[MUSIC PLAYING] SPEAKER: So if technology can help us in case investigations and contact tracing, let's go through some examples and how it can be used in each step. So as we think about technology, we should think about technology that can be used in each of the basic steps for case investigation and contact tracing. So, first, when we interview the case and are assessing their symptoms, we're asking them to isolate and providing support, and recalling information about contacts, so there's some technology we can use there. There's some technology that we may be able to use for notifying contacts, and some additional technology we could use for interviewing the contact. And that includes, again, assessing symptoms, ongoing tracking, and asking them to quarantine and provide support. First, let's talk about electronic case reporting. So when a patient or when someone gets tested for COVID-19, their information is typically entered into some kind of electronic system, because that system is how their information will be linked with their test result. So usually in a jurisdiction, there's a central database where positive test results are reported from the lab. It's going to vary by region exactly how this works, but, usually, there'll be some database that has a list of people and their information who have had a test. And then, when the test results come back from the lab, they'll link up there. And that's where you identify cases. So one problem at this step, is that it can take time to gather data and information on cases for investigations. So if you're doing this manually, looking in one place for patient information, looking in another place for the test results, it can take some time. So one solution, one technological solution, is an automated standardized reporting of positive tests to the case investigators. So there are some applications that have been developed to make this more of an automated process, so that you don't have to go looking through the databases to find cases individually. They'll just be reported out in more of an automated way. The added value of this, is that there's less time between the diagnosis, or when the test results come back, and the call from the public health team. So as a contact tracer, sometimes you'll just be given the list that's already put together of the cases that you need to identify and make contact with. And that often comes from an electronic case reporting system. As you'll recall, a really important step in case investigations and in keeping in touch with contacts is tracking of symptoms. So it's important for cases because if they develop worsening symptoms, that could require medical care, sometimes urgent medical care. You also need to know about their symptoms because you need to know when they've recovered and when they can end isolation. For contacts, it's important to identify if they develop signs or symptoms and need care or if they develop signs and symptoms and maybe to get access to a test because they may have become a COVID-19 case. So for both cases and contacts, it's important to track symptoms. Now the problem here is that the conventional way to do this is a daily call. So you would call cases and contacts every single day to follow up with them, and that can be time consuming for the contact tracer and also for the cases and contacts themselves to have this call every day. So one solution-- technological solution-- that has been proposed is there are applications where cases and contacts can directly enter symptoms into a database. Sometimes there are also text messages that can be sent to contacts in cases to report new or worsening symptoms. And sometimes this is automated. So in some places, for example, each case and contact may get a text message every day to ask if they have a fever that day and if so, what their temperature was. That could save some time. So you don't have to call them, and it's a more convenient way for them to enter in their symptoms each day and track them. Of course, these are going to vary by jurisdiction, but we just want you to know that these are some applications that are used in some places. The added value of this kind of technological tool for tracking symptoms is that there's less time required by the contact tracing team and, again, sometimes less time for cases and contacts. But the cases and contacts should always know that they can pick up the phone anytime and talk to their contact tracer or the local public health department if they need assistance. This doesn't replace the role of discussions and phone calls between contact tracers and cases and contacts, but it just helps it along if you don't need that daily conversation. As you know, asking people to isolate themselves and quarantine is asking a lot of people, and some people may require help with doing this. They may need help getting food or medicine to support quarantine, for example, and people are going to be more likely to isolate themselves in quarantine if they get more reminders. The problem here again is that if you're making daily calls to cases and contacts, it can be time consuming for them and for you. So one solution-- one technological solution that's been proposed-- is that text messages could be sent to cases and contacts to remind them every day that they're still in isolation or they're still in quarantine and remind them of what that means. Those automated messages can also provide them information about where and how to get support services if they need them. That can be useful because even though a contact may not need help the first time you talk to them, a few days later, they may realize that they do need some help with food or other services. So it's important for them to know every day where they can go if they need that service. The added value of this kind of automated communication is that it can require less time, like for the contact tracing team, and cases and contacts also get very frequent follow up. If you're supposed to be doing this by phone and the team is running behind, sometimes you could miss getting cases and contacts important information. So this makes sure that nothing slips through the cracks. It's always very challenging to identify contacts quickly. There can be numerous difficulties with identifying contacts quickly. First, cases may not remember all of their contacts, or they may not want to talk about their contacts with the interview, due to their own privacy concerns. Cases may not know the phone number or the address of their contacts, and phone numbers for contacts may be incorrect. So it takes some time to get the right information from cases about their contacts, and even with your best efforts, you may not have always the information that you need. Once you have that information, it takes time to find those contacts and get in touch with them. Sometimes they may not pick up the first time you call. It may take extra effort. So there are a few possible supportive technologies that you can think about or that you may use in your job that will help with this. If you've been following the news about the pandemic, you may have heard about some way that smartphones were used in other countries to quickly identify contacts. This kind of system is not being used in the United States, but we just want to talk to you about it so you know what the system is. And you can know how it's different than other types of systems that may be used in the US. So in places like China and South Korea, they used a centralized database of phone numbers and locations. So in these countries, phone numbers of all the citizens are available to the government. They're unique identification numbers that each person has, and those are linked with all of their phone records and their medical records. And these are all maintained on a central server. So the government can find any person, and for that person, they know their phone number. They can access their phone's data. So they know where they were, and they also have their medical records. So health authorities can quickly link positive test results with their recent contacts and locations using the GPS data from their phones. So in this kind of scenario, when the government has all of the data linked together about you, if you have a positive test, they can quickly send text messages to all the people you've been in contact with because they know, based on your phone and the GPS records, where you've been, and they know from the GPS records of everyone else's phone who was there at the same time. So the added value of this system, of course, is that all the contact information and contact tracing is done immediately. So public health has easy access to all the information, and they can send out text messages quickly to everyone who was at the same place that you were if you become a case. But this technology does bring in added concerns. So in many countries, people would not agree to having their movements tracked in a centralized database by the government. And this is true of the United States. There is no place now for the government to track our movements via our phone. And the other concern is that a GPS location is not a great way to identify who you had contact with. So let's say just because you were in the same shop with someone for a few minutes, that may not mean that you were really exposed to them. So it's not a great way to identify who's had a potentially infectious contact. So again, this isn't a system that's being used in the US or proposed in the US, but it is a system that was used in other countries to combat COVID-19. In the United States, however, there are some efforts to try to design applications that could use smartphones to identify who you've had contact with. So the idea here is that smartphone users could download an application onto their phone, and that application will communicate with other phones that also have the app. They'll use Bluetooth technology to communicate that you've been in contact, and in contact, we mean again within six feet for about 15 minutes or so just as an example. And so what happens is if a lot of people download this app, as you go about your day, you will come into contact with other people who also have that app on their phones. And so the apps on the phones will recognize each other and send a little message that says, hey, we were in contact for this amount of time. You won't be able to know any information about who that person is. The app will not collect any information about who the person is or where the contact happened. So there's no private or confidential information here. It's just keeping know of which other phones have been in contact with you. So it's basically just a list of those phones if they have the app on them. So then if you or someone else who had this app was diagnosed with COVID-19, you could enter the information in the app, and the app would immediately notify all the other contacts you had automatically if they had the app as well. So the added value with this kind of system is that contacts are notified of their exposure immediately-- well, at least as soon as a person who's infected puts that information into their app-- and then they would be advised to quarantine. So ideally, you're be cutting out some of the time that it might take public health to find you and let you know. Also the identity of the case and their contacts is always kept confidential because you don't know who it was in particular that you had contact with who was infected. This app could be useful, but there are still some added concerns. So it's unclear how the data could be used by public health teams, and the effectiveness of this contact tracing effort would depend on the number of people who use the app. So if you live in a place where no one's really using the app, then it's not going to be that useful. Also, not all of the contacts that are identified through the application may truly have been exposed. So that would be another complicating factor. So as I mentioned, these applications are still being developed. They're not finalized, but we wanted to let you know that they're out there because it's possible that in your contact tracing job, you may be using them one day, or at least in some version. These applications would need to be able to share data with the public health system in some way to make them really useful and valid. So we're still waiting to see how that might be done. I want to walk through with you just a timeline of what that notification app might look like. So you can see or think about how it might really work. So let's imagine this is you at home in the circle, and you have your smartphone. And you have the app on your smartphone. And the two people you live with also have the app on their smartphone. So when you're together in the home, those apps will be communicating with each other, and they will know that you have had contact with each other. Let's say you get on a train to go to work. You'll have some close contacts-- so people who were within six feet of you while you're on the train. You may also have people who are proximate contacts. So they're near you, maybe more than six feet away, but you're on the train together for, let's say, an hour on your commute. So their phones may also tell them that they've had proximate contact with you. When you go to work, you may also have other close contacts or nearby contacts. So people are who are in the same space with you for your workday, even if you did not come within six feet of them, if they have the apps on their phone, their apps are also logging their contact with you through the app. The same is true when you get back home that day. So let's imagine the next day, when you're back at home, you wake up with a fever, and you're sick. So you could put that information into your app, and it would notify both your close physical contacts and people who've been near you and tell them that they should quarantine. So you can see how this would speed up the communication process with close and nearby contacts, but you need to be sure of a few things, including the person entering the information really has COVID-19. So this application information would need to be linked with public health and the test results. You'd also need to know who those contacts are so that public health can follow up with them and make sure that they have all the quarantine and isolation instructions they need and also the social support they may need to carry out isolation and quarantine. So when we think about these technologies that could be useful, there are a few important considerations to keep in mind. Effective public health interventions depend on public trust. So any kind of technology that we use to support case investigations and contact tracing has to be a method that's trusted by the public, and they have to know that it's being done to support them. Sometimes we want to use technology to help contact tracing efforts, but some communities may have limited access to these technological tools. Some people may not have smartphones. Many people may not have good internet at home. So any kind of technology that we use should be usable and should be applicable for the people that we're trying to help. Finally, just knowing about being near someone who had a positive COVID-19 test and being asked to quarantine by text message really might not be enough to persuade people to act. So while sometimes these technological tools can help public health-- maybe they make notifications faster-- they really can't replace the role of public health and supporting people through isolation and quarantine-- so just keep this in mind. [MUSIC PLAYING]
