Behind the scenes of a COVID-19 contact tracer’s work, tough cases and how TraceTogether has helped
SINGAPORE: It looks like an open concept call centre, with workers sitting in small groups at different tables, surrounded by whiteboards scribbled with what looks like random numbers.
Upon closer inspection, the numbers were that of hospital hotlines, flight and hotel details, as well as stay-home notice information.
At one table, a man spoke firmly on the phone, asking if the person on the line took a bus straight to the hotel. He also asked if it was a big or small bus. If it was a big vehicle, could it fit 40 people?
This call centre is on the frontline of Singapore’s fight against COVID-19. It is where contact tracers from the Ministry of Health (MOH) identify close contacts of confirmed cases to ringfence the spread of the coronavirus.
On Tuesday (Jan 26), journalists were given a rare look at an MOH contact tracing centre, where officers call infected individuals to map out what they did in the past 14 days.
Officers then verify this information with different people, including the patient’s family members and colleagues, before deciding what to do with the close contacts based on the exposure rate and setting of their interactions.
Follow-up actions include placing close contacts on quarantine or phone surveillance. The latter involves a daily health check call for 14 days, before a swab test at the end.
It is a relentless process that started when Singapore reported its first case in January last year and still continues now.
“I think the whole of last year has been quite intense,” MOH communicable diseases director Associate Professor Vernon Lee told reporters on Tuesday.
“The contact tracing team has been working throughout the year. In fact, the tempo is 24/7 because the virus doesn't rest of course, so neither do we. We have to always keep abreast of the latest developments and global changes.”
The Health Ministry has two contact tracing centres whose locations cannot be revealed. Each centre has six contact tracing teams, and each team has a group of executive officers, contact tracers and activity mappers.
Executive officers prepare questions for patients or close contacts, decide what follow-up actions to take, and give a PowerPoint presentation of the patient’s activities to senior colleagues.
Contact tracers call the patients or close contacts, while activity mappers consolidate where they have been and what they have done.
READ: ‘Like an invisible criminal’: How police helped find missing link between COVID-19 church clusters in a day
The roles can be fluid when needed, such as when there are more cases or when some members are on leave. The officers make an average of 30 to 50 calls a day, and twice as many when cases spiked last year.
“If a case is very complex, we stay extra hours to get the job done,” said Mr Narasimhan Rao, 38, who has been a contact tracing executive officer since April last year.
THE DEAL WITH TRACETOGETHER AND SAFEENTRY
Indeed, the business of contact tracing is far from straightforward.
Patients might not recall where they went and what they did more than a week ago, and could end up giving inaccurate details. This is when officers corroborate the information by speaking to other people, before interviewing the patient again to confirm it.
READ: SAF making thousands of calls a day to contact trace, check stay-home compliance as COVID-19 fight hits ‘critical juncture’
“When we have a case, this data is then uploaded from the case’s TraceTogether app or token and also the SafeEntry points to a central database, and then the data is pumped to us in an analysable format,” Assoc Prof Lee said.
“So it's actually quite simple to use in that sense.”
In one real case, a patient told officers that he remembers not working on certain dates as he was on leave. But after speaking to other sources, the officers determined that he had worked the morning shift on those dates.
Using SafeEntry data, the officers could verify and confirm that the patient did go to work, with TraceTogether data indicating that he was also in close contact with a few colleagues, putting them at risk.
“Luckily, we now have that data so we can verify through that,” contact tracing centre head Lin Zhaoquan, 34, said. “We are able to speed up the process and investigate efficiently.”
Assoc Prof Lee said the data has halved the time needed to complete contact tracing for a single case, from a typical four days to fewer than two days.
“TraceTogether will help to identify close contacts, even if the individual cannot remember who he or she was with, or sometimes someone in close proximity that he or she may not even know the name of,” he added.
“SafeEntry is also very helpful because it locks the places that that person has been to, so it jogs the individual's memory, and from that, we can then continue the interview to find out what the person actually did at that point in time.
“So, all this supplements the contact tracing process and makes it a lot more streamlined, a lot quicker.”
FORGETFUL PATIENTS AND PROTECTIVE PARENTS
Still, the MOH officers will encounter roadblocks along the way, not least patients or close contacts who are difficult.
Those who try to withhold information are first given the benefit of doubt - that they might have forgotten the details. When confronted with information from other sources, Mr Lin said these individuals will usually cough it up.
For those who persist in not telling, Mr Rao said “there are measures put in place”. While he declined to elaborate, the Infectious Diseases Act can empower health officers to require a person to furnish any information within their knowledge.
Some patients or close contacts might not want to talk as they think they are in a scam call, in which case the officers can send a formal SMS or email, or encourage them to call the MOH hotline.
“We are not scammers because we don’t ask members of the public for their financial details or to transfer any money to us,” Mr Lin said. “This is something they should be aware of.”
READ: COVID-19 contact tracing ‘absolutely essential’; wearable TraceTogether tokens to be rolled out in June
And then there are young patients with parents who are “stressed” about their children being questioned, so they become overprotective, Mr Lin said.
Close contacts in “distress” might also make difficult requests, he said, recalling an incident involving a woman who, after she was put on quarantine in a dedicated facility, requested for a refrigerator to store breast milk.
The woman had previously been on stay-home notice when her husband tested positive, Mr Lin said. Therefore, her isolation was extended and led to “a lot of concerns”.
Mr Lin said the contact tracing team can relay such requests to different parties working with MOH.
“Sometimes they just want to vent their frustrations, so we need to have a big heart and listen to what they want first, and then direct this to the relevant stakeholders,” he added.
THE HUMAN TOUCH
Lending a listening ear and adding a human touch to interviews are skills that Mr Lin brought over from his previous job, as a leading steward for Singapore Airlines.
He joined MOH as a contact tracing executive officer last September, before becoming the head of a contact tracing centre three months later.
This “bigger responsibility” requires him to handle more difficult calls, take on more cases if needed, and oversee his colleagues’ well-being so they are “ready for the work”.
“There are many cases passed to you, so you need to have a bigger picture and understand more stories,” he added. “Initially it was a bit stressful, but that’s okay.”
Mr Lin looked back fondly at one incident when language proved to be an issue during contact tracing. A foreign national spoke some English but could not understand a question.
“We tried to get their details, for example, their birth dates, and they don’t understand what we are saying,” he said. “So what the tracers did was they sang a birthday song. So they understood that we wanted their birthdays.”
Ultimately, Mr Lin said he decided to do contact tracing because he wanted to do his part for Singapore while protecting his loved ones and the community.
“Sometimes we feel like public health detectives,” he said. “It's quite an honour to actually represent the community in doing this.”
Detectives sometimes take on tough cases, and Assoc Prof Lee said the large COVID-19 clusters linked to two churches early last year were “probably the most challenging” to contact trace.
“It was the first time we really had to put in all the resources and effort, and we had to learn from basics how to actually deal with it,” he said, pointing to the early use of serological tests and attempts to link the clusters.
When it comes to identifying clusters, Mr Lin said the contact tracing teams only identify close contacts of a confirmed case and “don’t really determine a cluster”.
Potential linked cases are rigorously examined by a separate team conducting epidemiological investigations, before senior officials declare them a cluster in official details released to the public.
READ: New COVID-19 cluster formed after 3 cases linked to sales employee at BS Industrial & Construction Supply
Singapore has identified three clusters in recent weeks, with Assoc Prof Lee saying they were “certainly a cause for concern”.
“Which is why there have been new announcements in terms of strengthening of some of our safe management measures,” he said, noting that the virus will “always try to exert pressure on us in terms of trying to spread”.
“The main thing is that we do our contact tracing rapidly ... And this is of course made possible by the hard work of the men and women in the contact tracing teams, and also the use of new technology like TraceTogether and SafeEntry.”
Assoc Prof Lee said the key is to get “high coverage” in terms of getting more people to use this technology, so close contacts can be identified even quicker. Currently, more than 80 per cent of the population is participating in the TraceTogether programme.
“We want to really beseech the population to use their TraceTogether app, or carry the TraceTogether token with them at all times when they leave the house, and also to do SafeEntry at all the venues that they go to,” he said.
READ: Police can only ask for TraceTogether data through person involved in criminal probe: Vivian Balakrishnan
In January, Minister of State for Home Affairs Desmond Tan told Parliament that TraceTogether data could be used for criminal investigations, triggering privacy concerns after the Government previously said that the data would only be used for contact tracing.
“We are always concerned if there's any reduction in the use of TraceTogether or SafeEntry, but we hope that people will understand that it is really for their own personal benefit and for the benefit of their loved ones, their friends and people who they may be in contact with,” Assoc Prof Lee added.
“Without such technology to aid us in contact tracing, the contact tracing process will take longer. And every minute more that we spend on contact tracing, means a minute more for the virus to transmit.”