By Lauren DeVos
The collection of public health data throughout the COVID-19 pandemic has proven to be the most pivotal piece for successfully slowing the spread of the virus and flattening the curve. As the pandemic continues and various solutions around contact tracing and exposure notifications emerge, questions about the impact and effectiveness of these solutions have surfaced.
U.S. Digital Response (USDR) has worked with governments and NGOs from across the country to support public health efforts, including standing up COVID testing sites, advising on data integrity and interoperability, and providing insights and recommendations surrounding contact tracing. Throughout this work, we realized there was a lack of efficacy data that could help government leaders and decision makers determine the best course of action regarding exposure notification technology.
In September, USDR partnered with The Rockefeller Foundation to uncover learnings around exposure notifications that could be useful for our government and NGO partners as they continue their COVID response efforts. Together, we saw an opportunity to learn from other countries, especially those with similar challenges to the U.S., that have successfully implemented exposure notification technology. The overarching goal was to learn about their processes and to understand the greater public health outcomes.
Officials from Germany and Ireland, who launched and led their countries’ exposure notification programs, joined USDR and the Rockefeller Foundation to host a virtual event centered around their work. Public health leaders, including more than a dozen “do-ers” from various states and a handful of countries, along with leaders from various think tanks, joined together to discuss the approaches and implementations thus far for Google Apple Exposure Notification (GAEN) apps. The following are practical takeaways from the conversation to help you implement a successful exposure notification program.
Integration with testing is critical.
If your state is taking 10 days to get back to people with COVID test results, all efforts around exposure notifications or contact tracing are moot. The most important aspect of a successful exposure notifications program is turnaround time with testing. Those who have opted in to receive exposure notification alerts need to know where to get tested if they’ve been exposed and have quick access to the results to determine next steps.
In Seattle, USDR partnered with city officials to rapidly vet and choose online software to allow the public to sign up for COVID-19 tests in advance. The online portal, offered by Solv Health, allowed the city to collect necessary billing and contact information up-front to facilitate efficient testing, resulting in Seattle testing nearly 300,000 people using the platform we vetted. The portal also enables contact tracers to communicate with individuals for whom COVID-19 was detected.
Rich and trustworthy consumer experiences lead to higher adoption rates.
Having a secure back-end and clearly communicating the measures taken to ensure privacy will pay dividends when it comes to whether the app actually catches on. Skepticism around data usage can be a strong deterrent for people considering downloading the app. Avoid any cause for concern by proactively addressing any potential questions in a way that will resonate with consumers. When Google and Apple announced their collaborative Exposure Notifications System, they placed great emphasis on the design elements in place to protect users’ privacy. In plain language, without technical jargon, they share details about how users can opt in for exposure notifications, how Bluetooth tracks proximity instead of location, how users’ identities are not divulged, and how only public health authorities have access to the data. The underlying concern is still there, however, as 71 percent of Americans say they don’t plan to download a COVID contact tracing app, citing digital privacy concerns as their main deterrent, according to a survey conducted by security software company Avira.
Germany and Ireland (along with many other countries) have open sourced most of their codebase, taking another approach to increasing transparency and building trust among privacy advocates, epidemiologists, and the public. An added benefit of open sourcing is that it’s created a community of interdisciplinary GAEN implementers who can customize the technology to their local context and transparently share learnings with one another, as we’ve seen through this event.
Comprehensive, properly executed programs result in positive public health outcomes.
Governments that deploy an exposure notifications app within the context of a larger, successful contact tracing effort will see positive outcomes for both. Many focus their attention primarily on the development of the app, but don’t always consider other important aspects, such as marketing, political buy-in, etc. When you can bring all of the workstreams together simultaneously — the team building the app, the marketing team, the security considerations, etc. — that’s when you can have impact. Just take Ireland for example. The COVID Tracker App’s launch consisted of over 500 meetings and a thousand video conferences for the 100+ people on the extended team. States striving to develop their own apps should be prepared for the lift.
To amplify political support, program organizers should focus on marketing efforts and plan a thoughtful and intentional public launch. This should include leaders broadcasting and talking about the exposure notification program and a consistent conversation about why testing and tracing matter. The goal should be to get the whole country, or in our case, the whole state, talking about the program. This can be a challenge here in the U.S. as these programs are administered at the state level. While we don’t have control over the federal narrative, states need to create their own narrative that cuts through the noise at the federal level.
Measurable data and interoperability determine whether a program is successful.
Building and launching an exposure notifications program is only the beginning. Continued analysis and data collection will allow for necessary iterations to ensure that the program is effective and properly maintained. In Ireland, for example, nearly 2 million people have downloaded the country’s Covid Tracker app since its launch, with 1.3 million active users. According to the Irish Department of Health, this represents 34 percent of the adult population (aged 16+) in Ireland. As of Oct. 13, the app had been used to inform more than 4,000 people of close contact with confirmed cases of the coronavirus.
Similarly, in Germany, the Federal Ministry of Health tracks a variety of metrics and scenarios to determine whether the program is making an impact. Beyond the number of downloads, the Ministry tracks whether a person’s contact information is on file in order to communicate with them; whether a person has meaningfully engaged with the app; whether people have been notified if a positive case is uploaded; and, if a person was notified, whether they were able to get tested.
Germany’s Corona-Warn-App and Ireland’s COVID tracker were recently part of the first phase of national apps to be included in an EU-wide system to ensure interoperability called the ‘gateway,’ along with Italy’s Immuni app. The gateway ensures that apps work seamlessly across borders, allowing users to only install one app and still benefit from contact tracing and receiving alerts, whether in their home country or abroad.
With the responsibility of app development falling to the state level in the U.S., the importance of interoperability looms larger to ensure the virus is kept at bay nationwide. To help make apps in the U.S. effective across jurisdictions, the Association of Public Health Laboratories has developed a national server that can securely host the data of affected users, eliminates duplication and enables notifications across state borders.
One piece of closing advice from the German team was to “keep [the app] as simple as possible. Whenever you try to implement something that is beyond the crucial MVP, then you get in trouble, from the time frame you’re planning to the technical risk.”
USDR and the Rockefeller Foundation are continuing to explore the impact of exposure notification programs, seeking opportunities to educate and support governments and NGOs in need of assistance. If you are interested in working with USDR to address topics such as COVID testing, contact tracing, data integrity, or other health data initiatives, fill out this brief intake form and we’ll follow up with you within days. The Rockefeller Foundation will continue to publish useful resources building on its National Testing & Tracing Action Plan, such as a testing & tracing message handbook, guidelines for testing and screening strategies, and testing strategies to reopen schools.
Additional Resources
Documentation and risk models:
- Germany: full documentation and risk model
- Ireland: full documentation and risk model
GAEN implementers community resource:
Select academic literature:
- “Modeling the combined effect of digital exposure notification and non-pharmaceutical interventions on the COVID-19 epidemic in Washington state” (Abueg, et al. — 09/02/20 pre-print)
- “Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing” (L Ferrett et al. — Science. 2020 May 8; 368(6491) — 03/31/20 publication)
- “Quantifying SARS-CoV-2 infection risk within the Google/Apple exposure notification framework to inform quarantine recommendations” (Preprint, not yet reviewed, Wilson et al. — 09/17/20 pre-print)
Lauren DeVos has worked in the healthcare industry for the past decade, with a focus on health technology, early stage ventures, and public health. She is currently volunteering with U.S. Digital Response with a focus on COVID testing, contact tracing, and food security.