Contact tracing of COVID-19 hybrid of old and new technologies

WASHINGTON - The truth about the coronavirus and contact tracing _ finding out who is infected, who else might have been exposed by an infected person and then isolating those people - is that national and local public health departments have had to cobble together old and new technologies to track the spread of COVID-19.


And in some cases, departments have had to jury-rig solutions to minimize the many hours of manual labor it takes to do thorough contact tracing as the volume of cases has swamped the capacity of agencies to cope with the pandemic.


Health departments have had to rely on databases and information systems developed by a handful of private companies as well as one developed by the Centers for Disease Control and Prevention. They have been in use for more than two decades to track the spread of dozens of diseases ranging from salmonella infections and rabies to tuberculosis, HIV, Ebola and others.


Makers of the databases and public health officials quickly developed modules earlier this year to track COVID-19 by adapting ones used to track other coronaviruses, such as the ones linked to SARS (severe acute respiratory syndrome), which first appeared in 2002, and MERS, the Middle East respiratory syndrome that emerged in 2012.


Private companies also are offering contact tracing as a service, providing trained personnel to states on a contract basis to call patients who test positive to figure out who else they have been in touch with.


Typically, testing labs, hospitals and doctors' offices in each state electronically report a positive test for any of the trackable diseases into a disease surveillance database. That then becomes the starting point for public health officials to figure out the origin of an outbreak, whether a grocery store selling contaminated meat or an individual with an airborne infection, and work to contain the spread. Each state's information then flows into the CDC system to give the federal agency a national view of the spread of a disease.


The system appears efficient and elegant in theory, but in practice public health officials run into challenges when coping with a high-volume disease such as COVID-19, especially because basic information on patients is still buried in electronic health records that don't automatically enter the disease surveillance database.


"The truth about surveillance reporting is we are still straddling the line between using advanced technology and automation to collect data and where that sort of intersection slams into old-fashioned ways," said Catherine Brown, the state epidemiologist at the Massachusetts Department of Public Health. "There's still room for improvement. This is not just in Massachusetts, but pretty consistent across the country."


Once the disease surveillance system electronically receives a positive report for a trackable disease, investigators call the physician who has treated the patient to ask for more details about places that a patient may have visited and other underlying health information about the patient, and that information is then manually added to the state's database, Brown said.


Working with software developers, Massachusetts has designed an algorithm that can extract information from electronic health records, Brown said, adding that the state is one of the first in the country to do so. That minimizes the manual labor in collecting the information from patients and doctors and entering them into databases.


Since 2006, the state has been using a disease surveillance system called Maven, made by Conduent, a New Jersey-based company.


The Maven system is used by 12 other states and five cities across the country, said Mark Brewer, president of Conduent's global public sector business.


The system is capable of tracking 90 different health conditions, and when COVID-19 emerged in early 2020, the company quickly added a CDC-compliant module to track the disease and made it available to states using the Maven system, Brewer said.


Maven provides a dashboard in the form of an automated workflow that helps epidemiologists and investigators track a case from the time it enters the system through follow-up with patients, including details of other people who may have been exposed to an infected person plus checking the quarantine status of all those who may have been exposed.


Nineteen states use a system developed by the CDC known as the National Electronic Disease Surveillance Base System, or NBS, a common platform that has been adapted by states to their respective needs.


Fifteen states use custom databases, while two use a system developed by Arizona-based Sunquest and two others use Epi Trax, an open-source platform.


Some states use a combination of systems, as in Virginia, for example.


The state uses Maven to track sexually transmitted diseases but uses the Virginia Electronic Disease Surveillance System, which is based on the CDC's NBS system to track COVID-19, said Marshall Vogt, an epidemiologist at the Virginia Department of Health.


When a case enters the system, investigators in Virginia call a patient and their contacts and try to enroll those who may have been exposed to the disease in an electronic alert called Sara Alert, which was developed by Mitre, a federally funded research and development organization that typically works with the Defense Department. The alert system is free for use by public health officials.


Once a person is enrolled in Sara Alert, the system sends alerts through emails or text messages to check on a patient's condition, allowing epidemiologists to track who is developing symptoms and needs hospitalization, Vogt said.


The alert system frees up public health officials to "focus on those with symptoms and work with those who don't have access to technology and may need daily visits," especially elderly citizens who may need to stay home, Vogt said.


Vogt said the state also is looking into developing a smartphone app based on the Bluetooth design recently developed by Apple and Google that could be used by the state's residents to keep track of their potential exposure to people who later test positive for COVID-19. The use of the app will be voluntary.


States also are beefing up the ranks of human contact tracers whose job it is to call patients and their contacts. The Association of State and Territorial Health Officials has estimated that the United States would need 300,000 contact investigators, or roughly about one case worker per 1,000 people.


States are mindful of the privacy implications of conducting contact tracing and are cordoning off some information from contact tracers.


Whether full-time state employees or contractors conduct contact tracing, "we had to look closely and carefully about what data they could access," Brown, the Massachusetts official said. The state created a separate information system for contact tracers so they only see information about specific people they are assigned to call, instead of seeing the entirety of the Maven database, Brown said.


The information gathered by contact tracers is then added back to Maven by authorized personnel, she said. "It sounds clunky but it's necessary from a data privacy standpoint," she said. "That's really important because the hallmark of public health is maintaining privacy and confidentiality."