Introduction

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has caused significant disruptions to people’s lives across the globe. The number of cases and fatalities has reached unprecedented levels [1]. This highly contagious virus has led to a surge in infections, causing healthcare systems to become overwhelmed and forcing many countries to implement lockdown measures [2,3]. It was a global challenge, with economic, healthcare, social issues, and administration.

Qatar is one of the six countries that form the Gulf Cooperation Council (GCC), with Saudi Arabia, Kuwait, Oman, Bahrain, and the United Arab Emirates. The first case of COVID-19 in Qatar was confirmed on 28 February 2020 among travelers who had returned to the homeland, almost nine weeks after the first cluster was identified in Wuhan, China [4,5]. The fatality rate of COVID-19 varies significantly across different countries. For instance, during the initial pandemic stage, Qatar had the lowest fatality rate at 0.16%, while Kuwait had a rate of 0.67%. However, developed countries such as the USA, Canada, and the UK reported much higher fatality rates of 3.2%, 7.5%, and 15%, respectively (as of 10 August 2020) [4,6]. Countries like France and Belgium have a fatality rate of over 16%. Qatar and Singapore are the only countries with a mortality rate less than 0.1% [7]. This wide variation and low fatality rate are due to prompt government response and patient demographics during a pandemic.

In recent years, Qatar has experienced rapid economic growth and globalization, resulting in a large influx of foreign expatriates from Western, other Middle Eastern, African, and Asian countries. The economic and demographic transition and the resulting dynamic socio-economic and socio-cultural environment may affect the social behaviors in the country; however, how these changes affected the behavioral risk factors and impacts the character of population in the country. Qatar has a dynamic population of approximately 2.8 million residents and citizens, with 88% being expatriate workforce from various nationalities. As a result of the expatriate workforce, 75% of the population is male [8]. According to the evidence, COVID-19 affects males more than females, and the elderly age group is more vulnerable to its adverse effects [9-11]. The pandemic situation is influenced by globalization and ease of travel to and from the country. This type of demographic shift is typical in regions with a large percentage of non-citizen or non-native populations, such as the countries of the Gulf Cooperation Council (GCC). There were no restrictions on travel during the initial period until 30th March 2020. However, on 31st March, all incoming flights to Qatar were suspended, which resulted in almost no visitors or residents coming in. Outbound travel was generally allowed. Still, it decreased significantly due to two factors: 1) global travel restrictions resulting in a sharp reduction in flights, and 2) essential workers, like healthcare professionals, being restricted from taking leave and traveling unless it was urgent or an emergency [4].

An Overview of the First COVID-19 Case from Wuhan, China to Qatar and Rapid Changes during the Pandemic

COVID-19 is mainly transmitted through respiratory droplets and airborne particles, so it is crucial to break the chain of human-to-human transmission to control its spread [12]. To control the spread of the virus, it is essential to promptly detect cases, isolate and test them, provide care, and do contact tracing and quarantine if necessary [13]. Qatar had already implemented comprehensive plans to identify and manage COVID-19-infected individuals before the first case was reported. The Ministry of Public Health’s existing identification and track n trace mechanism, which had previously proven effective during the Middle East respiratory syndrome coronavirus outbreak, was expanded and put on high alert [4,14,15]. In a previous successful experience, the Supreme Committee for Crisis Management (SCCM) and the Ministry of Public Health in Qatar effectively executed and implemented a contact tracing system to promptly identify and report cases of COVID-19. The committee recognizes Contact Tracing as an essential public health measure to fight COVID-19 and has implemented it alongside other measures. The effective application of Contact Tracing measures can reduce transmission and significantly impact the outbreak’s spread. Qatar’s contact tracing involves identifying people who have been in contact with confirmed cases. The goal is to identify positive cases as early as possible, including those who do not show symptoms, to break the chains of transmission and prevent further spread of the infection in the community. Early detection of positive cases plays a crucial role in slowing down the spread of the virus. It also allows for timely treatment, which can help prevent potential complications that may arise in patients suffering from existing medical conditions. Qatar has successfully maintained one of the world’s lowest COVID-19 mortality rates. “It is of utmost importance that the public cooperate with us. Providing accurate information when contacted and agreeing to get tested as soon as possible minimizes the risk on both the contact themselves and their families and colleagues,” statement of the Head of Vaccination at MOPH and COVID-19 Contact Track and Trace Lead Dr Soha Shawqi Albayat [16].

Qatar possesses a resilient healthcare infrastructure that is well-equipped to tackle any obstacles. With the help of a robust health system, effective measures, cooperation from citizens and residents, and their commitment to follow preventive measures, the State of Qatar has been able to move past the peak of the Coronavirus and flatten the curve. Although the transmission of the infection is under control, there are still some reported cases. The pandemic has overwhelmed and disrupted the healthcare system, exposing inefficiencies in the workflow and hidden weaknesses. This Supreme Committee for Crisis Management has been regularly monitoring and reviewing indicators. A threephase plan is in place to re-impose restrictions if needed. People’s commitment to preventive measures is crucial in limiting the virus’s spread. Socializing without proper caution has been identified as the country’s primary source of spreading COVID-19. As the pandemic spreads rapidly worldwide, it has become necessary to enforce mandatory quarantine for all travelers returning to the State of Qatar until further notice. The Supreme Committee for Crisis Management urges all citizens and residents to follow preventive measures such as wearing masks, maintaining a safe distance, and washing hands [17].

During the pandemic period, MOPH established a digital contact tracing team to interview the patients over the phone and identify the close contacts. The main objective of this process is to identify people who have come into contact with the infected individual, also known as the “Index case,” and interrupt the spread of the causative agent to vulnerable individuals who are not immune. Contact tracing is a well-established public health intervention strategy and has successfully in reduced mortality rate compared to global data [18], the spread of various infectious diseases [19].

Contact tracing is a process that includes several steps: It is the process of identifying, assessing, and managing people who have been exposed to a disease to prevent onward transmission.

Definition: A contact is defined as anyone with the following exposures to a COVID-19 confirmed case from 2 days before to 14 days after the case’s onset of illness/day of testing [12,13]:

• Being within one meter of a COVID-19 case for >15 minutes without any personal protective equipment (PPEs).
• Direct physical contact with a confirmed Covid-19 case.
• Providing direct care for patients with Covid-19 infection without using proper personal protective equipment (PPE).

Identifying contacts: this is done through a telephonic interview with the index patient to find out who they have been in contact with; all the interviews have been conducted virtually over the phone, and the reports collected has been recorded digitally in the health information systems record. For in-person interviews, contact tracers must maintain a safe distance (>1 meter), conduct interviews in well-ventilated areas or outdoors, and wear a medical mask according to standard and preventive measures. The contact tracing team should interview all contacts, request them to self-isolate, and provide support during quarantine for testing if required [12]. In some situations, identifying, monitoring, and quarantining all contacts may not be feasible. In general, duration and location of exposure determine the risk of transmission, although all contacts who meet the definitions above are at risk of infection [20]. WHO recommends a 14-day supported quarantine after contact with a confirmed case to reduce transmission risk [21]. Most cases develop symptoms within 14 days of exposure, with a median incubation period of 5-6 days [22]. It is essential to prioritize the follow-up actions:

1. Contacts at a higher risk of SARS-CoV-2 infection based on their degree of exposure to break chains transmission; and
2. Contacts at a higher risk of developing severe COVID-19 disease to ensure early referral to healthcare.

The primary objective of this study was to evaluate the performance of the Ministry of Public Health’s contact tracing team in containing COVID-19 transmission countrywide at both institutional and field levels.

Methods

A SWOT analysis (Strengths, Weaknesses, Opportunities, and Threats) was done to evaluate the performance of contact tracing data collected at the organizational and field levels in the Ministry of Public Health from April 2020 to June 2021. The study involved individuals who actively participated in the Contact Tracing Team of the Ministry of Public Health and the swab collection field team during the study period. We evaluated the ‘strengths,’ ‘weaknesses,’ ‘opportunities,’ and ‘threats’ involved at an organization and field level. This qualitative and descriptive study utilized the following four components to contain the spread of COVID-19 nationwide to do a SWOT analysis.

Contact tracing is a complex process that includes several steps:

Master List Team: The team obtains the list of all laboratories confirmed cases from the HMC virology lab. They check these records for any duplication or missing information. If any missing information needs to be corrected, they notify the concerned authorities, such as Ministry of Interior (MOI). The list is then divided into two categories based on the index case’s nationalities and spoken language preferences: Arab and non-Arab.

Operational Group: Each possible contact should be reached by phone or in-person to confirm if they meet the definition of a Contact. If they do, they should be advised on what action to take, including quarantine.

The team is made up of medical professionals with diverse backgrounds who are trained to conduct digital contact tracing interviews. To avoid language barriers, team members are of different nationalities. The Arab and Non-Arab teams have male and female members who work in shifts and are supervised by a team leader. The shift team supervisor for contact tracing then distributes the list among the team members. The contact tracing team interviews and calls the focal person and their close contacts. The team collects demographic information and records it for the Master List Team. They verify and examine the records for any missing data essential for contact tracing. The master list is shared daily with the team supervisor using a Microsoft Excel workbook.

After compiling a list, they sent it to the swabbing team in the field for further action.

Preparation for Contact visit: The Operational and Swabbing Teams worked together to arrange COVID-19 testing for all the suspected cases of COVID-19 or close contact.

Dispatch list: At the end of each shift, the Operational Team creates a list per zone number and geographic location and sends it to the swab team in the field twice daily. The relevant field teams arrange the tasks by zone numbers and priority.

Contact Management/ Mobile Swabbing Team: It comprised doctors, nurses, and paramedical staff and was temporarily located in each zone to help implement infection control measures. The swabbing stations are open for two shifts every day throughout the week.

After sending the dispatch list to the swabbing team, all identified contacts are to be swabbed within 48 hours. Contacts must sign an undertaking form with legal implications and quarantine at home after being swabbed.

Home visit and swabbing: The swabbing team collects nasopharyngeal and oropharyngeal swabs from contacts through home visits. These swabs are sent to the Virology Department of Hamad Medical Cooperation (HMC) National Reference Lab for laboratory confirmation tests.

Teams were dispatched to visit identified contacts and conduct assessments to determine if their home was appropriate for quarantine. During these visits, the team members were required to wear complete personal protective equipment (PPE) and swab the identified contacts. If the home was deemed unsuitable for quarantine, the team reported to the operational team for referral of the close contact to a designated facility. Team members were also required to collect consent signatures and submit the undertaking documentation to the Ministry of Interior (MOI) and the Ministry of Public Health (MOPH). Anyone with COVID-19 symptoms was referred to the Primary Health Care Corporation (PHCC) if required.

Before returning, the team reviewed all information, forms, and samples collected during the visits. The samples were promptly labeled and delivered to the Hamad Medical Corporation (HMC) lab.

Specimens’ collection

• Collect both Nasopharyngeal and Oropharyngeal swabs in the same vial with transport medium.
• Label the specimen with the appropriate code, store it in an ice box with frozen cold packs, and maintain the chain of custody until it is delivered to the virology lab.
• Discard Personal Protective Equipment (PPE), report to the Ministry of Public Health, and send confirmation of the tasks completed.

Screening of the Swabbing Team

The members of the swabbing team underwent weekly COVID-19 screenings through PCR tests.

Data Management

The Data Management team was responsible for compiling and analyzing the Contact Tracing team data. They prepared daily and weekly reports to monitor the progress and fluctuations in the number of cases during this period. The information for each contact was collected and added to a database that was updated daily for future reference and analysis.

The data team performed the following tasks:

• Developed a data entry sheet and entered the data from the swabbing teams.
• Compiled all the entered data into one master sheet.
• Analyzed the data and produced reports to help the higher authority develop or adjust the control intervention for the pandemic based on the result.
• Prepared weekly and quarterly reports.
• Made a comprehensive report to describe the activities and actions needed.
• If a contact was found to be a case, the change in status was linked to a case database (line list) through a common identifier.

Data Analysis

Primary data was collected from active members of the Contact Tracing Team and the swab collection field using convenient sampling methods. The primary data was analyzed using frequency and percentage. For qualitative data, interviews were conducted with the members of the contact tracing team and ensured that all relevant details were captured to achieve the objectives. Secondary data refers to all the records used by the Ministry of Public Health (MOPH) during the pandemic.

The SWOT analysis technique was used to identify strengths, weaknesses, opportunities, and threats to evaluate the performance of the contact tracing team at different levels. This technique analyzed internal factors, such as the program’s strengths and weaknesses, and external factors, like opportunities and threats related to the project [23]. It was divided into MOPH level (leaders, operational team, and data team) and Field level (swabbing team).

Understanding the performance of contact tracing for COVID-19 was crucial, which is why having key performance indicators (KPIs) is essential. These KPIs were measured at different stages of the contact tracing pathway and used to assess how well a system was performing. By tracking KPIs over time, we could make informed policy decisions, improve the quality of contact tracing programs, and manage resource needs. Global consultation with key partners was underway to develop detailed KPIs with initial benchmarks, updated regularly as new evidence was compiled. Each indicator’s threshold depended on the local transmission scenario and the timeliness and completeness of contact tracing and quarantine. Contact tracing could effectively reduce the reproductive number below one, provided the time between a case’s symptom onset and quarantine of at least 80% of their contacts does not exceed three days [24,25].

Results

In the early stages of the pandemic, Qatar’s contact tracing team encountered numerous difficulties in controlling the spread of COVID-19. However, a few weeks after the first confirmed case was reported in the country, Qatar successfully overcame all these challenges with a systematic approach implemented by the Supreme Committee for Crisis Management (SCCM) and the Ministry of Public Health (MOPH). The challenges are as follows:

• Lack of sufficient trained staff and logistical support (transportation, phones, computers).
• Initially, there were only 15-20 MOPH staff conducting case investigations, arranging for contact tracing, answering hotlines, conducting airport testing, and managing quarantine facilities.
• Staff worked 16-18 hours/day, 7 days a week, to manage the first wave of community cases leading to fatigue and exhaustion.
• Maintaining an adequate stock of high-quality PPE was an additional challenge due to the global shortage.
• Stress and concern amongst contact tracing staff when going to test contacts of positive cases.
• Lack of a proper case definition at the onset and formally documented guidelines for track and trace.
• Changing advice about who should be tested, the duration of quarantine and isolation required
• Slow/insufficient intersectoral coordination.
• Lack of adequate quarantine facilities and delays in transferring patients.
• Repeated COVID-19 tests remained positive for long periods in some patients.
• Fear and stigma regarding COVID-19 in the community.
• Refusal of family members to be separated from each other.
• Rumors regarding testing, treatment, and quarantine facilities.
• Many close contacts and symptomatic patients were afraid to be tested or moved to quarantine facilities.
• Poor compliance with home isolation and quarantine/Refusals to sign an undertaking.

Figure 1 illustrates that 707,934 individuals were tested by the national track n trace team. Of these, 388,815 (54.9%) were tested as part of contact tracing, while the rest, 319,119 (45.1%), were tested as part of survey.

Figure 1: Reasons for swabbing in Qatar from April 2021 to June 2021

Table 1 shows that a total of 309 individuals participated in contact tracing activities. Among them, 210 (68.0%) were male, out of which 17 (5.5%) were from MOPH institutions and 193 (62.5%) were working at the field level. Only 99 (32.0%) were females, with 15 (4.9%) working in MOPH institutions and 84 (32.0%) working at the field level. A significant proportion of the individuals were 277 (94.5%) involved in survey activities.

Table 1: Workforce distribution of contact tracing team by Institution and Field by Gender during the COVID-19 pandemic from April 2020 to June 2021 (N= 309).

Figure 2 illustrates the trend of data collection for swabbing by the contact tracing team. The number of swabs collected daily ranges from 1500 to 4000. During the third week of April 2020 and the first week of February 2021, the team collected over 3,000 swab samples daily.

Figure 2: Swabbing data collected by contact tracing teams from April 2020 to June 2023.

Figure 3 shows the high positivity rate among the middle age group. A positivity rate of 14.7% was reported among 30-34 years old, 12.9% among 35-39 years old, and 5% among those above 55 years old.

Figure 3: The COVID-19 positivity rate by age group from April 2020 to June 2021.

Figure 4 shows that there are eight municipalities in Qatar. Al Dawha had the highest COVID-19 positivity rate (41.1%), followed by Al Rayyan (32.1%), while Al Shamal had the lowest (0.4%) indicated in Figure 4.

Figure 4: Positivity rate by Municipalities in Qatar during the COVID-19 pandemic from April 2020 to June 2021.

Contact Tracing Indicators: There are three primary leading indicators to consider when measuring the activities:

First indicator: Timeliness

Based on analysis, it is found that 62.4% of the contacts were traced and tested within 48 hours and were considered on time. Another 30.8% of the contacts were identified late, taking 72 hours or more. Only 6.8% of the total contacts were identified very late, taking more than four days. Although the Timeliness indicator requires a percentage greater than 80%, achieving 60% is still an excellent accomplishment considering all the challenges.

Second indicator: Positivity among contacts

During contact tracing, 15% of swabbed contacts tested positive for COVID-19. This indicates the quality of contact identification.

Third indicator: The percent of positive COVID-19 cases identified through contact tracing was 91.6%. This information reveals the system’s ability to identify the chain of transmission and its efficacy in identifying cases in the community. It further proves that contact tracing plays a crucial role in combating the spread of the virus in the community.

At the Ministry of Public Health (MOPH) and field levels, strength, weakness, opportunities, and threats analysis (SWOT) was conducted by adapting Fred David’s strategic management matrix, which illustrates the four major elements of the analysis [23].