Utilising track and trace processes and technology to limit the spread of the virus
Setting the context
Why is contact tracing an important intervention to contain COVID-19?
Contact tracing has been a core disease-control measure employed by healthcare professionals around the world for decades. It is a fundamental approach to combat the spread of infectious diseases and is a key process for identifying clusters and preventing exposure in order to eliminate local transmission.
Contact tracing may reduce transmission at any stage of the COVID-19 epidemic, whether in countries or regions where the epidemic is emerging, at the peak of the epidemic or to support the safe transition out of a lockdown. However, contact tracing is most impactful during the early stages of the epidemic to control and contain the disease effectively.
In addition, effective contact tracing reduces the need for widespread and prolonged lockdowns, and thus helps to reduce the significant psychological, emotional and economic impact of restricted movement. Track and trace digital apps help to lighten the load on manual processes and can help slow the spread of infection until vaccines and treatments become widely available.
Some countries have experienced first-hand the trials and tribulations of employing contact tracing methods due to previous disease outbreaks such as SARS, Middle East Respiratory Syndrome (MERS), Ebola, tuberculosis and other infectious diseases. Hence, these countries/regions (examples include South Korea, Hong Kong, Australia and Singapore) are better equipped to coordinate and combat the spread of COVID-19 through effective contact tracing processes.
A summary of manual vs digital contact tracing
To date, there are two types of contact tracing approaches that can be deployed: manual contact tracing and digital contact tracing. The digital contact tracing approach is a mobile app that can be downloaded on a smartphone designed to identify and locate potential patients. This is an innovative strategy recently developed to combat the COVID-19 outbreak. The manual contact tracing approach relies on tried-and-tested methods of deploying healthcare professionals to screen and identify patients. Other professionals and civil servants such as immigration officers and police officers can also play an important role in manual contact tracing.
Manual contact tracing is a laborious activity which requires individuals with specialized skills. To be done effectively, it requires healthcare staff with the training, supervision, and access to social and medical support to handle patients and all contacts. Other professionals, such as immigration officers and police officers, need to be equipped with the right tools, knowledge and procedures to be able to identify and engage with potential patients and contacts without compromising their own safety and the safety of others.
In the case of manual contact tracing, patients diagnosed with COVID-19 are requested to provide a detailed history of contacts to prevent further transmission. However, those infected may struggle to recall all interactions within the minimum 14-day timeframe, leaving certain contacts undetected and untreated, thereby heightening the risk of transmission. However, such an approach ensures patient confidentiality, which is a major concern for most patients. In situations where there is an absence of a digital tool to track and trace the spread of the disease, the manual process can play a significant and complimentary role in reducing local transmission.
Digital contact tracing allows for swift distribution of information to alert individuals potentially exposed upon identification of a COVID-19-positive patient. Exposed individuals can act on real-time information and either self-isolate to prevent transmission or, if necessary, seek medical attention. The collation of real-time information also enables the government to conduct targeted testing to manage and further control the spread of the disease.
The scalability and speed of a digital approach, using apps embedded in smartphone devices, makes it a practical, cost-efficient solution. However, for such an approach to be effective, the disclosure of personal information is required, which inevitably limits mass user adoption.
Key findings from the analysis
Key Finding 1: Relying on manual contact tracing alone is labour intensive, costly and time consuming in a pandemic of the scale of COVID-19.
- Manual contact tracing requires trained and skilled healthcare professionals with a firm understanding of principles of exposure, infections, symptoms of diseases and contact tracing, in addition to interpersonal and interviewing skills to manage patients.
- The lack of a large talent pool of trained healthcare professionals and total cost of hiring can stretch a country’s financial resources, especially considering other competing priorities such as acquisition of medical equipment, the establishment of makeshift hospitals, and the need for additional drugs and medicine.
- Tracking contacts through interviews with confirmed patients can lead to uncertainties due to an over reliance on patient memory, in which the degree of accuracy in contact identification can be low. As such, contact tracing turnaround time will be slow, leaving room for the virus to transmit rapidly.
Manual contact tracing and its limitations
Traditional contact tracing processes have been honed and refined over decades in response to various infectious disease outbreaks such as SARS, MERS, and Ebola. Despite the introduction of contact tracing technology, trained contact tracers are still required to analyse data and information captured and subsequently, to engage with patients and their contacts. Timely communication with patients in times of crisis is key to prevent misinterpretation of information while patients are under emotional and mental stress. The following interventions typically take place via a manual approach:
- Officials can ask patients about their movements and recent contacts, and obtain a better understanding of the extent of the spread
- Officials can advise patients to get tested for the disease and make sure they are quarantined and adhere to the established SOPs
- Officials can offer direct advice on other related matters that may be of concern to the patient
Human interaction is considered important to establish the bond between two people. For healthcare professionals, the ability to engage with a patient and be able to answer their questions, address their needs and allay their concerns is seen as important in ensuring a productive contact tracing session. Additionally, building, earning and maintaining their trust and confidentiality is crucial in such times, and is a missing element in digital contact tracing. However, as we’ve seen, manual contact tracing can be time consuming and requires a large talent pool of skilled resources to manage patients.
Typically, competencies required by healthcare staff to implement manual contact tracing are as follows:
- A firm understanding of patient confidentiality, including the ability to conduct interviews without violating confidentiality
- Understanding of the medical terms, principles of exposure, risks of infection, incubation period, and symptoms of other underlying diseases that may be harmful
- Excellent and sensitive interpersonal skills, cultural sensitivity, and interviewing skills such that they can build and maintain trust with patients
- Basic skills of crisis counselling and the ability to refer patients and contacts for further care if needed
- Resourcefulness and proactivity in locating patients and contacts who may be difficult to reach, reluctant to engage due to privacy concerns, or unaware of reporting procedures
Considerations of manual contact tracing
A country or region needs a large number of trained contact tracers. These contact tracers need to locate contacts quickly, discuss what needs to be done and assist in arranging for patients to isolate themselves. They can also work with patients to identify people with whom they have been in close contact, so the contact tracer can locate them. The estimated number of medically trained staff needed is large and varies depending on a number of factors including but not limited to:
- The number of registered daily cases
- The number of contacts identified
- How quickly patients are isolated and advised to self-monitor and conduct standard tests and procedures
- How quickly contacts are informed to stay home, self-monitor and maintain social distance from others
Case Study: United States of America
The total cost of deploying a countrywide manual contact tracing programme for the US could reach USD 46.5 billion
New York City was one the hardest-hit regions in the world, and it showcases the difficulties that the US has had with building manual contact tracing capacity despite its capability and readiness to adopt digital contact tracing. New York City has a population exceeding 21 million people and has recorded over 32,000 COVID-19 deaths. As of 22 June 2020, they have hired over 3,000 contact tracers, but the programme is off to a slow start as they learn how to do this difficult and complex work.
Similar efforts are underway throughout states and cities in the US. Bloomberg Philanthropies has partnered with New York State to train up to 16,000 additional tracers, and has partnered with the Johns Hopkins School of Public Health to develop an online contact tracer training course that is free and accessible to all., 
These efforts all run into the same challenge: Contact tracing armies are difficult to build overnight. And the cost of a full-scale manual contact tracing approach can be substantial, subject to the scale of the operation designed for a country. In the US, two former federal health officials, Scott Gottlieb (former Food and Drug Administration chief for President Trump) and Andy Slavitt (former director of Medicare and Medicaid in the Obama administration), suggested the federal government create a massive manual contact tracing programme. The plan was co-signed by 14 other doctors, scholars, and policymakers. The suggested plan would cost a total of USD 46.5 billion, which includes the following:
- USD 12 billion for a maximum of 180,000 contact tracers
- USD 4.5 billion to house infected patients and exposed contacts in vacant hotels
- USD 30 billion for a total of 18 months of income to support those voluntarily self-isolating
The lack of digital adoption by the US stems from data privacy issues and the strong opposition to any form of government surveillance. Despite Apple and Google co-developing specifications that would allow apps to be developed with smartphone-based exposure notifications and minimal risk to privacy, most governments in the US have yet to warm to the idea of a digital approach, save for a few states such as North Dakota, South Dakota, Wyoming, Rhode Island and Utah, which have developed voluntary COVID-19 contact tracing apps., 
As of 24 July 2020, the US had recorded over 4.1 million COVID-19 cases. As a gauge, the country with the next highest number of cases is Brazil with over 2.3 million cases, almost one half of the US total. As a result, the US also suffers from the highest number of deaths at 147,672.
Whilst various factors contribute to the impact of COVID-19 in the US, it is not possible to ignore the sheer scale and monumental effort required to conduct manual contact tracing where there are more than a million active cases. Manual contact tracing is still ramping up, the efforts are fragmented across cities and states, and digital options are not under serious consideration to fill the gap. Despite the understandable data privacy issues, the reluctance to augment manual efforts with digital solutions, despite the quality of the infrastructure and high mobile penetration rate, could be costly in the long run.
Case Study: Sweden
Launch of digital contact tracing app without official government endorsement will limit user adoption
Sweden has not embarked on a government-driven-and-endorsed digital contact tracing initiative, given its unique approach in managing the COVID-19 pandemic to date. Instead, it still relies on a manual track and trace approach which is achieved through interview sessions to identify potentially exposed individuals.
Nonetheless, researchers at Sweden’s Lund University have been proactive in developing a digital solution and launched a free contact tracing app on 29 April 2020 to help map the spread of infection in Sweden. It was designed by a group of experts consisting of scientists and doctors at King’s College London, Guy’s and St Thomas’ Hospitals and Zoe Global Limited, a health technology company. Without official government endorsement, the app was only downloaded by 2,000 people during its first day of launch, despite the country recording almost 20,000 cases and 2,355 deaths on the same day.
However, to help collect meaningful and real-time data until the pandemic subsides, the researchers have encouraged local residents to use the app on a daily basis. Usage of the app takes one minute per day to answer simple questions about an individual’s health. Such commitment from the public could help contribute to a reduction in the spread of COVID-19. The aim of the app is to obtain the following information:
- Which locations in Sweden may have a high risk of COVID-19 infection
- Which behavioural factors raise a person’s susceptibility to infection
- How underlying health conditions affect risk
- How rapidly the virus is transmitting in different parts of Sweden
The app is not designed as diagnostic tool, and it does not collect data such as names, identification numbers, addresses or telephone numbers. Participants only provide their e-mail address when they first create a user account – however, e-mail addresses are not included in the research database. Furthermore, the location feature only records the first two digits of the user’s postal code for identity protection. No other geolocation features are collected to track a user’s movement.
All information is handled in accordance with the General Data Protection Regulation (GDPR), a regulation in EU law on data protection and privacy in the EU and the European Economic Area (EEA). Additionally, all information will only be used for research and not for commercial purposes. In line with opt-in configuration, the use of the app is strictly voluntary with users knowing that all information is purely for research purposes.
The app designed by the researchers from Lund University has been approved by the Swedish Ethical Review Authority under Sweden’s Public Health Agency, which is the body responsible for managing Sweden’s coronavirus response. However, there has been scepticism over how useful the app would be since the authority has already retrieved its own data via manual contact tracing.
- Sweden recorded its first COVID-19 case on 1February 2020 and recorded its highest single-day tally on 25 April 2020 when 812 new cases were recorded.
- Sweden has adopted a unique approach of fighting COVID-19 through herd immunity.
- Sweden’s government has closed public institutions and banned large public gatherings, but it has not mandated its citizens to remain indoors or wear protective gear. The government has offered sound medical advice but has not imposed a nation-wide lockdown.
- According to Sweden’s state epidemiologist, since the virus can be transmitted easily by people who show no symptoms of illness, it can’t be contained by lockdowns and contact tracing.
- Sweden has recorded higher cases than other Scandinavian countries, many of which have or are planning to, deploy a government-endorsed digital contract tracing app.
Key Finding 2: Government assurances on personal data protection are critical to user adoption of digital contact tracing apps.
- Without clear governance and guidelines on data protection, there is a serious risk that user adoption will be low. Countries such as Australia have introduced new data privacy laws in parliament specifically to govern data managed by contact tracing apps, with commitment to cease data collection for contact tracing initiatives once the pandemic is over.
- Design and configuration of apps should be user friendly and non-intrusive, with only necessary information captured (i.e. phone number, name and age). Apps should be equipped with security features and data should be encrypted to maintain confidentiality and prevent data breaches.
- Governments should ensure that only select personnel have access to data, and that all information will be deleted once it is no longer needed for public health purposes.
- Countries that have developed strong personal data protection measures for their contact tracing apps include Australia, Israel, Italy and Iceland.
Digital contact tracing
As of 17 May 2020, at least 16 of the top 20 countries have already adopted, or are in the midst of adopting a digital contact tracing approach, particularly those with ready infrastructure and high mobile penetration rates. However, challenges remain with regards to privacy laws and voluntary user adoption, both of which impact effectiveness and efficacy of the app. Digital contact tracing apps have been developed to achieve the following:
- Enhance traceability of infections through availability of real time data
- Identify infected individuals and subsequently trace and monitor the contacts of the infected individual for containment purposes
- Help ensure the safe, sustainable and effective quarantine of exposed individuals to prevent local transmission
- Increase awareness and notify the public of risk of exposure within a given area or concentration
- Improve the efficiency and accuracy of data management and automating tasks for public healthcare
- Reduce the burden of data collection on public health staff by allowing electronic self-reporting by infected individuals and contacts
- Enhance quality of data for analysis, reporting and formulation of solutions and policies
- Help communities and individuals re-enter society safely when the number of cases declines.
To address the COVID-19 pandemic swiftly, Apple and Google collaborated and co-developed a digital contact tracing framework that allows public health authorities around the world to create tailored mobile apps that notify the public when they have been exposed to the coronavirus.
The app is referred to as an ‘exposure notification’ tool and uses Bluetooth technology within smartphones. Apple and Google are providing the Application Programming Interface (API), but public health authorities will have to develop their own contact tracing apps based on their required configuration, guided by local privacy laws. In order to promote mass adoption and reduce fragmentation of a digital contact tracing approach, use of the API will be restricted to one app per country.
Apple and Google have confirmed that some states in the US (i.e. North Dakota, South Dakota and Utah) and 22 countries will be using the software.
How many contact tracing apps are available and how are they configured to ensure data privacy?
According to the Massachusetts Institute of Technology (MIT) COVID Tracing Tracker, more than 26 countries (and counting) have already deployed or are in the midst of developing a digital contract tracing app. In line with this digital approach, various countries are cautious in their app design and deployment, as they do so by adhering to various types of configurations, data privacy settings and governance in accordance to their data privacy laws. Additionally, some apps are produced locally by small groups of coders, while others are vast global operations. Some countries have adopted the Apple and Google co-developed app, which mobilises a large team to build their systems.
*Note: Not yet deployed, last updated 17 May 2020
Despite the myriad of services available, deployment of most apps is still relatively new and there is little information and direct evidence of their efficacy and their broader social implications. There are also numerous configurations across the different contact tracing apps that may impact user adoption. Additionally, not all countries have been completely transparent with the operations, management and policies that govern the apps, which raises questions for people and may affect uptake.
Typically, there are six distinct parameters that determines whether a digital contact tracing app fulfils its intended objective whilst maintaining data privacy and freedom of choice.
Voluntary Download: Can a person choose not to use the app with no ill effects and does the app require explicit permission from a user?
Limited Data Use: Are there strong and clear functionality limitations against using data for purposes other than public health?
Data Destruction: Do the technology and associated policies ensure data is deleted when it is no longer needed for public health purposes?
Minimised Data Sharing: Are policies in place to ensure only necessary info is collected? Is data sharing with outside entities prohibited?
Transparent: Are the government and the technology transparent about what data is acquired and from where, how the data is used and who has access to it?
Centralised/Decentralised: Is the data managed through a centralised or decentralised system? Centralised data is consolidated into one repository; Decentralised data stays on personal device.
Based on information available on the MIT COVID Tracing Tracker (17 May 2020), only three countries (i.e. Austria, Israel and Italy) have developed a contact tracing app that fulfils all six distinct parameters concerning data privacy and freedom of choice, including a decentralised model which ensures data remains with the user. However, this does not mean that these apps will be the most effective in combating the spread of COVID-19, neither does it mean user adoption will be highest compared to other apps.
Nonetheless, the development of a digital contact tracing app is still viewed as a viable option for most countries since cost of development is dramatically less than the cost of manual contact tracing. Subject to the levels of configurations, an app commissioned by a government for the purpose of contact tracing may cost anywhere between USD 100,000 to USD 500,000. Meanwhile, the cost to the economy of continuous lockdown has already reached billions of dollars. It is no surprise then that, despite the lack of evidence so far on the effectiveness of digital contract tracing, governments are willing to invest in digital contact tracing apps to support other initiatives.
Clear guidelines lead to effective implementation of a contact tracing digital app
In implementing a digital contact tracing app, the Centre for American Progress (CAP), one of the leading think tanks in Washington, DC, released a list of recommendations for countries and states who wish to adopt digital contact tracing. Their approach seeks to maximise privacy protection while encouraging the most effective and prudent use of digital contact tracing apps.
- Governments should consider adopting a decentralised approach. Data can be stored locally on people’s phones and anonymised for government storage.
- A digital contact tracing system is best designed for voluntary subscription. Earned trust is more valuable than compulsion, especially given the legitimate and heightened concerns about government surveillance.
- To encourage trust, governments can put in place limits on how long data will be stored, both locally and in anonymised databases. If Bluetooth is sufficient for contact tracing, there is no need to collect GPS or Wi-Fi information for geolocation features to tracks people’s movements.
- Governments may want to establish legally binding guidelines about what information will be collected and how it will be used. Only healthcare workers (not local and federal law enforcement agencies) involved in contact tracing initiatives require access to the information.
- To encourage transparency, governments can place the app software in the public domain or operate under an open source license. This can enable the public to understand how the app operates. Additionally, this can make it easier to build apps faster and coordinate across other local governments and states. Public health agencies can also commission and contract trustworthy and reputable companies with clean records.
- Any government-approved contact tracing app can be developed with patients and public health workers, with syndications with the general public prior to its deployment. This can enable transparency, ownership and buy-in from end-users, and eventually increase user adoption.
- Governments can set up independent advisory boards focused on privacy and civil rights; those panels can be empowered to hold hearings and collect information from documents and witnesses to provide this oversight.
It must be re-emphasised that digital contact tracing is still a novel approach and was only introduced during the start of the pandemic. Its effectiveness has yet to be proven as there is limited and inconsistent evidence to suggest that digital contact tracing alone can be a one-size-fits-all solution to future contact tracing efforts. Early results have varied in different countries, and best practice in terms of deployment approach, user experience and adoption, and implementation is still emerging.
Key Finding 3: Usage of Bluetooth technology can uphold data privacy whilst ensuring relevant contact data and information are sufficiently captured for tracing purposes.
- The introduction of Bluetooth technology in contact tracing apps has eliminated the need to use intrusive geolocation features such as GPS.
- All smartphones have Bluetooth-enabled connectivity. Information exchanged between devices using Bluetooth can be encrypted, increasing security measures and privacy.
- The current Bluetooth technology employed by most apps can be prone to false positives and false negatives due to its inability to detect whether contacts are taking precautions against the virus and whether barriers exist between contacts.
- Without appropriate measures to address the false signals, individuals who are not likely to be infected may be required to quarantine several times, impacting daily activities and employment.
Effective Practice Case Study: Australia – COVIDSafe App
The introduction of the COVIDSafe app is accompanied by new legislations that will uphold user data and privacy
The Australian government launched the COVIDSafe app on 26 April 2020 to enhance track and trace capabilities to contain COVID-19. The app was modelled after Singapore’s TraceTogether app, which records the Bluetooth connections a phone makes with a contact nearby, a central design feature of the app. The app was launched as part of Australia’s strategy to reopen the economy, based on the declining number of cases. The app would help enable the government to control and contain new cases.
The government target for uptake of the app is 40 per cent of Australian smartphone users – approximately 6 million users. As of 8 May 2020, uptake of the app has been positive with more than 5.3 million Australians downloading COVIDSafe since its launch on 26 April 2020.
Usage of the app is voluntary to acknowledge concerns about data privacy and government surveillance. The app only records a user’s name (or pseudonym), age range, postcode and phone number. The app does not perform location tracking, which has been a contentious feature of similar apps deployed in other countries. The Google version of the app, however, does request user permission for location information due to requirements permission needed for Bluetooth utilisation. The app can also be deleted at any time at the discretion of the user.
Using Bluetooth, the app records other individuals with the same app within close proximity (approximately 1.5 metres for 15 minutes or longer). The two apps then exchange anonymised IDs, which change every two hours and are stored and encrypted on the phones and deleted after 21 days. If a potential COVID-19 patient is identified, a designated health official will send a unique code via SMS for the infected person to key into the app for consent to upload the list of anonymised IDs which have had contact with the patient over the past 21 days. Upon consent, the data will be uploaded from the app at the time of positive testing and will be held by the federal government on an Amazon Web Services server in Australia. The system and analysis will then use signal strength and other information to identify who needs to be contacted.
With regards to data governance and storage, all information is stored and encrypted on a government server, and then passed on to state and territory health authorities where an individual’s contact has tested positive. During the launch, Greg Hunt, Australia’s Health Minster, announced a written directive that mandates only health authorities or those maintaining the app can access the information. Subsequently, on 14 May 2020, parliament passed the Privacy Amendment (Public Health Contact Information) Act to support the COVIDSafe app and ensure users’ privacy is protected. Furthermore, the COVIDSafe legislation provides additional protections under the Privacy Act 1995 including the following:
- The Office of the Australian Information Commissioner will have oversight over the collection and use of data by the COVIDSafe app.
- The operation of the Notifiable Data Breach Scheme is extended to include the protection of data collected by the apps at risk from eligible data breach.
- In addition to criminal sanctions (including imprisonment of up to five years), the COVIDSafe legislation sets penalties for any unauthorised disclosure of data to also include penalties imposed under the Privacy Act.
Such clarity and transparency in the configuration of the app and its servers, reinforced with specific legislation designed to protect user data and information, has enabled the Australian government to earn the trust of its citizens and to successfully deploy the COVIDSafe app.
However, despite the ongoing efforts of the government to ensure high utilisation, the app has yet to provide much meaningful assistance to local health authorities. This is in part due to the low levels of community transmissions recorded in Australia since its launch, hence the app’s capability has not been fully tested. As of 29 June 2020, the COVIDSafe app has yet to identify any new cases that were not already identified through manual contact tracing.
Nevertheless, health authorities still encourage Australians to download the app, as an unexpected spike in cases can occur, particularly due to the relaxing of lockdown measures which will result in social get-togethers, sporting events, and in certain cases, organised demonstrations (e.g. recent Black Lives Matter protests). In such circumstances, should a spike occur, the availability of such an app can greatly assist public health authorities to contain the virus quickly.
It is still unclear how successful the COVIDSafe app will be to Australia’s contact tracing approach, given that there are few public benchmarks available to measure against at the moment. It is still premature to judge the usefulness and effectiveness of the app given the current circumstances. In its efforts to cover all bases to combat COVID-19, the Australian government has taken a prudent approach to include contact tracing technology in its arsenal to protect Australian citizens and its economy from an unpredictable and highly infectious disease threat.
- Australia recorded its first case on 25 January 2020 in Melbourne.
- Australian borders were closed to all non-residents on 20 March 2020 after a series of increased daily cases, and social distancing rules were imposed on 21 March 2020.
- Australia implemented nation-wide lockdown on 23 March 2020, after a spike of 611 cases the day before. This was also Australia’s highest number of cases per day.
- Australia’s COVIDSafe app was launched on 26 April 2020, to help ease reopening of the economy after a continuous and significant decline in active cases.
Key Finding: Centrally managed and mandatory track and trace initiatives can be highly effective measures to contain COVID-19 transmission.
- Governments which have deployed mandatory track and trace initiatives such as South Korea and Hong Kong have been able to flatten the curve of transmission rapidly during peak periods through central management of data and coordinated efforts.
- Publicly available data can be utilized by third-party companies to develop user-friendly, enhanced features for effective warning systems, tracking and tracing.
- South Korea has legislation in place that explicitly allows authorities to publish personal information for the purpose of tracking and tracing infectious diseases.
Effective Practice Case Study: South Korea – Corona 100m app and Corona Map app
authentic and real-time data will enable app reliability and increase user adoption
South Korea was one of the first countries to be affected severely by COVID-19. To combat the spread, health authorities created a public database of COVID-19 cases for contact tracing that provides detailed information about every infected individual, including their age, sex, nationality and exact movements around the country. However, names are not made publicly available. Unlike most countries, GPS data is also used in contact tracing by health authorities. All data is stored in a government database. Through the database, text alerts are sent out at the discretion of regional governments and specifically target people in those areas, giving them an opportunity to avoid locations where active cases have been found. For individuals who test positive for COVID-19, investigators from the Korea Centre for Disease Control and Prevention (KCDC) interview patients first, then verify their whereabouts by checking closed-circuit television (CCTV) camera footage, credit card transaction records and GPS data from mobile phones.
South Korea operates a system to support epidemiological investigation of people infected with COVID-19 by utilising various cutting-edge technologies via a smart city technology system. The new system, co-developed by the Ministry of Science and ICT, the Ministry of Land, Infrastructure and Transport, and the KCDC, allows various data about confirmed COVID-19 patients to be immediately analysed and submitted to health investigators. The system is based on the country’s ‘smart city data hub programme’. Prior to the emergence of infectious disease threats, KCDC investigators had to formally request crucial contact tracing data such as CCTV footage and credit card transactions of confirmed patients from police investigators, resulting in protracted delays in epidemiological investigation. The contact tracing approach adopted by the South Korean government can be perceived as intrusive; however, its successful implementation hinges on the social and political culture of the country, and most importantly on citizen buy-in. It has not been adopted by any other country, apart from China. However, through this approach, South Korea has been able to manage the spread without imposing major lockdowns on its citizens and businesses
Following the serious MERS outbreak in 2015, which reportedly infected 186 people in South Korea and killed 36, the South Korean Parliament passed legislation that explicitly allows authorities to publish such personal information for the purpose of tracking and tracing infectious diseases.
South Korea’s Corona 100m app was launched on 11 February 2020 by a private developer and was downloaded over one million times in 10 days. Using publicly available COVID-19 health-related data as its main source, the app signals to users when they come within a 100-metre radius of a spot previously visited by an infected person. The Corona Map, which utilises the same publicly available data allows users to view where infected people are located using its real-time updated map. It also offers information about the dates the cases were confirmed, and the names of the hospitals and places that a person visited before testing positive.
With the support of legislation to minimise data privacy for the purpose of combating infectious diseases, South Korea was able to make vigorous use of the convergence of data and technology to rapidly improve the effectiveness of digital contact tracing. Despite being one of the first countries to experience the COVID-19 outbreak, past experiences from MERS coupled with the access to data, has enabled the country to manage the rate of transmission effectively. Data privacy concerns, however, have deterred many countries from adopting digital contact tracing at this level.
- South Korea recorded its first case on 20 January 2020. It reached peak cases on 3 February after recording 851 cases in a day.
- South Korea tightened its border checks on 19 March amidst lowering local transmissions.
- South Korea did not impose a major lockdown, but instead focused on diagnostic testing, isolation of contacts and social distancing.
- The Corona 100m app and Corona Map app were effective due to public availability of detailed health data for analysis.
Key Finding 5: Contact tracing applications are effective in identifying contacts and containing transmission when user adoption is high.
- A research team from the University of Oxford claims that around half of the population of a country needs to use a contact tracing app for it to be effective.
- Countries which lack communications infrastructure and have a low smartphone penetration rate will not be able to benefit from such an app.
- High-risk groups such as the aging population and low-income groups often do not have access to smartphones and internet connection, rendering them more susceptible to infections.
- Despite infrastructure readiness and a high mobile penetration rate, Singapore’s TraceTogether app has not achieved the desired level of user adoption.
Case Study: Singapore – TraceTogether app
Contact tracing apps are only as reliable as the number of users that willingly utilise them
On 20 March 2020, Singapore’s in-house IT agency, Technology Agency of Singapore (GovTech, in collaboration with the Ministry of Health, announced the launch of the TraceTogether app. The initiative was developed to help support contact tracing efforts in the nation-state to reduce the spread of COVID-19.
Singapore was the first country to deploy a digital contact tracing app. In order to help the international community address the escalating coronavirus situation, the government made the TraceTogether software freely available to developers around the world. Australia’s COVIDSafe app was modeled after the TraceTogether app, with slightly different configurations to suit local requirements.
Similar to most countries, the Singapore government has made the app a voluntary option for its citizens to download, and it can be deleted at any time. Once TraceTogether is uninstalled or the app’s functionality is disabled, all connection data collected on the phone will be lost. The user can also request for the mobile number and user ID to be removed from the centralised server by sending an email to email@example.com.
Additionally, data privacy is a priority. The only data that is collected by the government through the app is the user’s mobile number, which is logged and remains encrypted in the mobile device. Personal mobile numbers are not disclosed to other TraceTogether users. Only temporary IDs, which are generated by encrypting the user ID, are exchanged between phones. For additional security, the temporary IDs are designed to be refreshed regularly. The app does not collect or use location data or contacts, only who users might have been close to.
In terms of tracing technology, the app uses Bluetooth technology to exchange connections with nearby devices (within approximately two metres for 30 minutes or longer) that have the app. The app’s functionality is limited to present connections between devices, and not their locations. Data is stored in the phone for only 21 days and will not be accessed unless the individual is identified as a close contact. Only those who test positive for COVID-19 will be asked by the Ministry of Health to share the data logged to speed up contact tracing.
Within the first three days of the launch of the TraceTogether app, there were over 620,000 downloads. However, the hype around the launch quickly withered due to the resurgence of COVID-19 cases in Singapore in late March. Due to the loss of momentum in public engagement, only 32 per cent of the Singapore population downloaded the app since its launch on 20 March,, minimizing its overall effectiveness. In addition, the value and impact of any digital contact tracing app is limited in situations where maintaining robust social distancing is not followed.
The government also declared that should users be contacted by the Ministry of Health for contact tracing, they must submit and allow the authorities access to their stored data or be prosecuted under the Infectious Diseases Act. However, the law (passed in 1976 and revised in 2003) is vague and subject to interpretation. It suggests that users of the app are subject by law to submit data to the government and do not have full authority over the data stored on their mobile devices.
- Singapore recorded its first case on 23 January 2020.
- Singapore’s TraceTogether app was launched on 20 March 2020, the first digital contact tracing app introduced.
- Singaporean borders were closed to all tourists and short-term visitors on 25 March after two confirmed COVID-19-related deaths.
- Singapore implemented nation-wide lockdowns known as ‘circuit breakers’ on 3 April 2020.
- On 20 April, daily cases peaked at 1,426, primarily due to spread among migrant workers in dormitories.
Challenges with implementing digital contact tracing
- Encouraging citizens to voluntarily partake in an initiative is always a challenge, particularly if it involves opting into a system that has the potential for leakages and breaches in personal data.
- The use of Bluetooth technology is not foolproof, as it is still susceptible to register false positives and false negatives. Individuals may be falsely tagged as having contacted one another despite very low possibility of transmission – such as when the individuals are on the opposite sides of porous walls that a Bluetooth signal can penetrate. Additionally, the technology does not take into account when individuals take precautions, such as the use of personal protective equipment (PPE) in their interactions with others.
- Brief interactions, such as crossing paths in common public areas such as malls, cafes and parks will be substantially more common and less likely to cause transmission. If the apps detect these lower risk encounters as well, they will cast a wide net when reporting exposure. If most exposures detected by the apps would not lead to infection, many users will be instructed to self-quarantine even when they have not been infected. Individuals may tolerate a false positive once or twice, but after a few false alarms and the ensuing inconvenience of protracted self-isolation, many will start to disregard the warnings.
- The people in the highest risk groups, such as the aging or under-resourced individuals, are least likely to download the app while needing safety most. Other members of the public may download the app but be reluctant to report a positive status out of fear of being ostracised or stigmatised, or to prevent being quarantined and prevented from working.
- Hence, contact tracing apps cannot be the only tool to rely upon when assessing safety of community health. Ultimately, contact tracing is a public health intervention, not an individual health intervention. It can help prevent the public spread of the coronavirus, but it does not confer direct protection on any individual. As such, this creates incentive problems that require careful thought. Policy makers need to understand and devise initiatives that will naturally compel users of contact tracing apps to comply with instructions voluntarily, even without immediate benefit to them.
Country adoption of digital contact tracing apps
All countries in the top 10 recovery rankings have deployed a government-endorsed digital contact tracing app. Whilst their recovery successes have been anchored on a combination of strategic interventions, each country has decided to adopt a new and innovative approach toward contact tracing. This is particularly so as countries begin to ease lockdowns and prepare to subdue any potential of a second wave of infections. South Korea is the only country that saw a dip in its recovery index, despite being one of the earliest adopters of a digital contact tracing app. However, this was due to the easing of restrictions on public movements.
Other countries such as the US and Sweden, which have not developed government-endorsed digital contact tracing apps, are struggling with recovery efforts. Both countries are committed to manual contact tracing despite the challenges on capital outlay and resources required. Other considerations such as data privacy have weighed in heavily in considering a digital approach, even though both countries have excellent infrastructure and mobile penetration which could support digital contact tracing.
As countries begin to ease institutional lockdowns and movement restriction orders, all governments are actively considering proactive measures to prevent a second wave of COVID-19. Whilst the tried-and-trusted manual contact tracing approach can be a crucial strategy moving forward, it would make sense to combine it with digital contact tracing efforts in order to enhance detection coverage and increase public awareness. The emergence of technology in public healthcare is worth leveraging, given its scalability and cost effectiveness in combatting such a pandemic – especially when resources are inevitably stretched.
As governments develop bespoke contact tracing strategies, they are paying attention to the public’s concerns about data and information privacy. Particularly in an age where security breaches and leakages of private information are not uncommon, providing the highest level of assurance to the public on privacy is vitally important. This could be in the form of independent oversight of the data collected by the app, frequent audit exercises, and security clearance to access data, all enshrined in legislation. The careful development and successful implementation of digital contact tracing apps could be a game changer in combatting future infectious diseases and is worth exploring for inclusion as part of the wider healthcare infrastructure.
Recommendation 1: Deploy digital contact tracing apps alongside clear and implementable data privacy laws to encourage high user adoption.
- In a world governed by information and data, citizen privacy is bound to be a major concern for any government-commissioned app designed to track and trace the health status and location of an individual. Governments would benefit from providing the highest level of assurance on data privacy and governance to encourage user adoption.
- Countries such as Australia have done well to earn the trust of its citizens in deploying a voluntary contract tracing app. The introduction and tabling of the Privacy Amendment (Public Health Contact Information) Bill 2020 in parliament to address data privacy concerns on its COVIDSafe app seems to have quelled public concerns. The government will also legislate to prevent data from the app being moved offshore.
- In introducing such an app, government leadership need to engage in an open and transparent dialogue to ensure all privacy- and data-related concerns are publicly addressed with clear solutions and mitigations.
Recommendation 2: Combine manual and digital contact tracing to address gaps and limitations in both approaches.
- In a pandemic of the scale of COVID-19, it is not possible to contain the spread of the virus with manual contact tracing alone. The thoughtful use of digital technology can enhance efficiency and coverage.
- Contact tracing technology is still limited in its functionality and strict data privacy laws are necessary to gain public consent. The risk of false positives and false negatives with digital options could result in confusion and the misallocation of healthcare and financial resources. Furthermore, frequent false alarms will undermine the technology’s credibility.
- It therefore makes sense for governments to consider developing and deploying a holistic contact tracing approach involving both manual and digital contact tracing. Manual tracing is still required to ensure that the data and information collected are analysed correctly by trained healthcare staff and that patients and contacts can obtain the required medical advice. At the same time, digital contact tracing can be utilised as a first responder to isolate potentially exposed individuals before they obtain medical advice from healthcare professionals and/or immediate treatment.
Recommendation 3: Governments should ensure adequate access to testing facilities and clear advice on self-isolation at the time of the launch of a digital contact tracing app.
- Substantial reductions in the number of COVID-19 cases through contact tracing requires both easy access to proper testing and medical facilities, and clear isolation guidelines.
- increase in the number of patients and contacts identified through the contact tracing app.
- Enforcement of targeted measures and clear SOPs to ensure effective quarantining efforts would increase the benefit of a contact tracing app.
 As of 24th July 2020 – CNN Health
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