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As Victoria nears what health officials hope is the peak of our COVID-19 wave, one of our most important defences against the virus – the art of contact tracing – is undergoing a quiet revolution.

As recently as six weeks ago, the mission was to detect and stop every COVID-19 case in its tracks. Now, it has narrowed its focus to the cases that matter most.

South East Public Health Unit director Rhonda Stuart inside the contact tracing “war room” at the Monash Medical Centre.Credit:Justin McManus

What this means for someone who tests positive to COVID-19 will depend on who you are, where you work and live, and, increasingly, whether you are vaccinated against the virus.

If you are young and otherwise healthy, it is likely you will receive only a text message from the Health Department telling you to isolate at home. You may never hear from a contact tracer.

If you are old, obese, in the late stages of pregnancy or immuno-compromised, or if you work in aged care or heathcare or with young children, you should still expect a call from contact tracers.

With an effective, life-saving treatment for COVID-19 now being rolled out across Melbourne, what you tell the contact tracers could keep you out of intensive care. It may also stop the virus spreading to other vulnerable people.

Kate Matson, the Department of Health official responsible for Victoria’s contact tracing and outbreak management, explains that as the goal of our COVID-19 response shifted from eradicating to containing the virus, our approach to contact tracing also changed.

Where every COVID-19 case was once considered a public health risk, the first task of a contact tracer now is to identify which cases most need their attention and which ones don’t.

“We want to manage the highest-risk settings earliest and first,” Ms Matson tells The Age and Sydney Morning Herald.

“If you work in aged care or you work in a hospital or if you work in a childcare centre where, of course, children haven’t been able to be vaccinated, we are going to want to talk to you and understand your situation before we understand someone who might be a barista or a landscape gardener.”

People wedded to the idea of what contact tracers used to do will see this as a public health failure but Rhonda Stuart, an infectious disease expert who runs the Health Department’s South Eastern Public Health Unit, describes it as a necessary response to a changed COVID-19 landscape.

Finn Romanes, the director of the Western Public Health Unit which covers some of the Melbourne suburbs hardest hit by the pandemic, says there is an “intense pragmatism” behind the change.

“We looked at where there was risk and where there was consequence and tried to move our effort, our people and our focus to where we could make the biggest difference,” he says.

Professor Stuart describes the new approach as “risk stratification”, a form of public health triage which prioritises those most at risk and those who will benefit most from early intervention. Her unit is dealing with more than 5000 COVID-19 cases.

“We don’t have the ability to call every person and say you are positive,” she says. “They will get a text directly from the lab saying you are positive, stay home, isolate. There will also be a questionnaire they can complete asking ‘are you double vaccinated, do you have any risk factors, have you been to a sensitive setting’.

“Areas where people are at risk will still be contact traced but in general, cases will be managed in the community and close contacts will be defined as their household. We are going to have to start letting the public take on responsibility for containing the virus.”

Now that Victoria, like NSW, has abandoned its goal of COVID zero, much of what we understood about contact tracing and case management is under review by Chief Health Officer Brett Sutton and his public health team.

The old practice of contact tracers starting with a case and working their way outwards through concentric circles of ever more distant contacts has been abandoned, with health officials recognising that overwhelmingly, the virus transmits at home.

Terms such as primary and secondary close contacts and exposure sites are becoming redundant, with Dr Romanes saying his team is adopting simpler language and a clearer public health message.

The origin of new cases – the stories behind the numbers, as Premier Daniel Andrews used to say – is less important than completing prompt risk assessments of whether a case is likely to end up in ICU or infect someone who will.

The rules governing our public health response – the requirement for all positive cases and people they come into contact with to isolate for 14 days – are being redrafted to reduce the amount of time people are forced to spend off work or out of school.

The new rules will consider different risks associated with people who are vaccinated and those who are not. “We are still working it through as a public health team but I’d like to think that in a few short weeks we will be communicating changes,” Ms Matson said.

Victorian Department of Health Deputy Secretary Kate Matson.Credit:Chris Hopkins

Some of these possible changes are being trialled in supermarkets, where vaccinated employees potentially exposed to an infected colleague no longer have to stay at home for two weeks. “Our response has to evolve with the community response,” Professor Stuart says.

The impact of vaccination is a key consideration for contract tracers, with compelling data emerging from the Victorian and NSW epidemics. Ms Matson said that in the past three months, only 7.4 per cent of Victoria’s COVID-19 cases were fully vaccinated. Dr Romanes said data from NSW suggested that for every four people in their 50s vaccinated against COVID-19, one fewer person winds up in hospital.

The flipside of this equation is clear. “Eventually, if you are not vaccinated, everyone is going to become infected with COVID in the coming months,” Dr Romanes says. “It is impossible to stop COVID. If you make a choice to get vaccinated, you can substantially reduce your risk of hospitalisation and death.”

There is an emerging treatment which offers a lifeline to people infected with COVID-19 who are most at risk from dying from the disease. The Monash Hospital in Clayton has started intravenous infusions of the newly approved drug Sotrovimab, a monoclonal antibody which significantly reduces the likelihood of severe disease. The treatment will also be offered by the Western Hospital in coming days.

Professor Stuart says that to be effective, Sotrovimab must be administered within five days of the onset of COVID-19 symptoms. This is another reason for contact tracers to focus on those who most need their help.

“By decreasing the calls to every single case when we know the majority are going to be fine isolating at home and focusing on only those at risk – those that need an infusion or are more likely to transmit to others – we free up to capacity to do other important things,” she says.

“We are not failing; we are shifting the focus so we can deal with this virus, in all its tricky ways, and concentrate on those most at risk.”

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