During the 2014 Ebola outbreak in Guinea, global health researcher Anne Liu tried to convince health officials that apps and other technologies could help fight the spread of diseases. To repel the outbreak, officials had to locate anyone an Ebola patient may have interacted with while they were contagious. This is called contact tracking. Liu and her colleagues wanted investigators to use apps to gather information instead of pen and paper. It was a tough sale at the time.
"The fight was more, technology will be useful at all," said Liu, now the lead technical advisor at the Clinton Health Access Initiative. "I don't think that's more of a struggle."
During the ongoing novel coronavirus pandemic, some experts are turning to the technology to completely take over the contact tracking process. Countries such as Singapore and China use mobile phone-based tools to identify and monitor people who may have been exposed to someone with COVID-19. A contact tracking app is being created in the UK. In the United States, Google and Apple have jointly developed a Bluetooth-based tracking system that can automatically log people's interactions.
It is still unclear whether this type of technology could help stop an outbreak. It has never been examined before. Some experts are optimistic that automating contact tracking could increase COVID-19 response in the United States. However, creating systems that can do this work is just the beginning of the conversation.
“This type of technology is not a miracle cure. It has to be part of a comprehensive public health strategy. "
“This type of technology is not a miracle cure. It has to be part of a comprehensive public health strategy, ”says Liu. "Technology is usually the easy part." These new systems will not be useful without a dramatic increase in tests conducted in the United States, clear messaging, and strong integration into health policies.
Shift the load
The goal of contact tracking apps is pretty simple. They logged every phone in a specific area of a person. If that person later tested positive for COVID-19, they could send an alert to any phone nearby. Google and Apple have chosen Bluetooth, which allows them to monitor the other phones in your area without tracking your specific location. There are limitations to this approach: Bluetooth carries a wide network and may be difficult to determine whether two phones were actually close enough for their users to be able to transmit a virus between them. The systems are also unable to monitor the contacts of people who disagree or those who do not have a smartphone.
For this reason, app-based tracking will not be a complete replacement for manual contact tracking, and health authorities still need to significantly expand the contact tracking workforce in the United States. However, apps could do some of the work and make the process more efficient.
Irish Army cadets train for manual contact tracking.
Photo by PAUL FAITH / AFP via Getty Images
"In general, a lot of manual work is done. We need to increase the public health workforce and this new technology could significantly reduce this burden," said John Brownstein, epidemiologist for infectious diseases and chief innovation officer at Boston Children's Hospital.
An automatic system can do things that a manual contact tracer cannot. People find it difficult to remember everyone they interact with every day, let alone over a week or two week, and an app would take some guesswork out of the equation. It would also be able to tag people that someone may not know they are interacting with, like a stranger they were standing next to in a subway car.
"Let's say you're an infected worker in a grocery store," says Ranu Dhillon, a researcher in the Global Health Justice Department at Brigham and Women's Hospital. "There's no way to track who you may have exposed." An automated system could comprehensively identify these previously unknown contacts.
"The biggest advantage, I think, is speed"
An automated system is also fast. "The biggest advantage, I think, is speed," says Dhillon. It can take a few days for a contact tracer to manually track everyone on their list for each case – and during this time, infected people could pass the virus on to others. "Immediate notification can make a big difference," he says.
What happens next?
As soon as these notifications are made via the app, the second wave of work begins. It is still not clear whether the system will provide health authorities with information about the identified contacts of a known positive case.
"Typically, when tracking contacts, you want a health official to be able to follow up," Liu says. Manual check-ins or follow-ups may not be as important for COVID-19 contacts as for Ebola contacts. At Ebola, tracers return to contacts every day for a few weeks. People who are exposed to COVID-19 are usually only asked to monitor themselves for two weeks.
A contact tracer in Liberia is looking for Ebola symptoms.
Photo by John Moore / Getty Images
Liu still believes that it would be helpful for officials to know who the contacts of each case were, just as with manual contact tracking. She acknowledges that it could be a difficult question because people may feel different when this information is processed through an app or software. "I can understand that this can be challenging in an environment where people are concerned about privacy," she says. At the very least, contacts should still get public health information from the app so they can decide what to do after they find out they've been exposed.
The recommendations that each contact would receive depend heavily on the infrastructure and policies that apply to disease response. Ideally, Dhillon said, each contact could be tested for the novel coronavirus and possibly retested about a week later (to make sure that a first test, if it is negative, is not wrong).
There are currently not nearly enough tests available in the United States to make this possible. Instead, a notification of possible exposure to a person with COVID-19 is more likely to trigger a two-week quarantine recommendation. That is still useful, says Dhillon. "I would rather isolate all contacts than isolate them all. Contacts are still far fewer people than the entire population."
Without testing, however, the potential burden of notification would be higher. "You would ask a lot of people to potentially quarantine because of potential contact," Brownstein says. If the Bluetooth system is not specific enough and marks people as contacts who are not really at risk, these false alarms can be stressful and overwhelming. Too many perceived false alarms can also make people less likely to follow instructions after a warning.
Too many perceived false alarms can also make people less likely to follow instructions after a warning
However, if people are regularly alerted to a potential hazard, it may have more to do with the case load in their community than the reliability of Bluetooth – especially if the technology can be refined. "Marking people multiple times is likely to indicate that people are coming back positively on their social networks," says Dhillon. "It shouldn't be about false alarms as much as a number of cases."
When people get a lot of warnings, it can also mean that the number of people with COVID-19 is so high that contact tracking is no longer the best strategy – and that everyone should isolate anyway. "In this situation, you are in a situation like New York City where you have a widespread community broadcast. You have to assume that everyone was exposed," Liu says.
Telling someone that he was with someone with COVID-19 is not so useful when the disease is everywhere. Contact tracking is not done manually when the number of cases is high. Therefore, it may not be worthwhile to switch on automated systems. Decisions about when and where to send notifications need to take this context into account, Liu says. "This way you avoid this notification fatigue problem."
Communication is the key
Officials working with automated contact tracking not only have to ensure that a system works well and fit into the public health ecosystem, but also ensure clear communication with users. "Much of it is messaging itself," says Liu. "Regardless of the technology, it must be ensured that the news itself is clear."
"Regardless of the technology, you need to make sure the news itself is clear."
News from public health officials about the COVID-19 pandemic has been inconsistent and often misleading, which is not good for clear communication through an automated test system. However, experts say that this could affect or affect the proposed systems.
People who decide whether to use an app or opt for a tracking system need to understand exactly what the technology is for and how it is used. You also need to know what a notification from the system would mean and what you should do with this information. An alarm wouldn't necessarily mean that a person is in imminent danger, but it could mean that they have a certain risk of developing COVID-19 – and they need to know what those risks are. "We need a lot of public news where people can understand what the notification is and put it in context," says Dhillon.
Clear communication would also increase the likelihood of people opting for the automated system, which requires a high percentage of participation to work. In Singapore, for example, around 12 percent of the population downloaded a contact tracking app – statistically, however, this only means a probability of around 1 percent that two people use both. With such a low usage rate, not many random contacts are recorded. It's hard to say how many people in the U.S. would need an app to add value.
"What would be ideal from the point of view of disease control is not necessarily what is ideal on a social and political level, which is just as important," says Dhillon. "We need enough people to choose a bump."
The pandemic is moving at an unprecedented rate, and public health experts are sprinting to develop the tools that they believe could help bring it under control. "It's a little bit flying the plane while it's still being built," says Dhillon. Any automated contact tracking program would need to be carefully monitored to determine how well it helps curb COVID-19, how people interact with it, and whether it identifies more people than are actually exposed to exposure.
However the systems ultimately look, they need to be implemented along with the public health infrastructure to ensure that they have the greatest impact. "The tools cannot be used in isolation," says Liu. "You need to make sure the guidelines are in place to support them."