can be a daunting diagnosis for anyone. A positive test result triggers Public Health investigations related to Case Management, Contact Management, and Outbreak Management. Each one of these different types of investigations includes a group of complex protocols.
The Infectious Diseases Team at the Grey Bruce Health Unit helps clients with their diagnosis and case management. However, the Public Health investigative effort does not stop there; it continues under a set of robust protocols that ensure appropriate navigation through a series of complex tasks. The activities can include medical, legal, ethical, social, and technical aspects, among others. All of this is done under a formal investigation and with the utmost care and support for the client.
The Infectious Diseases Team at the Grey Bruce Health Unit investigates to follow up with every positive COVID-19 case and many presumptive, indeterminate, and sometimes negative cases. When someone tests positive for COVID-19, the Team automatically receives the result as every lab in Ontario is mandated by law to report the results to the local Medical Officer of Health. The Team follows-up immediately to prevent any further transmission of the virus, providing medical advice and support to the client while also addressing the public's potential risk.
Throughout the investigation, each interaction with a positive case must be professional, friendly, and firm when needed. We are managing a significant transmissible illness and need to convey the gravity of the situation to those that may not understand or share the required level of concern. With our initial and subsequent contacts, we seek to gain trust and understanding from the client. Trust is something that takes time and develops over days and weeks of daily calls.
Our approach is to support the client with as much knowledge as possible to ensure a successful recovery and prevention of transmission. We also have to ensure that the information they provide is reliable, and they comply with any requirements for isolation. For example, some clients may have memory disorders that make this task more challenging.
The investigation consists of multiple interviews with cases and contacts. From our interviews with positive clients, we build a list of all close contacts. The interview is structured to help people recall and share all details about movement and contact they have had with others – this is called contact tracing. We conduct interviews with these contacts as well. We do daily calls to all active, positive clients and contacts connected to the case. Through this ongoing exchange, we confirm the reliability of information from the client and contacts, and work with them to control the further potential spread of the virus. We have made thousands of calls since March to manage cases and contacts
These investigations have unique challenges. Isolation for those that test positive and their close contact(s) is critical to the success of limiting further spread. In rare cases, when cases and contacts do not follow the isolation orders, we will adopt additional measures to ensure the individuals understand the seriousness of the situation. Follow-up on those who fail to comply with isolation orders may involve sending our staff or collaborating with the police to ensure compliance with an isolation order. This level of follow-up has been needed only in a small number of cases. Most people understand the situation and fully comply, recognizing that we are there to support them and their contacts.
Other challenges include equity and access. As some clients may not have access to a phone, we provide cell phones to positive cases and their contacts during the isolation period. Utilizing language interpretation through Public Health Ontario has helped address challenges related to language barriers in some cases. Both of these strategies proved successful when working with a group of migrant farmworker cases and case contacts. Another challenge is the sheer number of required calls and interviews within the narrow window of time. The provincial target for health units is to follow-up with 90% of cases within 24 hours. With the 126 cases we have since March, thousands of calls and interviews have been completed. To date, we have been able to maintain the track record of follow-up within 24 hours in 100% of cases.
Living in small rural settings makes privacy that much more critical. We treat all cases and contacts with the utmost confidentiality. Names are never shared, and exact locations of positive cases are not made public to protect the client's identity. The Team does a thorough investigation and manage all contacts, independent of each other. Clients that test positive have no requirement to tell anyone of their diagnosis. When we call contacts, we only disclose that "you have been exposed to a COVID-19 case", we do not name the case. Unless individuals choose to disclose their status (case vs contact) to others, no one else will know their status. Although we operate in the public arena, we are legally bound to maintain strict privacy.
In addition to supporting individuals and preventing transmissions of the virus in the community, the investigations also support workplaces and prevent transmission and outbreaks in these occupational settings. Examples of these workplaces or organizations include big-box retail outlets, restaurants, factory settings, farms, clinics, and hospitals, etc. While the Ministry of Labour remains responsible for workplace safety and occupational illnesses, Public Health manages infectious disease cases and outbreaks in these facilities. During the investigation of every case, we evaluate the risk of transmission in the case's workplace. We manage cases and contacts related to these occupational settings. With all local cases so far, we have successfully ensured that no transmission of COVID-19 has occurred to co-workers or customers.
Depending on the complexity of the investigation, we sometimes call on the collaboration of the employer. At times, employers in their efforts to go above and beyond, act without Public Health direction. Although sometimes beneficial, actions that fall outside of those supported by Public Health can sometimes cause undue fear and stress in the population. We urge collaboration in these situations to ensure a consistent and united approach while containing the virus.
Notably, the Infectious Disease Team's efforts are mirrored by parallel efforts related to communication to partner organizations, agencies, and the public.
Investigations related to case management, contact management, and outbreak management are complex and challenging undertakings that require a competent team of professionals. If implemented appropriately, as they have been in Grey and Bruce Counties during the COVID-19, they break the transmission chain and provide the benefit of safety to individuals, families, and our communities. They allow us to keep healthy people healthy.
Please see our newly released video highlighting “What is Contact Tracing”
source: media release, Grey Bruce Health Unit
