Tracing the close contacts of people who test positive for coronavirus disease is a delicate dance. Here’s why these health workers wait for the cover of darkness to take action.
The screens of 254 cell phones light up.
The WhatsApp message that pops up on devices lodged in the pockets, backpacks and handbags of journalists all around South Africa is exactly the same.
There’s a new notification from Lwazi Manzi.
Manzi, a medical doctor, is the spokesperson for the country’s Health Minister, Zweli Mkhize. She’s posted an update on a group created to get updates on the coronavirus pandemic to the media, fast.
It’s just before five on a Friday afternoon.
There’s no real weekend anymore, at least not since the first case of coronavirus disease, or COVID-19, was confirmed on home soil early in March.
The reporters act quickly. Some rush to pen news articles while others hastily make shareable graphics to tweet out with the latest number of infections recorded in the country.
Normally, Manzi’s documents include a list of positive cases broken down by province, age, sex, and whether they were infected at home or abroad.
But today there’s something new in the document.
The first local infection in a church has been recorded.
“A call has been made for all members of this church who were present at the conference to cooperate,” the release reads.
Five international religious leaders who attended an enormous church gathering in early March have tested positive for the virus.
They had travelled to South Africa from the United States, Israel and France.
Now, unknowingly, they may have put hundreds of others at risk.
The secret life of tracers
Hours before the health ministry released the latest figures to the public, a government nurse shoves a dog-eared pile of papers into Claudia Mangwepape’s hands.
Mangwepape heads up the Free State office for the South African Red Cross Society.
The humanitarian organisation has teamed up with the provincial health department to help fight the spread of the coronavirus in the country. In the drought-stricken Free State, this battle is crucial. Water is a critical resource in people’s arsenal against the virus, since washing your hands regularly is currently one of the only ways you can protect yourself from infection.
Back in Bloemfontein, the health department’s nurses had started extensive, nearly hour-long interviews with the five COVID-19 patients from the Free State while their test results were trickling into the data centre at the National Institute for Communicable Diseases (NICD) in Johannesburg more than 400 kilometres away.
The five faithful who tested positive were immediately quarantined in the guesthouses where they were staying during the two-day church event. Any staff that came into contact with them were quarantined in rooms there as well.
Why interview people when they’ve tested positive for the coronavirus?
The nurses need to find out who else the five were in contact with since they started feeling ill – that’s the list Mangwepape is holding in her hands.
The process is called contact tracing.
These patients had been especially social in the days before they fell ill. Many of the contacts were other congregants of the church.
“There were 1 032 names,” she says. She’s speaking on the phone from outside the Divine Restoration Ministry’s church in Bloemfontein where the Red Cross and the health department have set up shop.
She and a team of about 20 specially trained contact tracers are now tasked to find each person on the list, wherever they might be in the province.
The coronavirus contact tracers each received five days of intensive training from the Red Cross before they could be deployed.
The people on the list need to be screened for symptoms of the disease, tested if they meet the criteria, and told to isolate themselves for 14 days to avoid spreading the virus to others. This kind of contact tracing is crucial in stopping the spread of the virus to other people.
Watch: South Africa’s coronavirus outbreak — how it spreads and what to do about it
SARS-CoV-2, the virus that causes COVID-19, takes between three and 13 days to show symptoms in your body after you’ve been exposed, says Cheryl Cohen, head of the NICD’s Centre for Respiratory Diseases and Meningitis.
This process is known as the incubation period.
Cohen explains: “The virus can be very low levels in your body [in this period]. If you do a test [the amount of virus in your blood] might be at too low a level for the test to pick it up.”
If you test negative in this phase, Cohen says, you could still go on to develop the illness.
“That’s why we use this 14-day interval. If you’ve been [isolating] for 14 days and you are well then you can say the incubation period has passed, you don’t have the disease – only then can you mix with people.”
Symptoms of the coronavirus are a cough, a fever, or difficulty breathing, according to NICD guidelines. Tests are only recommended if you have these symptoms but have also been travelling, working in a healthcare facility, or have come into contact with somebody who has tested positive.
Contact tracing has played a crucial role in slowing down the spread of the virus — also known as flattening the curve — in Singapore and Hong Kong.
In Singapore, every patient who tests positive is treated as the starting point of a miniature forensic investigation.
The Singaporean government doesn’t just treat people who arrive at testing facilities. Instead, they identify networks of possible transmission.
“We want to stay one or two steps ahead of the virus,” Vernon Lee, the director of the communicable diseases division at Singapore’s Ministry of Health, told the New York Times in March. “If you chase the virus, you will always be behind the curve.”
In South Korea, mass testing drives have allowed officials to zoom in on coronavirus hotspots such as churches or offices, according to Ki Mo-ran, an epidemiologist advising the government’s coronavirus response, who was quoted in the New York Times.
SARS-CoV-2 is not the first virus South Africa has traced. The country’s tuberculosis and HIV patients are also traced to make sure they take their medication correctly and to inform them about how to minimise the risk to others.
Looking down at the list in her hands, Mangwepape asks: “When do all these people need to be traced?”
The answer comes quickly, and it’s short: Tonight.
Ground zero: From prayer to testing positive
It’s a well-oiled machine. A tent is already being set up outside the Divine Restoration Ministries’ church grounds in Bloemfontein. A combi covered in NICD branding, which doubles as a mobile laboratory, is parked just beyond the makeshift testing centre.
Half of Mangwepape’s team is calling people on the list, urging them to come back to the church grounds, where they had gathered together weeks earlier. The other half gets ready to head out into the communities, to do home visits for those who can’t come to the church.
For three days in a row, the faithful convened at the evangelical Christian church in Bloemfontein to pray together. Some may have huddled close together, holding hands as they offered devotions.
Now, a queue of anxious churchgoers queue in a winding line outside the screening tent, standing nearly two metres apart.
Mangwepape explains: “The Church has been identified as ground zero. Nobody goes inside.”
The people in the queue are studying the health department’s educational flyers, with information about how the virus spreads, how it feels when you’ve got it, and how to protect yourself and others in your community.
When they reach the front, they’re screened for any symptoms of infection by a team that includes a doctor, nurse and volunteers that could be community health workers or students from the University of the Free State’s environmental health course.
If the tell-tale signs of COVID-19 are there – a cough, a wheeze, or a fever – they’ll be sent into the mobile lab, where NICD technicians will take an uncomfortable throat swab for testing.
Then, they’ll be told to isolate themselves until they get the results.
By the end of the weekend, more people from the church will test positive.
Contact tracing: A delicate dance
Dusk descends over Bloemfontein, the City of Roses. It’s been five days since South Africa’s President Cyril Ramaphosa announced a state of disaster, urging citizens to avoid unnecessary contact with other people, and to work from home if possible.
As night falls, families around the city settle in for the night, but Mangwepape and her team of contact tracers jump into action.
Tracing the close contacts of coronavirus disease is a delicate dance.
Mangwepape explains: “Not only must the tracers make sure they protect themselves from infection. They also need to make sure they don’t scare the people they come into contact with.”
In the outreach vehicle, the tracers begin to pull on the protective gear like special respirator masks that prevent them from inhaling the droplets that contain the virus, and surgical gloves.
She says: “We always call the people we’re going to on the way to explain to them that we’ll be wearing all this protective stuff. We’ll explain that you shouldn’t be afraid, and it doesn’t mean they are necessarily sick. It’s just a precaution.”
When the team stops outside the first house, they don’t just jump out and storm the household where they’ll screen people once they’re inside. They wait to see that there aren’t too many people around.
The team has to draw as little attention to themselves as possible, to avoid stigmatising the people they’re screening.
“You can imagine if your neighbours see all these people at your house, they might think you have this disease that they don’t want,” Mangwepape explains.
That’s why they’ve waited for the cover of darkness.
“The evening gives us a bit of privacy.”
The team gets back into the vehicle, armed with notebooks full of the detailed accounts of this household’s daily lives. Then, they move on to the next house.
It’s 02:00 when they tick off the last of the 1 032 names on the list they received nearly 12 hours ago. Each and every person has been contacted, and has either already been screened, or will be at the church for screening in the morning.
That means they’ve been asked about their travel history, and a doctor or nurse checked for any symptoms.
During the 20-minute car ride back to her house, Mangwepape calls up her cousin, who is looking after her two daughters, Thebang, 18, and Bokang, 10, for the time being.
“I’m on my way home,” she says. Mangwepape’s cousin knows what to do next.
Mangwepape has been working in disaster management with the Red Cross for nearly two decades so the girls know the drill by now. They won’t see their mother much in the coming weeks.
By the time she stops in her driveway, her cousin has left a black plastic bag outside the front door. She strips down, and puts the clothes on the plastic to be bundled into the washing machine later.
She explains: “I have to protect my children as much as possible. Everything has to be clean before I come into contact with them.”
Then, Mangwepape gets into the steaming bath her cousin has drawn, and scrubs herself clean.
When she finally flops into her bed, she’s exhausted.
Before she flips the switch on her bedside lamp, she sets an alarm. Her team will be stationed at the church all weekend, or as long as it takes to screen every single person who attended the church gathering.
The message on the app reads: “Alarm set for 3 hours and 40 minutes from now.”