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How 9 countries are sprinting to launch contact tracing—and 4 ways hospitals can get involved

by Paul Trigonoplos and Rebecca Soistmann

This is the second installment in our ‘Global Covid-19 Insights’ series. To access our first piece on how hospitals can prepare for a second Covid-19 wave, click here.

Much of the contact tracing conversation to date has centered on digital solutions that help identify Covid-positive individuals and isolate them. In March, countries like Singapore, South Korea, and Taiwan captured headlines with their advanced—and sometimes contentious—Covid-19 apps and surveillance methods. Meanwhile, the rest of the world was scantly contact tracing or not tracing at all. But by early May it was hard to find a country without its own app or plan that followed East Asia's lead.

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To help make sense of the global contact tracing landscape, and identify how hospitals around the world are leaning in to help, we analyzed contact tracing approaches across nine countries: three with mild outbreaks, three with moderate outbreaks, and three with severe outbreaks, where deaths per million people exceed 500.

Read on to get our analysis and key takeaways of this week’s data update. And then check out the grid below, which compares these countries' contact tracing approaches and summarizes a more detailed analysis of each country's Covid-19 response. To download the full research analysis last updated on May 19th, click here. Cells in green have been added or updated since our first iteration in this series on May 7th.

Global contact tracing app development sheds light on digital shortfalls

There has been a flurry of digital solutions developed recently, but early results are not as promising as many had hoped. Leaders in the countries we analyzed have learned that although the apps are necessary and helpful tools, they most likely will not work well enough to serve as "Plan A" solutions in the near-term due to this growing list of barriers:

  • Privacy concerns limit app uptake: Few countries have made their apps mandatory due to privacy implications, leaving citizens to opt in instead. Experts agree that at least 60% of a population must opt in for these programs to be effective—a number that is proving to be idealistic based on public surveys and experiences from early adopters. Singapore, for example, is stuck at 25%.

  • Bluetooth proves to be a shaky technology: Most apps use Bluetooth, which comes with its own set of problems. Not only can Bluetooth signal be spotty, but only ~80% of phones have Bluetooth functionality. One specific blind spot lies with the world's senior population, which has the highest risk of dying from Covid-19 but is also least likely to own a smartphone that has Bluetooth.

  • Stand-offs with private industry delay app releases: Apple and Google recently announced they will not update their operating systems to ensure Bluetooth works in apps that track GPS/location data or that store data on a central server when the phone is not in use. Tracking location data and storing data centrally are important features that we've seen in other countries' initial solutions, but in light of Google and Apple's announcement many are now having to readjust their approaches. For example, Germany, which was leading development for the EU's contact tracing app, pivoted away from their centralized data storage model and began developing a new app that aligns with Apple and Google’s policies and stores data on each phone anonymously. Singapore also is now updating their app to work with Apple and Google's policies too. While others, such as the UK and France, are holding out with their centralized approach, meaning no Apple or Google smartphone user will be able to use the NHS or French contact tracing apps while their phones are asleep.
  • Too many apps creates a coordination problem: Some countries, such as the US, have devolved app development to localities or states. Dozens of apps will roll out within small geographic areas, each with its own limits on what other contact tracing apps it can communicate with. We are also seeing this problem at the national scale on the UK's Irish border. And though Apple and Google's phones will eventually allow for contact tracing directly through the operating systems, without the need for an app, we don't have a hard date on when that will be rolled out.

4 ways hospitals can support boots-on-the-ground contact tracing

In response to these barriers, almost all of these nine countries—and many others—are doubling down on what public health experts say has been necessary all along: a vast contact tracing workforce, hired and trained immediately to manually track and isolate Covid-19 cases. Germany is looking to hire roughly 20,000 tracers, the UK 18,000, and the US upwards of 300,000, all in the matter of weeks.

In most jurisdictions, local public health bodies are leading the charge. But we have identified four ways that hospitals and health systems can lean in to help bring added scale, speed, and coordination to their local contact tracing responses. Consider how your hospital can support manual contact tracing in your region through these four strategies.

1. Partner with public health to help speed up the contact tracer hiring process.

Last week, New York City Mayor Bill de Blasio took contact tracing responsibility from the city's public health unit and put it in the hands of its hospital system, citing its ability to hire contact tracers much more quickly than the public health unit. This move, though quite contentious, points to a reality that some jurisdictions face: public health units around the world have been underfunded and understaffed for years, and hiring thousands of tracers in a short timespan would shock any organization's back-office. While we do not advise taking over the entire effort for numerous reasons, hospitals should instead partner with local public health agencies through joint planning and extending administrative support to get the process off the ground as fast as possible, together.

2. Publicly advertise volunteer positions and share through public channels.

We are seeing some health systems call on their communities, med students, and retired clinicians to help manually contact trace. This is particularly effective since most hospitals hold a prominent voice in their communities, and they already have these communication channels in place from their Covid-19 responses. And in England, where the NHS is handling all contact tracer job and volunteer advertisements (the jobs themselves sit with a smaller subsidiary of the government, Public Health England), there are some "workforce passport" apps hospitals already use that could help rapidly fill contact tracer volunteer slots and flex them across sites. Hospitals should proactively advertise contact tracing positions, share job postings on their career dashboards, and leverage public communication channels to ensure spots are filled quickly.

3. Form contact tracing teams in-house for your workforce and patients.

Tan Tock Seng Hospital in Singapore is a global leader in infectious disease response. Their Covid-19 control center uses location sensors and CCTV footage to track patients, staff, and equipment to inform contact patterns within the hospital. Privacy concerns complicate this translating to other countries, but the idea of contact tracing for your staff still holds. In the US, Mayo Clinic has developed their own, privacy-conscious approach that flags clinicians who may have been exposed through their EHR. The hospital then follows up with a questionnaire to get any added detail.

And at Singapore General Hospital, a team of three contact tracers helps jumpstart the tracing process for patients. Within two hours of a positive diagnosis, these contact tracers will have interviewed the patients, produced a report of all of their contacts and movements over the past 14 days, and sent it to the Ministry of Health. This rapid intake minimizes the time it takes for contact tracers to quarantine those the patient came in contact with. Hospitals should consider deploying their own contact tracing teams immediately to get a jumpstart on this work and safeguard their employees' and community's health.

4. Extend emotional and behavioral health support to the contact tracer workforce.

It can take up to 12 hours to conduct a contact tracing interview, and afterwards tracers can be left with hundreds of new people to contact. Add to this the fact that many people won't want to talk about the virus, or are still mourning a loved one, and it becomes clear that contact tracing is indeed an emotionally demanding job.

But perhaps a silver lining of the past few months is that health systems now (hopefully) have effective methods in place to support their own workforce's resilience through Covid-19. Hospitals should consider opening up access to online, self-service, or even walk-in support services to this new cadre of health workers who may not be fully prepared for the compassion fatigue they may experience.

The grid below compares these countries' contact tracing approaches and summarizes a more detailed analysis of each country's Covid-19 response. Click the grid to expand.

Covid-19 penetration:

  • Number: Deaths per million people as of May 20, 2020, 6:00am EST. This value was chosen to demonstrate disease penetration as it accounts for both population and varied case fatality rates.

Shading key:

  • Dark grey: Extensive government action—federal government led contact tracing app implementation; government using a centralized data storage system; boots-on-the-ground contact tracing efforts handled at the national level; government imposed strict social distancing and quarantine measures and most businesses, schools, and restaurants remain closed.

  • Light grey: Moderate government action—federal government will lead contact tracing app implementation after technology is developed through private companies; apps use a centralized data storage system; boots-on-the-ground contact tracing efforts devolved to state, territory, or regional levels; imposed moderate social distancing and quarantine measures and small numbers of businesses, restaurants and/or schools have reopened.

  • White: Limited government action—contact tracing app implementation devolved to state, territory, or regional levels; app data stored through a decentralized data storage system; boots-on-the-ground contact tracing efforts non-existent; lax social distancing and quarantine measures and most businesses, schools, and restaurants reopened.

Footnotes from grid:

  1. MOH: Ministry of Health

  2. KCDC: Korea Centers for Disease Control and Prevention

  3. ISS: Istituto Superiore di Sanità; the National Institute of Health in Italy provides the research and education arms of the Ministry of Health

  4. SAP: Singaporean Asia Publishers – global technology company that serves markets in North America, Europe, Africa, Australia, and Asia; developed Singapore’s TraceTogether contact tracing app

  5. PEPP-PT: Pan-European Privacy-Preserving Proximity Tracing – an initiative to create a contact tracing app that could be used across most countries in Europe

  6. NHSX: Arm of the National Health Service that leads digital transformation and innovation in health care for the United Kingdom

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