Contact Tracing

Contact Tracing

Human Contact Tracing

Humans are better than apps at understanding the unique and complex needs of patients during isolation and treatment, and complement apps in contact tracing

Technology does not always trump on-the-ground human action when it comes to contact tracing efforts, because human tracers are able to form bonds with patients and address their complex and unique needs in ways that digital apps by themselves cannot. Lessons learned from previous epidemics across sub-Saharan Africa have provided countries like Liberia with robust contact tracing training programs and knowledge. Across the globe, in countries like Ethiopia, Rwanda, and Cuba, community health workers are seeking out cases, finding close contacts, and providing COVID-19 education. In India, anganwadi workers, 3.5 million poorly paid, semi-literate women, have become the frontline responders and are playing an essential role in protecting the population of 1.4 billion people.

The state of  Massachusetts, in collaboration with Partners in Health, provides a useful model for contact tracing in the U.S. Its efforts include connecting infected persons with care resource coordinators who help patients access medical and non-medical services necessary for effective isolation and treatment. Still, challenges remain in implementation, as in New York City, where tracers have been slow to mobilize. But contact tracing efforts in the US are highly fragmented, with bottom-up initiatives at the town, city, and state levels, with varying degrees of coordination across these levels and no system for coordination nationally (even though people commonly move freely within and across state boundaries).

Potential Contacts: Partners in Health

Related Ideas: Digital Contact Tracing; Managing Outbreaks in Congested Areas; Rapid Response Teams for Outbreaks; Leveraging a National Response

Digital Contact Tracing

Using smartphones and apps, authorities have access to granular data on location, timing, and nearby contacts that is unachievable through human contact tracing (but at the risk of infringing on privacy)

East Asian countries have capitalized on the opportunity to digitize contact tracing. The WHO has released guidelines for digital contact tracing, highlighting several related tools: outbreak response tools, proximity tools, and symptom tracking tools.

Outbreak response tools, such as those used in China, are comprehensive contact tracing platforms that integrate contact lists with confirmed cases, laboratory results, and other relevant information. China's system tracks an individual's movements, purchases, health status, and other data and includes an individualized QR code that determines whether the user is permitted to move freely.

Proximity tools, such as Singapore's TraceTogether platform, track where users go and who they come in contact with. Developed by GovTech, the platform uses both Bluetooth technology, which captures and stores information on the users-end, and GPS technology, which captures location information independently of the user. Both technologies present opportunities and risks and require public buy-in to work. For citizens without cell phones, Singapore's wearable pods serve as bluetooth transmitters and receivers for TraceTogether.

Symptom tracking tools allow users to input their symptoms: cough, fever, aches, etc. into a central repository that is then used to track the disease's spread across the population.

Potential Contacts: GovTech

Related Ideas: Individual QR Codes; COVID-19 Mapping Apps; Capturing and Reporting Data; Human Contact Tracing

Individual QR Codes

Individual QR codes can be used to classify citizens into distinct risk categories for spreading the infection and to track and control movement

Big data and advanced data integration systems have allowed the Chinese government to assign health codes and track movements of its citizens. Chinese citizens in certain cities are assigned QR codes through an app associated with Alibaba that categorizes people into three groups – red, yellow, and green: red codes for suspected and confirmed cases, yellow for contacts of confirmed cases, and green for those thought to be uninfected. These QR codes control where people can shop, places they can visit, and whether they can use public transport. People's assigned color change dynamically, based on who they come in contact with, places they visit, or when their mandated quarantine period ends.

Versions of a QR code contact tracing system have rolled out in Russia and South Korea as well. Singapore's SafeEntry program gives users unique QR codes to scan upon entry into business, but also allows the use of the country's national identification card if a phone is unavailable or the app is not working.

Related Ideas: Digital Contact Tracing; E-Fencing; Digital Check-In System

Rapid Response Teams for Outbreaks

Countries in East Asia have guarded against a second wave by responding speedily to the first signs of a new flare-up with aggressive testing, contact tracing and targeted lock downs.

Countries such as China, South Korea, and Singapore that managed to contain a first wave of  COVID-19's now face the challenge of containing the second wave. Leaders are debating the reintroduction of strict social distancing rules and selective lock downs. Unlike the U.S., where many states have been slow in responding, South Korea has been quick to reinstate restrictions to control outbreaks, using digital contact tracing and increased testing.

In China, Wuhan and Beijing have both experienced outbreaks after containing the first wave. After lifting a 76-day lockdown in April, authorities in Wuhan were notified of six new cases in the beginning of May 2020. A massive testing campaign began on May 12, 2020 that aimed to test all 11 million residents. Testing stations were established across the city and samples were pooled together in batches to increase testing capacity. At the height of the campaign, which lasted approximately 2 weeks, one million people were swabbed each day.

In Beijing, an outbreak in a wholesale food market in mid-June 2020 caused the city to immediately shut down the market and lock down eleven surrounding neighborhoods, effectively implementing a “wartime emergency mode.” Guards were stationed in neighborhoods 24/7 to enforce the lock down. Tens of thousands of citizens underwent testing and temperature checks, while authorities attempted to track market visitors and their close contacts. In a city with more than 20 million people, the outbreak infected only 355 people and was successfully stifled, thanks to large-scale batch testing and targeted lock downs. As of July 7, 2020, Beijing had reported 0 new cases for 26 days in a row, with China as a whole reporting 0 local cases as well.

Related Ideas: Digital Contact Tracing; COVID-19 Command Centers; City-wide Testing; Batch/Pooled Testing

Managing Outbreaks in Congested Areas

Containment efforts in shanty towns and highly congested neighborhoods in Asia and Africa may offer lessons for how to control outbreaks in poor, urban settings in developed countries

Across Asia and Africa, urban areas often have large informal settlements where people live in very close proximity and therefore present a high risk of spreading COVID-19. Residents face challenges such as shared water resources, shared toilets, tight living spaces, and wage-earners who have to go out daily to make a living. Several of these communities have mounted impressive fights against COVID-19.

An extreme example is Mumbai's Dharavi slum, where one million people live in a one-square-mile area. Here, public health officials and volunteers have used door-to-door screenings, makeshift quarantine centers, and a commitment to building trust as cornerstones of a containment strategy that has been hailed as a potential model for success.

Similarly, in Kibera, an informal settlement in Kenya with 500,000 to 700,000 residents living on less than US$2 per day, everyone is required to wear a mask, hand-washing stations are provided, and streets and public transportation are disinfected (trains, buses). Because the area lacks a formal grocery store, informal market places have been allowed to remain open. And, instead of applying a lock down, which would destroy livelihoods, Kenya has made public transportation safer.

In Brazil, 400 “street presidents” are taking charge of the COVID-19 response in Paraisópolis, São Paulo's largest informal settlement. Tasked with documenting the needs of neighbors – food, aid, health care- the street presidents are bypassing an unresponsive public system. Low-income favelas across Latin America are using this model to build increasingly sophisticated systems. Some communities are hiring their own ambulances, creating unemployment funds, and creating databases to track cases and deaths–all in the attempt to fight COVID-19.

Even in prosperous Singapore, dormitories that house migrant workers in cramped quarters have led to rapid spread of COVID-19 and required the government to quarantine entire dormitories (in April 2020), at which time foreign workers accounted for 88% of Singapore's cases. The government plans to build additional dormitories to reduce living densities by year's end. Creating more space to allow distancing will be key to preventing further outbreaks.

Related Ideas: Access to Masks; Human Contact Tracing; Repurposing Public Venues for Mild Cases; Safe Handwashing

COVID-19 Command Centers

Central control can improve coordination across government agencies and echelons

Some countries created a central command center to coordinate policies and actions across ministries and government agencies, and across different levels of government (federal, state, local). For example, Taiwan activated its National Health Command Center (NHCC) in January 2020, under the head of its CDC, even before confirmation of the first case. Shaped by their experience of the 2003 SARS outbreak, the NHCC implemented over 120 policy action items, cutting across many parts of government, within five weeks.

Similarly, drawing on the experience of fighting Ebola, Rwanda established a COVID-19 Command Post in the capital city of Kigali, bringing together 400 professionals from different sectors to coordinate response efforts.

In the US, President Trump created a White House Coronavirus Task Force with representatives from more than 20 departments or agencies of the federal government and chaired by Vice President Mike Pence. But it has lacked the coordination and speed of counterparts in China, Rwanda, South Korea, Taiwan, or Vietnam.

Related Ideas: Leveraging a National Response; Disease Severity Indicator