Challenges of contact tracing in Pacific communities

-OPINION-

Dr Collin Tukuitonga
Associate Member, Koi Tū: The Centre for Informed Futures

Introduction

The socio-economic circumstances of, and cultural practices among, Pacific communities in Aotearoa/NZ makes some of the measures required to contain or eliminate COVID-19, including contact tracing, challenging.  The effectiveness of the entire contact tracing regime in Aotearoa/NZ is dependent on all parts of the system working well.  Contact tracing in Pacific communities will require additional measures to ensure success, including staff who are of those communities and able to speak a Pacific language, and who have an understanding of the cultural and practical dynamics of these communities.

Background

Until an effective, affordable and safe vaccine is available, the world will continue to rely on traditional public health measures to contain the spread of COVID-19.  These measures are designed to limit the movement of people between and within nations.  They are effective if there is a high level of social cohesion and adherence to the interventions.

New Zealand’s geographical position played a large part in determining our response to COVID-19 and the consequent early success. Rapid case identification and isolation, prompt contact tracing and effective quarantine are among the measures that have been used to limit the spread of infectious diseases over the years, including in the current campaign to deal with COVID-19.  Additional measures such as social distancing, hand washing and coughing/sneezing etiquette have been effective in those  countries that have adopted these measures.  These measures, on top of our geographical isolation, proved effective in successfully contained the spread of COVID-19 in Aotearoa/New Zealand, which is  among a handful of developed nations globally that have been successful in containing the spread of COVID-19.

The current Level 2 status in Aotearoa/NZ, and talk of further loosening of restrictions toward Level 1,  implies that the risk of spread of COVID-19 has reduced considerably in our nation, and that the pandemic is under control.  We have been fortunate that most/all of the cases of COVID-19 have been reported in overseas travellers and/or clusters identified as being directly connected to these cases.  The number of active cases continues to decline, and new cases are now rare.

Nevertheless, there are concerns about the occurrence of a ‘second or third wave’ of COVID-19, similar to the spike in cases that have been observed in Singapore, China and South Korea.  There is much to learn about the natural history of COVID-19 and the future evolution of the disease.  It would be prudent to continue to prepare for a second wave of COVID-19 in Aotearoa/NZ. Once borders are loosened the risk will rise significantly.

It is possible that New Zealand will experience a protracted period where clusters of COVID-19 cases will occur from time-to-time.  Depending on the effectiveness of the interventions that will be deployed, it is highly likely that these clusters will be contained and an epidemic is unlikely, especially if there is early identification and isolation of cases, prompt contact tracing and effective quarantining .  The future progress of the pandemic depends on the effectiveness of measures used  and the willingness of the majority of the population in New Zealand to continue to adhere to the guidelines.

The practice of quarantining began in the 14th century in an effort to protect coastal cities from the spread of plague epidemics. Ships arriving in Venice, Italy from infected ports were required to sit at anchor for 40 days before landing.  The term quarantine was derived from the Italian words quarantara giorni, which means 40 days.

Aotearoa/New Zealand has a long history of quarantine practice designed to prevent the introduction of multiple diseases, including smallpox, leprosy, typhoid and others.  Several quarantine stations were established around the country, notably Matiu/Somes Island in Wellington Harbour, Otamahua/Quail island Leper Colony near the Canterbury port of Lyttelton, and Motuihe, Hauraki Gulf Island in Auckland Harbour and Quarantine Island/Kamau Taurua in Otago.

Contact Tracing in Aotearoa/New Zealand

Contact tracing is a fundamental public health intervention that includes working with a person (symptomatic and asymptomatic) who has been diagnosed with an infectious disease to identify and provide support to people (contacts) who may have been infected through exposure to the patient.  This process prevents further transmission of the disease by separating people who have (or may have) an infectious disease from people who do not. It is a core disease control measure that has been employed by public health agencies for decades. Contact tracing tracing is difficult even with optimum resource and staffing levels.  It is most effective when part of a multi-faceted response to an outbreak.

Prompt contact tracing and rapid case detection, combined with other basic public health measures, is highly effective at reducing the spread of COVID-19 through populations.  A recent audit of contact tracing for COVID-19 in Aotearoa/New Zealand by Dr Ayesha Verrall showed several weaknesses in the national capability.[1]  Inadequate capacity within New Zealand’s 12 Public Health Units (PHUs) was the primary factor limiting the ability to scale up the case management and contact tracing response to COVID-19. In March 2020, the workload of PHUs exceeded their capacity to conduct rapid contact tracing on occasion, even though case numbers were less than 100 per day.  Dr Verrall recommended that Aotearoa/New Zealand needed to scale up its contact tracing capability by a factor of 3-4 times in order to respond effectively to a COVID-19 outbreak in the country.

Increasing the capacity needs to be matched by a good understanding of the various communities that make up Aotearoa/New Zealand.  Pacific people are widely regarded as a high risk group due to a combination of socio-economic and cultural characteristics.

A digital COVID-19 app, which is effectively a location diary, was recently introduced in Aotearoa/New Zealand to assist the overall contact tracing strategy in New Zealand.  Experience with the use of (quite different) contact tracing app in other countries suggests modest benefits.   However, it is worth noting that approximately only two thirds of Pacific households have access to the internet and the benefit of the app in these communities will be low.

Pacific Communities Highly Vulnerable to COVID-19

The 2018 New Zealand Census showed that there were 381,642 Pacific people living in Aotearoa/New Zealand.  The Pacific population consists of more than seven distinct language groups, of which Samoans make up about half of the total population.  Census information and other studies confirm that Pacific people are over-represented in the lower socio-economic groups with lower incomes and high health needs.  Approximately 40% of Pacific people live in crowded/overcrowded housing and 33% live in cold and damp houses.  Overcrowded and sub-standard housing is a major contributor to poor health among Pacific families.  Pacific communities consist of large extended families practicing high levels of social interaction and group activities.  Their cultures reinforce the importance of family events and church gatherings which usually include large numbers of people.  These socio-cultural characteristics elevates their risk and the possibility of a rapid spread of infectious diseases, including COVID-19.  Furthermore, Pacific peoples regularly report severe problems accessing health care, despite their high health needs.

The total number of Pacific people with confirmed COVID-19 was 81 (5.4%) of a total of 1,504  (24 May 2020).  This is lower than the share of the total New Zealand population, reflecting the fact most of the COVID-19 cases in Aotearoa/New Zealand were reported in overseas travellers or clusters linked to these travellers.  The apparent lack of community transmission is an additional benefit.  If community transmission had taken place in Aotearoa/New Zealand, Pacific peoples would have been severely and adversely affected.  These predictions are based on the high prevalence of co-morbidities such as diabetes, heart disease and respiratory conditions and difficulties accessing health care when needed.

Dawn Raids Revisited

It is believed that Pacific peoples constitute approximately half of the estimated 10,000 ‘overstayers’ in New Zealand. Unlike previous immigration policies, the current policy does not support the active identification of overstayers.  The current government has issued a policy of including overstayers in the current COVID-19 pandemic prevention activities.  It is unclear how overstayers will react to this policy.

The response by Pacific communities to official government policies is influenced by their experiences of the ‘dawn raids’ of the 1970s.  Pacific people had been welcomed into Aotearoa/New Zealand in the 1960s to meet the workforce needs of a growing economy.  In the economic downturn of the 1970s, the Kirk Labour Government introduced the policy of deporting overstayers.  All Pacific peoples  were targeted by the ‘dawn raids’ of their homes in Auckland, which included arrests of Māori and citizens of realm countries such as the  Cook Islands, Tokelau  and Niue. Dawn raids have had a lasting impact on Pacific families and fuelled a distrust of official government policies and officials.

It is likely that these experiences will influence the responses by the Pacific communities to contact tracing activities for COVID-19.

Our Weakest Link

The socio-economic conditions of many Pacific families, their cultures and history in Aotearoa/New Zealand suggests that contact tracing in these communities requires careful thought and preparation.  In addition to the measures already adopted by the Ministry of Health to strengthen the contact tracing regime, it is worth considering further measures for, and with, Pacific communities.  Engaging trained contact tracing staff who are able to speak Pacific languages would be helpful.  It is also important to ensure that links with the Pacific health care organisations and professional associations such as the Pasifika Medical Association and various Pacific Nursing organisations are strengthened.  Young Pacific people have high levels of participation with social media. Such contacts could be used as the link with their families and communities. These measures will be critical to control the spread of COVID-19 should new cases begin to appear and spread through communities.


[1] Verrall, A. (2020) Rapid Audit of Contact Tracing for COVID-19 in New Zealand. https://www.health.govt.nz/publication/rapid-audit-contact-tracing-covid-19-new-zealand

Dr Tukuitonga recently took up the post of inaugural Associate Dean Pacific at the University of Auckland’s Health and Medical Sciences faculty, and is an Associate Member of Koi Tū: The Centre for Informed Futures.  Dr Tukuitonga, who is Niuean, was the Director-General of the Pacific Community (SPC) from 2014 to 2019. He has also headed New Zealand’s Ministry of Pacific Islands Affairs and has worked with the WHO.