This article is a part of Privacy in Pandemic, Future Tense series.
As Americans enter the second month of corona virus isolation, experts think of what systems we need to have before loosening boundaries. The general consensus is we will need extensive testing in place, as well as methods for managing the next inevitable outbreak. Some countries, like Singapore and Singapore Korea, has launched an application that tracks the user’s location and plays it if they have just met someone who has tested positive for COVID-19. Apple and Google recently announced plans for a tool that allows developers to build similar applications in the US and elsewhere. This is a digital incarnation of contact tracking, a long-term strategy in public health.
Long before COVID, contact tracers tracked the spread of other diseases such as gonorrhea, cryptosporidiosis, HIV, Zika, tuberculosis, and measles. So as COVID-19 increased, local and regional public health officials registered the closest university to help through tracking old-school contacts. Shannan Rich, an epidemiologist with a Ph.D. a student at the University of Florida, started volunteering as a tracker after the Florida Department of Health reached it about a month ago. His job: to reach people who tested positive for COVID and their close contacts.
Sometimes the people he calls realize they are tested positive, but at other times he has to deliver the news. The next step is to ask questions to help them remember who they were recently in the hope of identifying potential sources. “The aim is to find out whether we can connect them with others who are positively confirmed – perhaps through the event they attend,” he said. It also helps identify anyone they might be infected with. While the scientific community is still investigating how long COVID-positive people might be contagious, Florida’s contact tracing program now defines the infectious period as two days before people first show symptoms until the date of their interview with the contact tracker. Any “close contact” – anyone who has been within 6 feet of you for more than 30 minutes during the specified infection period – is told that they have interacted with a COVID positive person. (In health care settings, where the risk of transmission may be higher, the standard for “close contact” is sometimes adjusted down to 5 minutes of exposure.) Trackers will ask those who are exposed if they have experienced symptoms and, if they have been stricken with it. disease, encourage them to be tested. If they are stated positive, their contact will be notified, hopefully breaking the transmission chain. This is not a perfect system, but according to it statistics from the World Health Organization, contact tracing helped Chinese health officials identify hundreds of “close contacts” newly infected within one day.
Crucial human elements will be difficult to apply with any application, however good was designed.
This type of old-school detective work might sound direct: call people and find out who else they might see. But with science developing rapidly and standards shifting to accommodate new knowledge, contact tracers must navigate complicated situations, work to maintain individual privacy while ensuring the right people are notified. As a general policy, trackers are not permitted to reveal the identity of people who are COVID positive, even if people have suspicions, and can only disclose the date they believe that exposure occurred. But Rich says telling people who live with COVID positive people is easier with so many people who are alone. Normally, he records people’s info and calls them individually, but because many people are at home, infected people may even give up their privacy rights and only put their housemates, spouses, and children on the speakerphone. But it gets more complicated when, say, COVID-positive patients go to a health clinic and interact with many nurses and patients during their visit, whose names they may not be able to remember. In that case, the task of the tracker is to find out how to tell the right people without revealing the identity of a COVID positive person.
The job also requires empathy, patience, and the ability to calmly explain the next step. Some people who are called by Rich panic and are worried about being COVID-positive or have been exposed to someone who also. “It’s easy to interview them and ask the main questions like robots, but there is an important education section,” he said. He explained to them what actions they should take, such as quarantine, and could answer people’s questions about their personal circumstances, such as how they could isolate themselves from those who lived with them or how to access foodstuffs. “There is a lot of sensitivity involved in contact tracing, and the diversity of situations that people experience, how they respond to knowing about their status or exposure, is a human part of this work,” said Stacey King, a public health expert at Harvard TH Chan School of Public Health, which is a co-lead of the Academic Academic Community Health Volunteer who works with the state of Massachusetts to track contacts. “To be honest, I think human contact now with contact tracers is about more than health surveillance and data. It’s also about helping them navigate all that. ”
This crucial human element will be difficult to implement with any application, no matter how well designed. For one, the application is not a substitute for the educational aspects of contact tracker calls. An application might have a FAQ section, but it doesn’t seem possible to respond to very specific questions or problems that people have about their personal circumstances, and it certainly can’t provide guarantees in the same way as human voice. It also tends to have the flexibility of human experts to think about difficult questions. “Every case is different. Many of these can not be just a decision a computer can make, “Rich said. “Everything is very new, and we made a decision in consultation with administrators at the state and national level. Like, we have never met this scenario – what should we do? There are many questions where we have to judge on a case by case basis. “For example, Rich mentioned that they had considered a scenario where a health professional might be exposed. Their recommendations may differ depending on the type of protective mask worn by professionals at the time. (With widespread shortcomings, many health workers are left with inadequate personal protective equipment.) Knowing that information requires talks with hospital infection control units, and trackers can then consult with superiors, such as epidemiologists from the local health department.
Rich is also concerned that tracing contacts through the application can produce unnecessary large amounts of “exposure” warnings. “If you are at the grocery store, and someone there is positive and they walk near you, does that show exposure?” According to current model for digital contact tracing, including existing applications such as the Singapore Footprint together, yes, of course. Spreading a wide net may encourage people to err on the side of caution and alienation, but it can also result in Lots warning – and decreased compliance when people become accustomed to it. Plus, “there are real psychological implications for telling someone that they have been exposed, and I think it’s important that the person who designed this application thought about it from the start,” Rich said. Some people are really scared, and getting a warning from somewhere can make them angry; Rich suggests that even just including links to counseling resources in such warnings can help.
Like coronavirus testing, plans to launch contact tracing have been driven primarily by states, districts and academic institutions rather than the federal government. During the 2014 Ebola outbreak in Dallas, the Centers for Disease Control and Prevention work with local and state officials to track contacts. At this time, an agency appeared recognize the need to expand contact tracing but has not yet announced plans for a national effort. Meanwhile, contact tracers and staff organizing these programs have full capacity to build and run operations, but are still trying to make time to advise colleagues about starting their own programs. Harvard’s King told me that several students at the University of Pennsylvania expressed interest in starting a contact tracking program, and he also heard from a graduate of his department who wanted to support the Native American community in California. “We organically hear from different people. I don’t know how they heard about us, “he said.” I know other states have reached Massachusetts, and the state is planning to put together a device and some other resources. “When I asked Raja and Rich if they knew of national efforts to tracking contacts or records which country or country has a program, both say no.
Meanwhile, our neighbor in Canada launched a national contact tracking program in early April and per week ago already 27,000 volunteers. We’re not like that at U.S. – the Florida program currently includes around 100 trackers, Massachusetts has just hired around 1,000 – and experts estimate we will need more, more. Today, epidemiologists and public health experts estimate we will need both 100,000 and 300,000 contact tracers work to identify outbreak patterns if the self-isolation policy is lifted. City of Wuhan itself ask for 9,000 trackers who work in groups of five; each group is led by an epidemiologist.
Adding digital tracking applications to the mix will introduce more variability to this decentralized effort; it is not clear which health department might have access to this data and how it fits with existing contact tracking and tracking efforts. But if digital tools are used intelligently, they can save investigators time and effort. Rich mentions a new application called NextTrace, which asks COVID positive individuals to fill out forms that ask many of the same questions that contact tracers might ask in the initial interview. “That can be very powerful, potentially, in helping the health department focus on high priority investigations,” he said, such as spreading in hospitals or nursing homes. In the drive to develop applications, several companies have focused specifically on these “high priority” locations – CarePredict, for example, provides wristbands that track the movement of people to senior care facilities. If a resident becomes ill, the facility receives notification and can use the bracelet location data to determine which staff and occupants should be tested and isolated, and which areas of the facility should get extra deep cleaning.
King agrees that digital tools can be useful to inform public health officials’ responses to COVID. “There is no doubt that having such data is the goal of contact tracing,” he said. But that data can only show us so much; people don’t need to download this tracking application, nor do they need to carry their cellphones wherever they go. Stopping COVID in the end will still require real people to use their expertise, and King said the response from the community was extraordinary. After the call for voluntary contact tracers came out, “1,500 students responded in 72 hours,” King said. “I have never seen anything move so fast – to ask so many people to say, ‘Yes, we will help,’ and ask this large institution to say, ‘Yes, we will mobilize resources.'” Let’s hope it continues.
For more information on coronavirus contact tracking, listen to Friday What’s Next: TBD.
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