In L.A. County, Public Health Leaders Take Another Swing at Contact Tracing

In this recurring section, Healthcare Innovation editors take an in-depth look into the numerous ways the COVID-19 pandemic is impacting the healthcare ecosystem. In this issue, we specifically look at recent digital contact tracing efforts, and the core ethical and logistical questions around vaccine distribution.

Contact tracing has been a massive undertaking in the U.S. so far, and with COVID-19 cases continuing to surge upwards of 200,000 per day, the job won’t get any easier. Although identifying individuals who may have come into contact with an infected person and then collecting data on these contacts is considered a key element to help curtail the pandemic, these efforts have been littered with challenges to date. 

A recent survey from Pew Research Center of more than 10,000 U.S. adults, for instance, found that only half of respondents said they would be comfortable or likely to engage on the three key steps involved with contact tracing—speaking with a public health official, or contact tracer, who reached out to them about COVID-19; sharing the names of people they have had close contact with as well as the places they have recently visited; and willing to quarantine for 14 days if they were advised to.

Indeed, contact tracing is the last two-thirds of public health leaders’ “test-trace-isolate” strategy, but in the U.S. so far, the results have not been there. A Reuters survey of 121 local agencies, published in August, concluded that the U.S. “badly lags other wealthy countries in contact tracing, including South Korea and Germany, which ramped up their programs months ago. Contributing to the faltering U.S. response is the government’s failure to provide accurate and timely diagnostic testing, something other countries were able to roll out much faster and more broadly,” that report noted.

In California, healthcare leaders recently rolled out CA Notify, a new digital contact tracing tool that was made available to all Californians starting Dec. 10. The tool was developed in partnership with Google and Apple, and piloted with the help of the University California, San Diego and the University of California, San Francisco. California residents can enable CA Notify in their iPhone settings or on Android phones by downloading the CA notify app from the Google Play Store, and when the app is downloaded, users can opt-in to receive COVID-19 notifications informing them if they have been exposed to someone who has tested positive for the virus. State officials contend that the digital tool protects privacy and security, does not collect device location to detect exposure, and does not share a user’s identity.

Back in April, Apple and Google announced a joint effort around contact tracing leveraging Bluetooth technology. As of late-November, only a handful of U.S. states had contact tracing options for iOS and Android, although several more deployments could be in the works. California, via its CA Notify solution, has now become the largest state to join the Apple-Google contact-tracing initiative thus far.

When individuals voluntarily activate CA Notify, the tool uses Bluetooth technology to exchange random codes between phones without revealing the user’s identity or location. If a CA Notify user tests positive for COVID-19, they will receive a verification code to plug into the app, if they choose. Any other CA Notify users who have been within 6 feet for 15 minutes or more of the COVID-19 positive individual will get an anonymous notification of possible exposure, explained officials from California Gov. Gavin Newsom’s office.

Another organization joining the fight to stop COVID-19 spread is Healthvana, a patient engagement solutions company that is working with the Los Angeles County Department of Health Services on rolling out a solution enabling individuals with a positive test to immediately and anonymously notify anyone with whom they have recently come in close contact, using their mobile phones.

Los Angeles County has partnered with Healthvana since April 2020 on the delivery of test results for county-operated sites; test result notifications are sent via text message or email the moment the lab processes the sample. With this new added feature, individuals who receive a positive test result can simply click a link within the web-based patient portal to enter contact information for any recent close contacts. These close contacts instantly receive a notification from Healthvana alerting them that they may have been exposed to COVID-19 with links to resources, including locations where they can schedule a free COVID-19 test. The contact tracing feature will be initially rolled out to county-operated testing sites, according to county officials.

One of the most important elements of this solution is that the Healthvana notifications to close contacts come in minutes or hours, rather than days, meaning there is a real opportunity to act right away as time is of the essence, says Clemens Hong, M.D., director of whole person care with the L.A. Department of Health Services, which oversees the county’s testing sites. Like many others, Hong believes that engagement is the most critical piece to any contact tracing strategy, because without it, no tool can make up for non-committed users. In the first four weeks of the tracing program, more than 3,000 people were notified of an exposure within hours from when the original positive test result was recorded. And the vast majority of those 3,000 individuals open the exposure notification within five minutes. “So it pretty much touches just about everyone within the first day,” says Hong. What’s more, about 30 percent of the close contacts who received a notification click on a link to access a COVID test.

At the same time, Hong acknowledges that the 3,000 users who received notifications represent just 3 percent or so of the COVID-positive users. “So of the individuals who received a COVID test, 3.5 percent of those who were positive entered a contact [in the Healthvana app]. The majority of those who engage do enter [that information] within the first hour, but it’s still not reaching a large percentage. So there’s a lot of opportunity for us to improve there,” says Hong.

The early data also shows that about three quarters of the most engaged folks on Healthvana are people of color, “and that’s where we’ve seen an overwhelming number of infections, as [the virus] has had a disproportionate impact on people and communities of color,” says Hong. The other data point he refers to is that respondents are notifying 1.3 contacts on average, “and if you look at our county data, that’s almost double what we have been seeing in terms of people who are notified. So maybe there’s something about the anonymity [of this app] that’s encouraging people to add more contacts,” Hong speculates.

Is there a “right” contact tracing strategy?

So far, there doesn’t seem to be a one-size-fits-all solution to contact tracing in the U.S., with a big reason being that state and county resources can’t keep up with the surge in positive cases. Some are even asking residents to do their own tracing and notifying.

There were several common challenges and barriers to contact tracing mentioned in the aforementioned Reuters report, including: efforts to simply reach people who tested positive, let alone interview them; a lack of sufficient staff and funds; and technical problems and poor coordination. Per the report, one local health director in Wisconsin said responses her team got when calling positive patients ranged from “yelling and hanging up, to those telling us that they have already contacted all of their friends and will not give us those names.”

The Pew research reinforced this anecdote in its survey, as just 19 percent of Americans said they generally answer their cell phones when an unknown phone number calls. About 67 percent said they don’t answer, but would check a voicemail if one is left. And 14 percent said they generally don’t answer and would ignore a voicemail. On the ground, some state leaders are quickly realizing this reality. In early December, New Jersey Gov. Phil Murphy reported that the number of New Jerseyans with COVID-19 who refuse to cooperate with contact tracers continues to grow; recent data showed that 74 percent of cases do not give information about recent contacts with others to government health employees who call them. Murphy called the non-cooperation “unacceptable.”

Although not the norm, there have been some pockets of tracing success in the U.S. In San Francisco, more than 83 percent of COVID-19 cases and contacts are reached on a regular basis, according to a late October ABC News report. In September, more than 1,600 COVID cases there resulted in tracing more than 1,700 contacts. Close to 60 percent of those contacts then got tested, representing a significant jump from four months prior, according to that report.

The U.S. has more than 50,000 contact tracers for the first time since the coronavirus pandemic hit, according to an October survey of states conducted by the Johns Hopkins Center for Health Security in collaboration with NPR. Public health experts have previously called for 100,000 contact tracers nationwide, a number that’s also been mentioned by incoming President Joe Biden.

This is where some experts believe that digital apps could help fill the gap by automating the contact tracing process, but thus far there have mostly been low adoption rates and stymied progress. In Nevada, for instance, despite state authorities strongly recommending that residents download their contact tracing app, just 3 percent of the adult population has so far, and not a single exposure was registered in the app throughout the month of September, during which the state reported more than 10,000 new cases, according to a November report in Time.

Hong believes that a combination of digital technology with manual effort is likely the right approach moving forward. The Healthvana solution, he points out, enables the ability to get information out quickly, make contacts aware, and allow them to quarantine. On top of that, two days later they’ll get a call from public health official who can do a much deeper interview that helps authorities identify where the person got infected and whether or not there are outbreaks that need to be chased. “So I think the idea is that these two pieces can really work together to address this, especially right now when we’re seeing so many cases,” he contends.

In the end, engagement is by far the most crucial success factor, and to that point, Hong says Healthvana is working on deploying functionality where a second notification is sent out to close contacts 24 hours after the first one—perhaps at a different time of the day—with the goal to get more users and more responses. But Hong also touts that L.A County has already reached 3,000 people with the Healthvana app so far. “If we could have those 3,000 individuals stop spread to two people, you are changing the trajectory, at least within their communities, their families, or their workplaces,” he says. 

Vaccine Distribution Raises Ethical, Logistical Questions

State, local public health agencies and health systems grapple with distribution priorities

Because initial COVID-19 vaccine supply will not meet demand, rationing will be inevitable. That raises ethical and logistical questions about how policymakers and health systems will make allocation decisions. In addition to addressing the logistical complexity of vaccine distribution, many public health leaders are seeking to address inequities and focus their efforts on vulnerable groups. But questions remain about ordering priorities. When will outpatient clinics that serve homeless populations get doses? What about incarcerated populations? School teachers?

A Dec. 5 story in the New York Times notes that “Health care workers and the frailest of the elderly — residents of long-term-care facilities — will almost certainly get the first shots, under guidelines the Centers for Disease Control and Prevention issued. But with vaccination expected to start, the debate among federal and state health officials about who goes next, and lobbying from outside groups to be included, is growing more urgent. It’s a question increasingly guided by concerns over the inequities laid bare by the pandemic, from disproportionately high rates of infection and death among poor people and people of color to disparate access to testing, child care and technology for online schooling.”

As part of a Dec. 4 online seminar on vaccine distribution and social justice, Nicole Lurie, M.D., strategic advisor to the CEO of the Coalition for Epidemic Preparedness Initiatives, noted that the first available vaccine has substantial cold chain requirements and will be in short supply — there is likely to be a lot less available initially than we anticipated there would be. “What that means is that the vaccine will be distributed to a fixed number of locations that are capable of high throughput for phase 1A populations. It is going to be really complicated,” said Lurie, who previously served as assistant secretary for preparedness and response at the Department of Health & Human Services. In that role, she led the HHS response to numerous public health emergencies, ranging from infectious disease to natural and man-made disasters.

Lurie stressed that there has not been adequate planning for vaccine distribution. Information systems have not been set up. There may be enough doses for only 6 percent of front-line workers in phase 1a. “How do you figure out who those people are? Who decides?” she asked.

Lurie noted that we are looking to Congress to pass a bill to provide financial relief to state and local governments to run a vaccination campaign. Money has to go from the federal government to states and local government to hire vaccinators and the work force to pull this off. “It is not straightforward,” she said. State and local governments need to convene to approve spending the money. That can take a long time and you can’t spend money you don’t have. In past administrations, she said, there were strong partnerships with governors and mayors, and they planned for months to create a consistent framework at the federal level and have state and local governments adapt as needed. “We are way behind in all those efforts,” she said. “If money is not made available, it puts us further behind.”

The four-part seminar series is co-hosted by Ariadne Labs, Boston College, the Harvard Chan School of Public Health, the International Society for Priorities in Health, MIT, O’Neil Institute/Georgetown, the University of Pennsylvania’s Department of Medical Ethics and Health Policy, and the Leonard Davis Institute of Health Economics.

Caroline Johnson, M.D., deputy health commissioner for the City of Philadelphia, described the city’s work to prepare for a situation where there is a large demand and a limited supply. Planning for distribution started in the summer, she said. The city convened an advisory committee made up of people from healthcare provider organizations and community-based organizations to talk about getting vaccines into high-priority groups, with healthcare workers at the top of the list. The first step was cataloging how many of these workers there are and how to access them.

Health systems will have to grapple with equitable ways to distribute within certain physical locations such as emergency departments rather than by job descriptions.

“We thought hospitals and healthcare systems would be interested in standardizing on prioritization,” Johnson said. “But as it turns out, they wanted to make internal decisions based on the needs of different facilities, so we have not established what the sub-prioritization groups should be. Most health systems are comfortable determining within their own agencies.”

Philadelphia also plans to set up clinics early in the communities of color hit hardest by the virus and to partner with groups that serve communities of color to promote vaccination, she said.

Michelle Fiscus, M.D., medical director of the Vaccine-Preventable Diseases and Immunization Program in the Tennessee Department of Health, described the challenge of planning for distribution across the diverse parts of the rural state, including using a social vulnerability index to identify regions of high need as well as overcoming hesitancy about taking the vaccine. Because of the cold chain requirements, rural areas of the state will have to wait for the Moderna vaccine, she said.

She said they were taking the time to micro-plan at the county level to protect the most vulnerable populations. “I don’t know how many plans we have crumpled up and thrown away as changes have come down,” Fiscus said. “It feels like it happens on a daily basis. But I think it is possible to plan for the unknown and create a safe harbor to promote health for every Tennessean.”

Atul Gawande, M.D., founder and chair of Ariadne Labs, began his talk by thanking local public health officials and calling them heroes, saying he could not understate the burden they have been under. They have inadequate staff and computer systems while having to scale up testing and tracing programs, do case reporting, and coordinate with hospitals. “Now we are asking them to lead on making sure vaccine distribution runs smoothly.”

Gawande said other advanced countries have advantages over the United States. For instance, in the U.K., everyone has insurance coverage and most people have relationships with physicians. “The U.K. has a flu list of the most chronically ill already identified. They can use that. Not us. We don’t have any of those systems.”

He said a key to success will be demonstrating to the public that a vaccine system is working and equitable, “and that bus drivers can get prioritized ahead of bankers. If we’re going to demonstrate a working and equitable vaccine allocation, we need a fair system and one simple enough for the public to understand.”

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