As Quebec prepares to deconfigure several regions of Quebec and increase the number of COVID-19 screening tests to 14,000 per day, is the network ready to carry out the meticulous investigations that will have to be the subject all cases declared positive? Some doubt that the current teams, sometimes overwhelmed, are in sufficient number to carry out this vital operation.
Posted on May 9, 2020 at 5:00 a.m.
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Is Quebec ready?
Former hockey player Georges Laraque, hit by COVID-19, was admitted to Charles-Le Moyne Hospital in Longueuil on April 30. The same day, he received a positive diagnosis. The one who is now a radio host gets his leave on May 5. Public Health called him that day to investigate the whereabouts of his contacts. “They told me it was a little late, but they were so overwhelmed with the calls that they had to make. “
Five days is a long time. For such an investigation to be successful, it should ideally be carried out within 48 hours of confirmation of a diagnosis, specifies the president of the Association of specialists in preventive medicine of Quebec, the Dre Isabelle Samson. ” The earlier the better. But if we are talking about three, four, five days of delay […], The bulk of the damage is done, “she said.
Difficult for Dre Samson to comment on the specific case of Georges Laraque. For hospitalized patients, says the doctor, the investigative work is sometimes carried out in concert with the hospital’s infection control and prevention team.
But as Quebec prepares to deconfine certain regions, these epidemiological investigations are becoming crucial, according to experts. The “rule of good practice in public health” is to reach everyone with whom the confirmed cases have been in contact, explains the Dre Samson. By tracing the cases, Public Health wants to “break the chain of transmission because there is no treatment to offer” for COVID-19.
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Hundreds of thousands of Quebecers will return to work, elementary school and child care starting Monday in several regions of Quebec. Greater Montreal is expected to follow two weeks later. More people are at risk of being infected, and more cases will be detected, since we will double the number of tests performed across Quebec.
Is Public Health ready to investigate this possible tsunami of COVID-19 cases?
Certainly, since the start of the pandemic in Quebec, more than 35,000 cases of COVID-19 have been confirmed and all of them have been investigated, according to what the Ministry of Health and Social Services claims. (MSSS).
Has the 48-hour deadline been respected everywhere, even in hot areas? “It depends on the regions. But in most cases, yes, “says Dre Samson.
This “race for contacts” is a real monk’s job, said on Wednesday at a press conference the regional director of public health of Lanaudière, the Dr Richard Lessard. In Lanaudière, where on average 100 new cases of COVID-19 are detected every day, 80 people are busy with this task.
Scientific literature around the world has shown that the detection of COVID-19 cases followed by the “contact race” were two decisive conditions for the success of a post-pandemic deconfinement.
In fact, Quebec announced on April 30 that it would reduce the number of screening tests performed daily from 7,000 to 14,000. In all cases declared positive, there will be an investigation, ensures the MSSS. The goal is to “investigate [sur] all of these cases like regional public health departments [DRSP] have been doing so since the start of the pandemic. ”
Do we have enough staff to get there? The Dre Isabelle Samson explains that there is “no magic number” on the ideal ratio of investigators per number of cases to be examined per day. She says that in several regions of Quebec, regional public health departments “have the capacity to be reactive” and to quickly investigate all cases of COVID-19.
But in warm regions, such as Montreal, “there are still significant challenges”. As for CHSLDs, Dre Samson explains that public health teams “need people full time”. “It makes teams more fragile when people come and go, come and go …”, she says.
However, she would like specific indicators to be put in place to “measure the performance of public health”. At present, it is unknown what proportion of people are contacted within this crucial 48-hour period, she said. Does the DSP have plans to monitor the performance of its regional offices in this way? The Dre Samson would like to know. “Not in the spirit of criticism, but in order to be well-equipped in terms of manpower,” she said.
The Dr Paul Le Guerrier, medical consultant attached to the infectious disease prevention and control team in Montreal and the Montreal Public Health Department, would also like the Department to define indicators that could serve as a benchmark to be reached in terms of tracing before deconfinement, as Ontario has done. “It is not in Montreal to define them,” he said.
The Dre Samson says he has never been contacted to establish a roadmap to determine the medical workforce needed in public health during a pandemic.
Human resources experts should address the issue of the public health workforce and establish systems to better support hot regions.
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The Dre Isabelle Samson, President of the Association of Specialists in Preventive Medicine of Quebec
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Critical investigations
Asked about the number of additional people who will be mobilized to carry out this “contact race” across Quebec, the MSSS asked The Press to contact the 18 regional public health directorates. We contacted 15. We received responses from six DRSPs. None of them plan to hire tracing workers, except Montreal and Laval. In Outaoutais, six medical microbiology technologists will be reassigned to meet additional needs.
Benoît Mâsse, professor at the School of Public Health at the University of Montreal, doubts that the government currently has sufficient human resources to intensify screening, tracing risky contacts, a particularly time-consuming task, and their monitoring in isolation .
“Ideally, everything should be already in place when we start to deconfinate. The virus cannot leave before us, ”notes the researcher.
This is even more true in Montreal, where the situation is far from being controlled, which increases the risk of an outbreak in the event of an error. “We have no room for maneuver” allowing errors, says Mâsse.
We are starting to realize that there are many failures, many hesitations in the government response. I am willing to trust them, but I am worried.
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Benoît Mâsse, professor at the School of Public Health at the University of Montreal
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It is indeed Montreal that will absorb a good proportion of the cases resulting from the increase in screening tests. The team responsible for tracing the risky contacts of people diagnosed with COVID-19, at the Direction de santé publique de Montréal, is already receiving nearly 400 new records per day, even though its management capacity is from “350 to 400”, depending on the Dr The warrior.
Clinical nurse who works with the tracing team in Montreal, Jacynthe Caron notes that it has already been necessary to add a lot of staff to deal with the increase in the number of cases since the appearance of the first case of COVID-19 on Montreal soil at the end of February. Colleagues within the DSP were urgently mobilized to lend a hand. School nurses, medical students and dental hygienists were also called for help.
The Dr Le Guerrier notes that around 80 investigators are mobilized daily to conduct initial interviews and identify problematic contacts. About 60 support staff are required to perform data entry at various stages of the process. Note that information on new cases is currently arriving by fax and must be entered manually.
The doctor agrees that the projected increase in the number of daily tests to 14,000 per day in the province will translate into a significant increase in the number of cases to be treated and the workload of the Montreal tracing team, but he cannot estimate it precisely for the time being.
” I have no idea. I expect it to increase and we will have to adapt to the situation, “he said in an interview with The Press Thursday.
The Dre Mylène Drouin, regional director of public health for Montreal, said at a press conference on Friday that it would be necessary to hire more than a hundred employees to meet the demand for tracing.
The Laval Public Health Department, whose tracing team currently treats between 100 and 150 cases daily, expects this volume to double with the intensification of screening tests.
Alexandre St-Denis, assistant to the director of public health for health protection, predicts that it will be necessary to add thirty people to the team to ultimately meet the demand while maintaining the efficiency of the system in place. “We are aware that this is a major challenge,” notes Mr. St-Denis.
Currently, it usually takes less than 24 hours between the time a new case of infection is reported and the call to people who have had risky contact with the patient, he said.
“The quicker the investigation, the better,” says Dre Yannick Lavoie, medical coordinator of the infectious diseases team.
In Lanaudière, the Dr Lessard believes he will have enough staff. ” I think so. Because we are allocated resources that are not on other work, “he said. CISSS de Lanaudière CEO Daniel Castonguay explains that 800 people in the area were relieved of their usual activities at the start of the pandemic and that part of them were sent to support the Public Health team. Among them, many pregnant women and immunosuppressed workers.
Head of regional department, infectious diseases at the Montérégie Public Health Department, Jérôme Latreille “dares to hope” that he will have the manpower necessary to respond to a possible increase in the number of surveys to be carried out. “But there are still several unknowns. For example, we know that we will test more. We expect more cases, but how much? We don’t know, ”he says.
IT to the rescue
To help it in its hunt for contacts, the MSSS also says it is betting on its Akinox platform. For the past few weeks, this new system has made it possible to electronically monitor the symptoms of people called to isolate themselves after risky contact with an infected person. The platform needs to be enhanced to allow initial interviews to identify particularly long at-risk contacts to be shortened using electronic forms completed by those infected, but the process is behind schedule.
“In the context of deconfinement and the increase in the number of screening tests, the administration of a self-administered questionnaire by the person suffering from COVID-19 has a huge advantage in the management by public health departments. , facilitates and reduces the workload of the investigative nurses while increasing the data available as quickly as possible to public health protection actions, ”indicates the MSSS.
“The first call [pour identifier les contacts à risque], which lasts 1 hour, or even 1 hour 30, could last five or six minutes. That would help us to considerably increase our capacity, ”notes the Dr The warrior.
“We will have fewer paper files. Everything will be centralized. Communication can be done by email. It will reduce the number of human resources needed and it will be easier, ”believes Dre Samson.
No investigation of certain cases
Quebec officially has 35,000 cases of COVID-19. But a number of these people infected with the coronavirus are “clinical cases”, which have not been tested and cannot necessarily be linked to a patient. They are not counted in official cases and, until this week, were not the subject of an epidemiological investigation.
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How many cases in Quebec?
• 30,889 cases of COVID-19 were confirmed by a laboratory test.
• 4,349 cases of COVID-19 were diagnosed by epidemiological link.
• A minimum of 1352 clinical cases have been reported by physicians, but there are likely to be many more.
The national director of public health, Horacio Arruda, mentioned last Friday the figure of 250,000 Quebecers infected, or 3% of the population.
A study by the Université de Montréal using a statistical model established the number of cases in Quebec as of April 22, 256,000.
No investigation for clinical cases so far
One such “clinical case” is Laurie-Anne Ménard. The 28-year-old Montrealer started having trouble managing her asthma three weeks ago. She then saw her condition deteriorate. Her nose started to run.
“One day I got up and my toes itched a lot. I also had toe pain. I thought to myself: OK, there is something wrong. I called the COVID line. “
PHOTO EDOUARD PLANTE-FRÉCHETTE, THE PRESS
Laurie-Anne Ménard
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During this call, the 1er May, he is given a telephone appointment with a doctor. “The doctor told me that they were not testing the general population, but she confirmed a positive diagnosis for COVID. She declared me positive to Public Health, says Mme Menard. The doctor told me that someone may be calling me in the next few days to check on my trips and other information. She also said that they might not call me because they are overworked. “
Neither her relatives nor she were contacted. Since the diagnosis, M’s state of healthme Ménard has degraded. She has a fever, has trouble eating and has diarrhea.
Roxanne Gendreau is also a “clinical case” of COVID-19. She was tested positive for the virus on April 16 by a doctor at a screening clinic. Since she was not getting better, she went to Anna-Laberge Hospital on April 28. “The doctor didn’t test me, but he told me it was COVID. He told me that I had spots on my lungs, that the virus had given me pneumonia […]. They did not investigate, “she said.
Surveys starting this week
Until now, clinical cases have not been the subject of an investigation by Public Health, specifies Jérôme Latreille, head of regional service at the Direction de santé publique de la Montérégie.
Latreille said the patients were still diagnosed by their doctor and that doctor “passed on recommendations for isolation.” Why are we not investigating in this case? “It was an approach that kept you from being overwhelmed by background noise” for which there was, he said, “no added value” to investigate.
But the situation has changed this week, he said. “With deconfinement, we come to test and investigate differently. […] We have just enlarged the population pool that can have access to tests to be in phase with deconfinement. “
Since May 4, clinical cases have also been investigated. “With deconfinement, the reporting of clinical cases will be an important source of information in order to identify as early as possible any outbreaks that may occur,” said Robert Maranda, spokesperson for the Department of Health and Social Services.
How do surveys work?
An orthopedic surgeon at Charles-Le Moyne Hospital, Hai Nguyen was reassigned several weeks ago to the Montérégie Public Health investigation team, for which he works three to four days a week. Explanations.
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At the start of the day, the Dr Nguyen receives some case files which have been confirmed, by test or by epidemiological link. Begins careful work lasting several hours.
First step: communicate with the patient, who has already been informed of his diagnosis, usually within the previous 48 hours. The appeal covers two main areas: questions, particularly to determine where the patient may have contracted the disease, and very specific advice on isolation. Precautions to be taken not to contaminate other occupants of the house, symptoms to watch for and, if the condition worsens, where to go to see and by what means of transport. Because even after more than two months in confinement to be bombarded with information on COVID-19, the instructions are far from being integrated by all.
PHOTO FRANÇOIS ROY, LA PRESSE
The Dr Hai Nguyen
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The investigator must also determine if the patient’s contacts have symptoms, whether to test them and to open records for them. Each patient generates an average of one new case, estimates the Dr Nguyen. After this call, which has lasted 30 to 45 minutes, you must contact the employer or, if they are health care workers, the authorities responsible for dealing with such cases.
In businesses, for example, you must notify the supervisor of the last shift performed by the infected employee, communicate the contact list provided by him, ask him to check if there are others and the inform the instructions to give to the employees concerned (being absent from work for 14 days, monitoring their symptoms, etc.)
“And there is all the paperwork that comes with it and that is not negligible either,” notes Dr Nguyen. At the end of a day, he will have completed on average four files for the Montérégie Public Health.
Indeed, beyond the official stages to be accomplished, he must sometimes engage in a real investigation. It is not uncommon for the patient’s phone number entered in the chart to be incorrect or not available, or the laboratory result not included. “It has sometimes taken me pretty acrobatics to find,” he says.
With his access to the Quebec Health Record (DSQ), he succeeds in finding laboratory results and patient coordinates. Finding an inpatient with the wrong last name was more difficult. “I ended up managing in the hospital system, which I know well, and calling the floor and the care so that this patient does not fall between two chairs. “
But he doesn’t take offense. “Mistake is human and we should expect a lot of human error in a time like this,” he said.
“A work by Sherlock Holmes”
Jacynthe Caron, a clinical nurse, works for the Infectious Disease Prevention and Control team at the Montreal Public Health Department. At the start of the crisis, it had provided a large drawer for filing files to deal with confirmed cases of new coronavirus infection.
A colleague gently laughed at her, telling her that she would never need so much space, but the multiplication of cases since the end of February quickly got the better of the drawer and put it forced to review its archiving plans.
Work has not stopped since for the nurse and her colleagues who multiply the calls every day to identify the risky contacts that the infected people may have had and to inform the individuals concerned of the need to isolate themselves and to monitor their symptoms.
Mme Caron notes that investigators must be psychologically sensitive to the situation of people infected with coronavirus, who sometimes learn from their mouths of the test result even if it is normally expected that the attending physician will assume this task.
“You have to get them to trust very quickly,” said the nurse, who sometimes had to hire an interpreter to achieve her goals.
The interview is crucial since it identifies people at risk. But also because it can lead on the trail of establishments or environments threatened by a major outbreak.
The identification of contacts sometimes forces investigators to carry out further research, in particular because the information intended to make it possible to reach them is sometimes inaccurate or the people have changed their residence.
“I like to say it’s a Sherlock Holmes job,” said the nurse.
The different stages of tracing
• Interview with the person diagnosed with COVID-19 to establish the contact list: 45 minutes
• Time of initial call with each contact: 10 minutes
• Number of contacts per case: from 10 to 30
Source: European Center for Disease Control and Prevention
Variable importance from one country to another
States embarking on gradual deconfinitions almost unanimously point out that tracing contact with people with COVID-19 is a central part of their pandemic plan. Some governments have, however, been more determined than others over the past few months.
Singapore
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Like other Asian states such as South Korea and Taiwan that have managed to contain the crisis, the health authorities of this densely urban city-nation quickly put a strong emphasis on screening tests and tracing. . People who have been in close contact with infected people are identified and asked to place themselves in quarantine, in their own home or in government establishments. Police work with health officials, especially when it is difficult to trace a contact. A phone application has also been developed to identify close contacts between individuals, but it has only been adopted by a small fraction of the population, which limits its usefulness. The government’s vigorous tracing initially helped control the coronavirus, but a new outbreak subsequently forced the imposition of severe confinement measures which must remain in place until 1er June.
New Zealand
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The Prime Minister of the small country of 5 million people announced a few weeks ago that the battle against COVID-19 had been “won” and that community transmission was “largely” under control. She warned in the process that her government did not intend to drop the guard and would continue to test and systematically trace the contacts of infected persons, in particular by providing itself with sufficient resources so that the tracing team could manage up to 10 000 calls per day. The situation on this front was more difficult in March. An audit released by the government noted that tracing personnel had been overwhelmed a few times while the number of new cases of contamination did not exceed 100 per day. Efforts to put in place a specialized team that can intervene in support of regional public health services have also been unsuccessful.
Germany
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The German government is frequently cited as an example for how it responded to the pandemic. He particularly emphasized screening, increasing the number of tests while effectively identifying the contacts of infected people before testing them in turn. The authorities are now seeking to strengthen the system in place to be able to deconfinement while minimizing the risk of rebound, and they are working in this context in particular in the development of a phone application similar to that which has been tested in Singapore. It should store contact data on the devices of affected individuals rather than centrally due to concerns about privacy invasions. Several other European states are studying these applications, including the United Kingdom, which this week undertook to test a version on the population of an island of 80,000 inhabitants.
United States
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The US response to the COVID-19 pandemic has varied widely from state to state since the onset of the crisis, and the use of contact tracing has not escaped the phenomenon. As President Donald Trump pushes to accelerate a process of deconfinement that many analysts deem hasty, multiple voices are rising to demand a massive increase in human resources devoted to this task. In a report released a few weeks ago, the Association of State and Territorial Health Officials noted that there are only 2,000 specialized investigators in the country at the moment and that at the very least 100,000 employees should be added to the existing tracing services to meet needs. A group of medical experts recently wrote to leaders of both chambers of Congress, citing an even higher figure of 180,000 people as hiring targets. “We are going to need to significantly increase the number of field workers in public health,” says director of the Centers for Disease Control and Prevention (CDC), Robert Redfield, who promises a “very energetic” approach. In terms of screening and tracing.
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