COVID-19 Interest Group

                                             June 21, 2020

                                                                            CIG Bulletin #15

                                    Contact Tracing, New Technologies and YOU
                                                      By Tina Etcheverry

As our cities and counties start to loosen restrictions on stay-at-home orders, we are seeing a significant increase in new COVID cases. We probably cannot stop the opening up of businesses, but we have tools to try to limit the spread of new cases – testing followed by contact tracing.

What is Contact Tracing?
COVID testing centers and hospital labs are now reporting new cases to the Public Health services of their community, giving contact tracers information they need to go to work. Some cities in Texas have implemented self-reporting hot lines to get that information quickly to the Public Health services. The contact tracer then goes on to interview the infected individual and takes the history of where they have been recently. The question they ask is “have they been within 6 feet of anyone for more than 30 minutes?” The tracer plays a role as a health detective. They start by making calls to individuals and commercial locations (gyms, stores, beauty salons, night clubs, religious organizations) saying, “This is the Health Department. You or your employees may have been in close contact with someone who has tested positive for coronavirus.” They go on to explain what symptoms to look out for and how to get tested, what it means to quarantine, and the need for isolation for 2 weeks. They may even suggest to owners that they should close their business and get all their employees tested. The contact tracers are assigned caseloads to follow localized outbreaks and continue investigations throughout a spider web of interactions.

“Hot Spots” in the News
There are multiple documented examples of COVID “hot spots”. Nursing homes, meat processing plants, and prisons. Broad testing is being performed at these locations, not only of the inmates or residents, but testing of the employees and close contacts and family members. In mid-May, Iowa was faced with increased cases in both prisons and slaughterhouses. The labor intensive process of questioning positive patients on who they may have been in contact within 6 feet for more than 30 minutes required the Public health departments to request help from the National Guard to assist in tracing contacts and doing the case investigations.

One example of the failed system was the coronavirus spreading rapidly through San Quentin Prison. Cases tripled from 15 to 46 in two weeks after a bungled transfer of inmates away from an outbreak in Chino Correctional Facility to San Quentin, introducing the virus into a new population. The lack of testing prior to transfer allowed the jump from one facility to another. Bad decision-making and lack of testing data with no oversight by public health officials illustrates the gap that needs to be resolved.

In California, we see that Latinos are especially vulnerable, living in high density housing and working at essential jobs that expose them to the public. San Francisco used a community led project with Unidos En Salud to go door to door in the Mission District to test 3,000 residents. The 70 or so positive cases mobilized an extensive follow-up with individuals who may have been exposed. Here is an example that the ability of contact tracers to use telephone investigations doesn’t always work: people refuse to answer the phone when strangers call, or they fear for their immigration status. Therefore UCSF and SFDPH turned to a trusted community organization to mobilize this program.

In Alameda county, Latinos make up more than half of the coronavirus cases (2,320 of the total 4,585 and 28% of the deaths). Public health departments are assigning contact tracers in these communities to expand testing and shelter-in-place to protect the families. Education on the importance of wearing masks, washing hands, and maintaining 6 feet social distance becomes part of their job.

In China, contact tracing has slowed the spread of virus. In one study, 391 patients who tested positive had reported 1,286 close contacts within a 4-week period. Of those contacts, 6.6% ended up positive, most of them being close household members or relatives. Their conclusion is that identification and isolation of cases can drop infection rates by one-half (reproductive # 0.4).

But today we face a growing concern: the majority of new infections are in younger people in the 18 -50 year old age bracket. Contact tracing goes out the window when the virus spreads too fast, too quickly. Younger people are flocking to bars and restaurants, beaches and nightclubs. Not to mention taking to the streets to protest Black Lives Matter. Dr. Gottlieb recently said that contact tracing at the county level is not going to be sufficient.

What about new technologies for contract tracing?
Surveillance technologies are evolving that can provide information more rapidly than manual processes. These are widely used in China and South Korea. It is unlikely that individual wrist bands to track locations will be required of private citizens in the United States. However, many of us already can be “located” by our cell phones. The debate will continue as to whether if this is invasive and infringes on personal privacy or should it be allowed for public safety and the better good.

One example, Kinsa, produces a smart thermometer that connects a fever reading through cell phones to a database that is being tracked by the company. Over 10 million thermometers have been sold so you can see that it is reaching into many individual households. In early March, Kinsa saw unusual levels of high fever temperatures being measured in New York City, but they were not aware of the importance of this information until the coronavirus outbreak became news. They now realize that their on-line thermometer system can be an early warning system for illness spreading in communities. The data that is collected indicates where, when and how fast high fevers are spreading. For example, last week they saw fever spikes in Missouri, Maine, Louisiana and Oklahoma. The data can pinpoint hot spots but is not used to locate individual households.

Cell phone location services may provide the missing link in contact tracing. For example, in late May, Australia launched a national app called COVIDsafe to find and alert the contacts of people infected with coronavirus. Immediately 2 million people downloaded the app. The intent is to use digital contact tracing to identify people who have been exposed to coronavirus, notify them and ask that they take steps to be tested and volunteer self-imposed isolation.

“It’s very appealing—that you have an app that does all this work … and does it quickly,” says Hannah Clapham, an epidemiologist at the National University of Singapore Saw Swee Hock School of Public Health. But she warns that an app can’t replace the work of human contact tracers. “I hope that it works. But I worry that we think it’s going to save us.”

I personally find it disturbing to think others can use our personal information, but maybe we need to think differently about the existential dread of our personal lives being exposed and the ultimate cost to our health. Live free or die? should no longer be our slogan.