As Covid arrives in the regions, local contact-tracing efforts are being stepped up with whiteboards and Post-It notes.

Stuff reporter Scott Yeoman spent an afternoon in the Tauranga command centre.

Dr Phil Shoemack is fast asleep in bed when his phone starts to ring.

It's after 11pm, unusually late for the lab to be calling.

Shoemack is the on-call medical officer of health at Toi Te Ora, the public health unit covering Bay of Plenty and Lakes district health boards – a large area encompassing Tauranga, Rotorua, Whakatāne, and Taupō, from Waihī Beach to Whangaparāoa on the east coast, and as far inland as Tūrangi.

Toi Te Ora serves a population of more than 375,000 people.

The unexpected late night call on Tuesday was to tell Shoemack one of those people had tested positive for Covid-19.

The case was in Waimana, a small rural community south of Whakatāne, on the edge of Te Urewera. That's why it was urgent.

'That's our first case of confirmed Covid-19 in the Eastern Bay of Plenty since April last year,” Shoemack later explained.

'So obviously there's a fair level of anxiety, not surprisingly, particularly in the small community that the individual's from.”

Not to mention the vaccination rate there: the latest data from the Ministry of Health showed less than 70 per cent of the eligible population in the Waingarara-Waimana area had received at least one dose of the Covid-19 vaccine, and just 55 per cent were fully vaccinated.

Shoemack got out of bed on Tuesday night, took his computer to the kitchen table, and started working on a response.

He called Whakatāne Hospital, where the Waimana case had presented earlier in the day and was tested.

He spoke with a senior doctor, passed on the news of the positive test result, and got as much information about the case as he could. He then put together an email alerting Bay of Plenty DHB leadership.

'With a note saying, ‘can one of you please let the mayor know in Whakatāne'.”

By about 6.30am the next morning, Shoemack had left home and was cycling to work when his phone started ringing again.

It was the lab, with more positive test results to report.

No going back

New Zealand's Delta outbreak began in Auckland in August and there has been no going back.

Like many parts of the country, Bay of Plenty and the Lakes managed to stay Delta-free for almost three months – despite some close calls and false alarms – but the good run ended late on November 12, a Friday, when a positive Covid case was confirmed in Taupō.

Cases in Rotorua soon followed, and before long the virus was also in the community in Tauranga.

By Wednesday afternoon, November 24, when Stuff arrived at the Toi Te Ora office in central Tauranga, there were more than 50 positive cases across Bay of Plenty and the Lakes.

That has since climbed to 70, with cases popping up in several schools.

After showing our vaccine passes at the locked front door – and with masks on – we were given behind-the-scenes, real-time access to the local public health response to this Covid-19 pandemic.

We watched on as Toi Te Ora staff traced new Covid infections in the community and worked quickly to try and prevent further spread of the virus.

We sat in on meetings as local health leaders and regional heads of government departments discussed the biggest challenges facing them in the weeks and months ahead.

Stuff organised the visit to Toi Te Ora late last week but by Wednesday the local outbreak had escalated further, and Shoemack warned on arrival 'things are pretty hectic”.

Some staff at Toi Te Ora are focused on identifying exposure events and talking with businesses, workplaces or schools to set out the public health guidance they need to follow.

Each morning at 8.30am, Toi Te Ora tallies up the number of new cases confirmed in its patch over the past 24 hours.

At that cut-off point on Wednesday morning, there were 11 new cases – all of them in Bay of Plenty, including the one in Waimana.

By lunchtime, more cases had trickled in and would continue to throughout the afternoon.

Shoemack said almost all of Toi Te Ora's capacity is dedicated to Covid-19 right now – somewhere between 30 and 40 staff members on any given day.

'There's very little non-Covid work we're doing at the moment,” he said.

'For a few months, we've been handling some cases on behalf of Auckland, but somehow it feels a bit different when you know the person lives just down the road.”

Covid by the numbers

Most New Zealanders think of this Delta outbreak in terms of numbers because, more often than not, that's all we have to go by.

How many new confirmed cases were reported today? Is that a new daily record? What does that take our total to? How many of those cases are linked? How many close contacts are there?

When the numbers are growing by 10, 20, or 100 a day it's easy to forget that behind each new batch of cases is a group of individuals, each one of them needing to be contacted.

At Toi Te Ora, we were led downstairs to an area of the office some staff call 'the basement” or, as one of them said with a laugh, 'dungeon is another word that gets thrown around”.

It is the engine room of this local contact-tracing effort, and it was humming when we arrived.

A steady chorus of keyboards tapping as emails were hurriedly typed up. Small groups huddled together, their voices muffled behind masks. Others on the phone, with snatches of conversation briefly audible as you walked past desks – '... go home and isolate”.

At the end of the room were two large whiteboards covered with brightly-coloured Post-It notes, each of them a confirmed case. Between some notes, a dotted line had been drawn – signifying a potential link. Others were connected by a solid line – the link already confirmed.

The Bay of Plenty and Lakes Delta outbreak was recorded on two whiteboards, mapped out by hand, case by case.

Almost all the cases, at that stage, were grouped under four main clusters – Pāpāmoa, Tauranga, Taupō, and Rotorua – with a few outliers so-far unlinked.

'We've got more whiteboards coming,” Shoemack said.

'We've talked about getting IT solutions, and collectively decided that this is so much more flexible.

'Give us another five years, and it could be different.”

How the process works

Every Covid-19 swab in Bay of Plenty and the Lakes is sent to a Pathlab facility in Tauranga to be tested.

Each time a positive result is returned, the lab's first call is to the on-call medical officer of health at Toi Te Ora, to notify them. Increasingly, there are a few new cases to report at a time.

An email with further details is then sent by the lab to Toi Te Ora, where each new confirmed case is allocated to a contact-tracer, before being entered into a national database.

The first call or contact is key, and needs to be done as soon as possible if not too late at night.

Shoemack said contact-tracing obviously relies on people answering their phones, or being at home.

'Sometimes people will be unresponsive for 24 hours, which is always a concern.”

He said there is usually a good reason for it – dead battery, bad cellphone coverage – and none of the confirmed cases have disappeared completely, but some have been uncontactable for a few days.

In that first call, which can sometimes take up to an hour, the contact-tracer will inform the person they have tested positive for Covid-19 and tell them they have to stay at home and isolate.

They will ask what they can do to help the person stay at home – do they need groceries, for example.

'Our goal is to do what we can to prevent further spread, and one crucial part to that is to keep that person where they are, so they don't keep mixing in the community,” Shoemack said.

The contact-tracer will then start to get into detail with an extensive set of questions about where the person has been, who they have been in contact with, and how many members of their household there are.

This is to try and identify how the person became infected in the first place, how long they may have been infectious for, and who they might have passed the virus on to.

Each case and situation is different, some of them are complex. Sometimes that first phone call is actually two calls, or three. People might suddenly remember a location two days later.

Overall, Shoemack said most people are 'incredibly thankful” and appreciative when Toi Te Ora contact them.

'It's encouraging how helpful people are. There's always a few instances where someone gets angry, I mean, you know, you're giving them bad news, and sometimes people react in interesting ways to bad news.”

Toi Te Ora is working to open contact-tracing offices in Whakatāne and Rotorua, to utilise local knowledge and provide back-up options in case a Tauranga staff member is infected.

Shoemack said one of the biggest challenges is having enough staff for the increasing workload, and they are constantly recruiting.

‘It's about the people'

The team working away in 'the basement” in Tauranga is made up of people from all different backgrounds – some young doctors, nurses, and health staff have stepped out of their normal roles at the district health boards to help out.

Hannah Kelly, 34, usually works in health promotion, supporting businesses to implement health and wellbeing programmes.

Now she is in the team working to identify Covid-19 exposure events, assessing infection risk at each location, whether there are likely to be close or casual contacts, and talking with businesses, workplaces or schools to set out the next steps they need to follow.

'It's definitely upped the ante as far as pace goes,” she said.

Hannah Kelly is part of the 'exposure events” team, which has her working at a much different pace to her normal health promotion role.

It was Tessa Dodson's first day at Toi Te Ora on Wednesday.

The 18-year-old is a health sciences student at the University of Otago.

'I just wanted to help out, and I saw an opportunity to. And it's interesting ... I'm excited to work,” she said.

It was Tessa Dodson's first day at Toi Te ora, and she was excited to get going.

It was also the first day for Jeannie Bruning, who is in her 60s.

She worked as a nurse for more than 40 years and in September left her senior nursing role at Tauranga Hospital to have a break and consider her next step.

When she got a call asking if she would be interested in joining the Covid-19 response effort, her mind was suddenly made up.

'If there's any little thing I can make a difference in some person's life, to me, it's worth it,” Bruning said.

Jeannie Bruning was a nurse for more than 40 years.

Shoemack said modelling suggested the peak of the Delta outbreak could be somewhere in the second half of February.

By that point, depending on variables like vaccination rates, there could be between 150 and 450 new cases per week across Bay of Plenty and Lakes.

Those numbers would put enormous pressure on the local contact-tracing effort, but Shoemack said they would continue the work for as long as they could, even if there were as many as 50 new cases per day.

'It will depend on us retaining our existing workforce, not burning them out, and continuing to attract and train new ones.”

The precarious balance between workload and workforce was one of the main challenges talked about on Wednesday during meetings with local health leaders and regional heads of government departments.

The other standout issue was coordinating the welfare needs of people who suddenly have to isolate, and working out which public service might step up to help, providing everything from food to accommodation, phone credit to dog walking, while avoiding double-ups and people falling through the cracks.

'It's all about the people,” Shoemack said.

-Stuff/Scott Yeoman.