As policy and public health leaders get set to roll out their phased-in approaches to reopening their respective states in the coming days and weeks, most experts agree that ramped-up testing and contact tracing will be the keys to keeping people as safe as possible.
Contact tracing—identifying individuals who may have come into contact with an infected person and then collecting data on these contacts—has helped stop previous deadly outbreaks, but the current COVID-19 virus presents a far greater challenge given that there’s been nearly 1.5 million confirmed cases in the U.S. already. Nonetheless, public health officials are ramping up efforts to monitor and contain new cases through this surveillance-based approach. During a recent webinar sponsored by the Alliance for Health Policy, industry leaders discussed case studies from abroad and best practices as policymakers look to implement a contact tracing strategy in the U.S.
One of the key points that the program’s speakers all strongly emphasized was that productive tracing efforts go far beyond gathering data on collected individuals; real success will only be seen with a motivated workforce of tracers, timely intervention, and persistent follow-up efforts.
Speaking from the experiences of Germany—a country with one of the lowest COVID-19 death rates in the world—Dr. Rudolf Blankart, professor of regulatory affairs at the Center of Competence for Public Management (KPM), University of Bern in Switzerland, noted that every person who has come into contact with an infected patient in the past two weeks is tracked down and tested.
He further explained that physicians, hospitals, and public health agencies will send results of infected patients to their respective state database, which then goes to the Robert Koch Institute, a federal database. Public health workers then contact the infected, who report all the people they have had close contact with in the few days before their symptoms first started. These COVID-suspected close contacts then are required to quarantine, either at home, in the hospital—if necessary—or at a designated “coronavirus hotel,” as Blankart called it, if they couldn’t isolate at home. If any of these suspected contacts test positive, the process restarts with tracers tracking down that person’s close contacts. One key to Germany’s success, Blankart noted, has been that tests are free with excessive testing capacity. The general population usually also gets their results back in under eight hours, with “fast testers” getting results back in two hours.
Who’s doing the work?
If the process seems exhaustive, that’s because it is. Blankart said that in Germany, various different tracing teams were set up to do the outreach, and make calls to those in isolation to try to prevent depression, while also providing care management services such as bringing food to their doors. KJ Seung, M.D., an infectious disease specialist and chief of strategy and policy for the Massachusetts COVID Response group, contended during the webinar that the outreach and support energy put forth by the tracers is a massive undertaking, but absolutely necessary to spread containment efforts.
Seung, who also works with the Massachusetts Community Tracing Collaborative, a program focused on reaching out to the contacts of confirmed positive COVID-19 patients to help others who have been potentially exposed to the virus, stressed that supporting those in isolation to make sure they stay quarantined and get what they need is essential. “After you trace, if you can’t prevent infection to other people, testing and tracing is an empty exercise. People need to be supported at home or in a facility,” he said, noting that up to 20 percent of people the Collaborative have called need support to isolate at home and would welcome isolation facilities in their towns.
Contact tracing is not just an epidemiological or data collection exercise, Seung emphasized. “You have to think about the downstream activities,” he stated. He pointed out that one of the biggest lessons learned in Massachusetts has been that in order to successfully reach the most vulnerable communities hit hardest by COVID-19, there is a need to leverage the expertise of local organizations that have already been in contact with folks in these neighborhoods. This could mean local boards of health or public health departments that have “decades of experience working with communities and people, and making sure they are linked into services. Community health centers are also important to work with. They have [experience] working with those who speak different languages and developing personal relationships,” he said, adding that this intimate local knowledge is “priceless.”
Put simply, Seung attested, “If you can’t provide any support, whether that is food delivery, child care, or a referral to a facility, the likelihood you will prevent transmission within the home, and perhaps in the workplace, is close to zero.”
Massachusetts has employed nearly 2,000 contact tracers—some nurses, some community health center staff, and some from the Collaborative—and Seung said these workers don’t necessarily need to be clinical or public health experts. “It’s a great opportunity for highly-motivated laypeople. But it’s difficult to do as a volunteer, and these tracing programs will be needed until a vaccine is developed,” he said.
To this end, in a recent funding plan developed by Andy Slavitt and Scott Gottlieb, M.D., the former federal health officials called for $12 billion for an expanded contact tracing workforce, a number they came up with by estimating the contact tracing workload per case and multiplying it by the number of daily cases. They specifically estimated that the necessary contract tracing workforce needs to be expanded by 180,000 until a safe and effective vaccine is on the market. The plan also called for $30 billion in funding over the course of 18 months that will be needed to offer income support to individuals who need to self-isolate for 14 days but can’t afford to take off work.
Seung noted that the Collaborative has fielded calls from others around the country looking for tracing insight, and believes that Massachusetts is around four to six weeks ahead of other states in implementing a contact tracing plan. However, he added, in the grand scheme of things, they are still far behind some East Asian countries and Germany in this area.
Anand Parekh, M.D., chief medical advisor for the Bipartisan Policy Center and former deputy assistant secretary for health at the U.S. Department of Health and Human Services (HHS), estimated during the webinar that the U.S. will require about 300,000 human contact tracers. He said Germany deployed five tracers per 20,000 individuals.
Agreement on digital health tools
Parekh pointed out that the Bipartisan Policy Center analyzed 15 countries—10 in Europe and 5 in East Asia—and in regard to contact tracing efforts, the results of the analysis show that there isn’t a one-sized-fits all solution, nor is there uniform agreement in those nations on who the tracers should be.
At the same time, contact tracing strategies in countries such as Singapore, South Korea and Taiwan have had varying degrees of success. South Korea, for example, looked at actual GPS location tracking data, facial-recognition CCTV surveillance, and monitoring credit card transactions, while Singapore developed its own app.
Privacy concerns are very real, however, and Parekh brought up that many privacy advocates have questions over the de-centralizing of the data. A de-centralized model gives users more control over their information by keeping it on their smartphone, while alerting them where COVID geographic hotspots are. Under a centralized model, on the other hand, app developers or government officials get availability to the data for tracking and matching purposes.
Some experts believe that he surveillance approaches used in South Korea, for example, have significant legal limitations in the U.S. Last month, Google and Apple made big news when they announced a joint effort around contact tracing that will leverage Bluetooth technology that includes application programming interfaces (APIs), as leaders from the tech companies opted to go with a de-centralized, opt-in approach.