Better Contact Tracing Essential: Requires Improved Public Health Systems

Recently, I came across the following graph of the waves of the Spanish Flu in 1918-1919. I don’t know the exact source of this graph. However, the information on the graph lines up exactly with what the Centre for Disease Control (CDC) describes as the three waves of the Spanish Flu.

To be clear, nobody at this time knows if the same pattern will be followed by COVID19. We know that the flu tends to have decreased transmission in humid weather, but we don’t know if COVID19 (caused by a different virus) will follow that pattern. Or even if that will make a difference during the first season of a pandemic. There’s a nice video explaining that here.

However, should this pattern be followed by the COVID19, suffice it to say that we are all in for a very long road ahead.

So what can be done to reduce the intensity of the second and third waves (if they come)? Physical distancing of course is number one on the list. While many physicians (myself included) suggested not wearing masks in public initially, we know know that doing so will keep YOU from spreading COVID19 if you are a carrier. So wear a mask. Finally, we need a robust tracking and isolating system (aka Contact Tracing) for people who test positive for COVID19, which frustratingly, we don’t have right now.

Widespread testing for COVID19 along with Contact Tracing is what the four most successful governments in the world have done to control the spread of COVID19. We need to learn from these governments. But for now it is something that we seem to be unable to do in Ontario, and there are multiple reasons why.

Piecemeal Structure of Public Health Units (PHUs)

The first is the piecemeal structure of PHUs in Ontario. Now to be clear, PHUs are manned by terrific doctors and front line staff. I had the pleasure of meeting many of them during my term as President of the Ontario Medical Association and they are all excellent, hard working people. But the infrastructure of PHUs, from the point of view of this family doctor, leaves a lot to be desired.

By my count, there are about 40 Public Health Units across the Province. To a large extent, they work somewhat independently from each other and use different referral forms. My office has patients from patients in both the Grey Bruce and the Simcoe Muskoka health units, and while the staff in both units is excellent, it’s frankly annoying to have two different sets of forms to refer patients (and have two different formats of reports come in).

Worse, not all of the Public Health Units are on an electronic records (seriously, some use paper), and there is not one consistent electronic record for PHU’s across the Province. This only complicates the collection of data and the ability to Contact Trace.

Curiously enough, addressing the disjointed nature of the public health units was something that the current provincial government tried to address early in it’s mandate. Part of the initial plans were to reduce the number of PHUs and standardize the processes. This was supposed to result in savings of 25% in the PHU budgets. (NB – personally I can’t see that much in savings, I’m thinking closer to 10% would have been achieved).

Of course given what happened with the COVID19 pandemic, and the “two second sound bite” nature of our media reporting, the story has become “Doug Ford cut spending – we have a pandemic – solution – spend more”. It’s a nice simple argument. “Hey we spent more money, problem solved.”

However, just spending more on public health (and to be clear again – I support wise investments in public health), isn’t enough. There’s no sense in spending more on a disjointed system. What’s needed is to get all the PHU’s across the Province to integrate into one standard electronic system of record keeping, so that they can more efficiently and effectively contact trace.

More Wide Spread Testing for COVID19

Next of course, we still need more wide spread testing, and ideally we need something called “point of care” testing. Once again, the four countries I referenced earlier led the way in testing as many people as possible. So this needs doing as well.

APP for Contact Tracing

Finally, we really should authorize a provincial app for Contact Tracing. Alberta already has one. Alberta has taken many precautions to ensure that patient privacy is protected (app does not use GPS, has a randomized non-identifiable ID, erases data every 21 days etc). We could just use that one, or a more Ontario centric one like this excellent one developed by physicians . It has some what more features and ease of use but uses GPS. Better yet, why not link and App to a patient’s own health care portal like MyChart, which already integrates COVID19 test results?

As the New York Times pointed out, Contact Tracing is hard. However, we need to get on with it. Without effective Contact Tracing, we can’t mitigate against the potential second and third waves of this pandemic. Without mitigation, the economic and health disaster will continue and untold millions more will continue to suffer.

Here’s hoping that instead of just throwing money at a problem, governments of all levels invest smartly at the right tools (standardized PHUs, contact tracing APPs etc.) to deal with the COVID19 Pandemic. The alternative is too frightening to consider.