Emma Ross
Good morning and thank you for joining us for this week’s Chatham House COVID-19 briefing with Chatham House’s Distinguished Fellow, David Heymann. Our guest today is Dr Oliver Morgan, who heads the Epidemiology Group for WHO’s COVID-19 response, the disease detective aspect, and he’s right in the middle of leading a three-day online global consultation on contact tracing, looking at key aspects, such as scaling up, training a workforce of contact tracers, getting the community onboard, experience with contact tracing apps, etc. So, welcome, Oliver. I just want to go over the bit of housekeeping first. The briefing is on the record, and questions can be submitted using the ‘Q&A’ function on Zoom. Upvoted questions are more likely to be selected.
Before we turn to you, Oliver, I just would like to turn to David to ask David if you could give us your thoughts on what you think are the most important issues in the pandemic at the moment, just to kind of orient us.
Professor David Heymann CBE
Well, thanks, Emma, and good morning to everybody. I think right now on everybody’s mind in almost every country in the world is transitioning out of this lockdown situation, or the circuit breaker situations that are occurring in Asia, and moving into a more equitable distribution of travel and trade, if you would. And I think countries are looking to the example that’s been set by Australia and New Zealand, and possibly other countries are beginning to do that, and that is these two countries have equalised the risk and equalised their response capacity in such a way that they feel that travel and trade between the two countries is possible and there is minimal risk in doing that.
What does that mean, lowering the risk or equalising the risk and equalising the response mechanism? Well, what that means is that countries that have the same risk of transmission, of people getting infected, would have the same risk, and so if, for example, in the UK, the reproductive number can be brought down to a very low level, and this is thought to be equivalent to what’s going on in neighbouring countries, or in other countries, it might be that they then begin to think about transported people and goods between the two countries. But they would also want to be sure that there were a monitoring system in place that would say when that transmission might increase in one of those two countries, and they would also have to have a good response capacity in case it does increase. So, the low risk would go along with a monitoring system.
Some countries are innovating, some countries, for example, are looking in their sewerage system to get a baseline of what virus is in their sewerage system now, and they would then, maybe in another six weeks or two months, look again to see if that’s decreasing, increasing, or whether it’s staying the same. That might be one system that some countries would use, others will have a system of looking at antibody levels, if they have sensitive and specific antibody tests, that might create a baseline and then see whether that’s increasing or decreasing over time. So, the low risk would go along with a monitoring system and then the response capacity. Since there’s no vaccine and no therapeutic that’s really important, what’s very important is rapid detection of cases, and this would require surveillance systems, such as the UK has for influenza-like illness or the automatic system that they’re looking for respiratory syndromes to be increasing, those systems would determine whether or not there is virus present or who’s infected, and then a rapid response would have to occur to contain that outbreak, to stop future change of transmission, and that would concentrate heavily on the only real tools that we have for outbreak response, and that is contact tracing and linking that to a rational system of diagnosis of disease.
And so, it’s really appropriate that Oliver is with us today, Emma, to be talking about what WHO views as that appropriate contact tracing and diagnosis system. So, back to you, Emma.
Emma Ross
Thank you, David. So, yes, so today’s topic is contact tracing, which, as David said, is one of the cornerstones of outbreak control, and when countries were told, at the end of January, to get ready for the virus, part of getting ready meant getting the capacity in place to find the infected and trace the people they’ve been in close contact with, so they could be quarantined and monitored and avoid further spread. But it’s a capacity that so many countries around the world seemed to have failed to get in place, in a robust way during that period. So, yes, it is a good time for us to be tackling it now, because getting contact tracing right seems to be one of the keys to being able to avoid the need for further lockdowns. Oliver, could you open up by telling us what exactly contact tracing entails and why it’s so important and what’s emerging from this consultation that you’re currently doing, in terms of what efficient case finding and contract tracing looks like in this pandemic and what it takes to get it right?
Dr Oliver Morgan
Well, thanks very much, Emma. Thanks very much, David. I think David alluded to, you know, one important aspect of contact tracing, which is it’s integrated within the healthcare system response to any disease. So, it’s important not to see it as a standalone activity. So, contact tracing requires both the notification of cases, as David mentioned, but also, the ability to then, when you detect additional cases, refer them to either healthcare facilities or some other additional quarantine, if necessary. So, that integration approach is pretty important to underline.
So, what is contact tracing? Well, contact tracing is a way to optimise the finding of new cases and the way we do that is by looking at those individuals we believe are exposed and most likely at risk and, from many diseases, those are the contacts, close contacts, of cases that we know about. So, by looking among the contacts of those cases, we maximise our potential for finding new additional cases. That’s not to say that there aren’t additional measures beyond contact tracing that are needed to find new cases, such as active case finding, and that might be done in certain settings where the contacts are either very complex to identify or maybe it’s not practical to be tracing all the contacts. But really, contact tracing is designed to identify who is likely to be exposed and at risk, to follow them up, and in the contacts – context, excuse me, of COVID-19 in particular, to ensure those individuals are quarantined and, should they become ill themselves, that they don’t spread disease to others. So, that’s really the essence of contact tracing.
Emma Ross
Okay, thank you. I just wanted to zero in on what is a contact, or what is contact, especially in the context of these apps that, you know, that talk about Bluetooth contact, but I want to get onto that separately later. But in terms of what is a contact, are we talking about – is this an infected runner breezes past you from behind panting, is that contact? Someone you brush past coming out of a shop, sitting next to on a bus for 20 minutes, how are we defining what contact is when you’re doing contact tracing? What is noise, what is real contact?
Dr Oliver Morgan
Well, thanks, Emma, I think the questions you ask highlight actually how complex contact tracing is and assessing whether an individual is really a contact or not requires skilled – a skilled workforce, and trained people to do these investigations and ask these questions in a – with a – in a public health way. So, we have, at WHO, we’ve got a guidance document that provides some definitions of contacts. Broadly speaking, these are individuals who have been in close proximity to a known case for more than 15 minutes, and we define that as at least a one metre distance from a known case, while they were symptomatic. And we also define a number of different settings and number of different ways to determine contacts in those settings, for example, in healthcare settings, or on public transport, or in other residential facilities, where people may be exposed. So, the answer is that it does require some engagement with the case and understand what the environment is. Ideally, there should be an investigator discussing it with the case to identify the likely contacts in their setting, but we do have some definitions and viewers can find those more detailed definitions on our WHO website.
Emma Ross
Okay, so what have you learned so far in this consultation? Are you gleaning anything useful that might change the way we do this, or inform contact tracing?
Dr Oliver Morgan
Well, it’s some very interesting feedback from many countries who are participating. We have a three-day virtual consultation, with a number of different countries, but also different partners who we routinely work with on contact tracing. And I think some of the high level messages is really just to reiterate, as David mentioned, that contact tracing, when integrated into your COVID-19 response, is really a critical element, both for managing risk and keeping that risk low. So, that’s a widely agreed perspective. The other thing that we’re learning is the emphasis, and I’m really going to re-emphasise what I’ve just said about the importance of the trained workforce, is that, yes, technology can help us to some degree, but really, we need the trained workforce to be able to do effective contact tracing. And that has been reiterated from all of the different countries and partners who are participating in this meeting, and that’s even places where they, you know, have tried to implement technologies to assist with contact tracing, it is the inquiry of a trained contact tracer that yields the best contact tracing results.
Emma Ross
Thank you. David, I wanted to ask you, can you bring a contact tracing system in at any time and get on top of an outbreak, or is there a window of opportunity and, if you don’t make that window, that opportunity is lost? So, is it ever impossible to do contact tracing, or no matter where you are, how out of control your outbreak is or your capacity is, you can still bring in contact tracing and benefit from it?
Professor David Heymann CBE
Well, Emma, it’s probably important to go back and look how contact tracing has originated over the past decades. And it certainly is integrated within the health system when it comes to sexually transmitted infections, and there contact tracing is extremely important in order to make sure that everyone who has this infection is treated and doesn’t transmit to others. And that’s the objective, as Oliver said, identify people who have been in contact with someone who’s infected and, in the context of sexually transmitted diseases, that would be having had sexual contact with a person who has a disease and then making sure that they get tested and that they are treated appropriately, so that they cannot transmit the disease further, and so that they themselves will become healthy again. In this case, with COVID, we don’t have the therapeutics, we don’t have any way of treating patients, and so what’s necessary is to isolate those patients, as Oliver said, those contacts, in case they do get sick later on, or in case they are transmitting, they’re isolated in a way that they can’t spread it to others.
We’re very fortunate with COVID that it is a disease, which occurs both in clusters and then transmits into the community, whereas influenza doesn’t usually – I’m sorry, not in clusters, but in outbreaks, whereas influenza usually doesn’t occur in outbreaks. Influenza is very difficult t0 stop in a discrete outbreak, whereas COVID-19 can be stopped. And countries that began early with contact tracing and outbreak containment and continued right through the period of time when they had this lockdown, or whatever you wish to call it, have had the best success in sustaining a low level of transmission. That is a low reproductive number, one that’s less than one, meaning that less than one person per infected person is infected. So, in essence, contact tracing, being the only tool, is really important in this outbreak, because you can stop discrete outbreaks and prevent community transmission from those outbreaks.
Emma Ross
But is it ever too late to bring in contact tracing, or no matter how out of control you are, you can still mount it?
Professor David Heymann CBE
Well, in this outbreak, it’s not too late. In some outbreaks, it might be too late, but in this outbreak it clearly is not, just as it’s not in Ebola or meningitis or any other type of outbreaks. Identifying contacts, if there’s a treatment, getting them treated, if there’s a vaccine, making sure that they’re protected, is the way to stop outbreaks. It’s been known for many, many years and it continues to be the major way that we can deal with an outbreak, such as the current pandemic.
Emma Ross
But given that this was – this is known to be such a cornerstone of outbreak control, I’m just wondering, this really is a question for both of you in turn, is why has it been such a struggle for so many countries to get on top of contact tracing in this whole system? If it’s so well-known, what is the bottleneck? And at the WHO briefing the other day, Mike was saying that most countries do not – they’re not up on top of this. I mean, why are they not? Is it really difficult to get this going? What is the problem with just throwing this system up and doing it?
Dr Oliver Morgan
Maybe I…
Professor David Heymann CBE
Oliver, yeah.
Dr Oliver Morgan
Maybe I’ll have a first start – answer to that – give a first answer to that question and David can supplement. I think just briefly touching on your – the issue of [inaudible – 15:49] who laid – I think the important principle is one of adaptability and flexibility in public health. So, there’s never a single solution to every single problem and we must continue to be adaptable and use the measures that we have available. So, if there’s very widespread transmission, we see measures that are a wide scale and are not targeted, such as stay at home orders for everybody. But if we have capacity, such as contact tracing, you can really target your interventions to encourage the individuals who are highest at risk to stay at home and others are – have maybe different measures recommended to them. So, I think that as outbreaks increase and decrease, the level of the contact tracing similarly can flex and you can target your contact tracing in different ways. So, if the lar – the number of cases is increasing large – quickly, to a large number, you could focus your contact tracing, if it’s to the highest risk individuals or particularly vulnerable populations that need protecting, and then use other measures for the larger group.
I think in terms of your question around why has it been so difficult? I think contact tracing is a very difficult thing to do and I think not a large number of people do it routinely. David mentioned programmes to control sexually transmitted infections, there are other disease control programmes, such as tuberculosis, that use contact tracing quite extensively, but it’s a capacity that actually takes quite a significant amount of effort and skilled workforce, as I’ve mentioned several times. I think it’s scaling it up to the level that’s needed is undoubtedly a challenge. So, an important aspect of public health response to COVID is that you need to have these capacities everywhere, all of the time, even when there are no cases, because as soon as you get cases, you need to respond quickly and control what starts out as small outbreaks and prevent them becoming big outbreaks. So, that’s really been a fundamental challenge for all countries around the world, is how do you get that capacity in place very quickly in – for your entire country and for all communities? And it’s an aspect that’s quite important for contact tracing is that for some populations, you really need to have teams that understand the communities very well, in order to work with them for contact tracing. So, it’s complex and it needs to be done at scale.
Emma Ross
But some countries have done it, and with big outbreaks, so what – why were they able to do it and others not? Is it…
Dr Oliver Morgan
Well, I…
Emma Ross
…about previous investment in public health infrastructure, they’ve been investing in it all along, or is it that, I don’t know, they have pandemic preparedness plans that they could just flip into action, ‘cause some countries have done it, haven’t they?
Dr Oliver Morgan
So, I don’t think any country has done it easily. I think everybody has had to work extremely hard to get their contact tracing capacities in place. Some countries had recent experience with other coronavirus outbreaks, such as MERS and a little bit further before, a little earlier than that in SARS, have had that experience that is quite analogous to COVID-19, so they have some of those capacities maybe already in place. So, I think, you know, I think that’s where contact tracing is done more frequently, clearly, it’s easy to scale up. I think there is an investment issue in general, but I think that many countries now are, you kn0w, moving quite well and we’ve seen in our consultation over the last few days that really, all countries are working towards having stronger contact tracing.
Emma Ross
David, is there anything you want to add as to your thoughts as to why this has been such a struggle, when it’s such a known intervention?
Professor David Heymann CBE
I think Oliver has really covered it very well. It’s an economic issue, it’s a preparedness issue, it’s a whole series of things, and Asia clearly has done better. They started earlier in contact tracing, and they’ve continued to do that, despite the other activities that they’ve had to introduce, such as these circuit breakers where they lockdown a segment of the population for a time and then unlock it. Germany and Europe started with contact tracing, as did the UK. Germany continued, whereas the UK didn’t continue, they shifted to a pyramid integration strategy, as they would do for influenza, and this happened in many other European countries and it happened because, in my analysis, and I think this is what most people believe, when it was noted how Italy was unable to accommodate all the patients who were becoming sick and were seeing an increase in mortality, countries were – began a reaction to follow what China had done, just to lockdown the economies, in the hopes that they could flatten that curve of people who were infected and so that they wouldn’t have a rush into their hospitals and not be able to accommodate. And, as a result, many countries developed a surge capacity in addition, but they found that by locking down the economies, they did decrease immediately, almost immediately, hospital admissions and hospital deaths. And so, they continued that and now, many of them locked down without this transition strategy and they’re struggling now to unlock their economies, understanding that they must equalise the risk and equalise their capacity to respond with other countries and, to do that, they have to begin to do investing – investment in training and in doing the things that are necessary to have good outbreak containment activities, including detection systems throughout the country, and also, response capacity, including contact tracing. So, it’s a whole shift in mentality from trying to flatten the curve, to trying now to approach this as Asia and Germany have done since the very beginning in dealing with discrete outbreaks when they occur to decrease the community transmission.
Emma Ross
Before we go onto the apps discussion, Oliver, I wanted to ask you whether anything’s emerging from this consultation about how well you have to do contact tracing for it to be effective? So, as far as how right you have to get it, how rigorous does the quarantine of contacts have to be? Does it need to be 100% compliant, you know, do you have to find all the contacts, is there a threshold where it works and below which it really is a bit, you know, not very effective?
Dr Oliver Morgan
Well, Emma, I think there are a couple of really interesting aspects to that question actually. One is that contact tracing has to be adapted for different – the different disease that you’re doing contact tracing for. So, it’s not a one size fits all that you apply to every single disease in a uniform way, but you must adapt your contact tracing for the disease that you’re trying to control. In the – for COVID-19, we’re actually still learning quite a lot about the optimal ways to have that community level control of the disease and so what we’re hearing from the consultation process is feedback from different countries who are trying different approaches and learning different things. So, that’s really a critical process for the world to engage in a continuous, you know, improvement cycle, so that we optimise our contact tracing.
We see a few different things. We see that even if you can’t be 100% on everything, it still has an important impact and I think this is a very, very key message here, is that even if you are unable to get 100% of your contacts, even if you’re unable to quarantine all of the contacts for the entire 14-day period, which we recommend, there is still a benefit for doing this. And I think this is, again, another principle of public health and outbreak control is that you do the best that you can with what you have, and you keep going. You do have to adapt and there are times where you have to change your strategy or you have to have an adaptive strategy, but contact tracing, we’re learning for COVID-19, does have an impact and especially when it’s done in conjunction with other measures. So, I think the – there’s maybe been some misconception that we have to do contact tracing at 100% effectiveness for it to have any impact. But actually, what we’re learning from this consultation is that, in conjunction with other disease control measures, even if you’re not hitting 100%, even if you’re hitting 80% or below, it’s still having an impact. So, I think that’s probably the most important message there.
Emma Ross
And it would seem that getting the buy-in of the public to co-operate with this would be important, especially if you’re asking people to quarantine at home versus plucking them out of their homes and putting them in a quarantine centre. David, you’re nodding, do you want to start on that as far as for this pandemic, you know, how important is that, or not, and how do you both see that playing out in this pandemic? Is there much co-operation with this from the public and how do you gain that?
Professor David Heymann CBE
You know, Emma, the public is at the heart of all of this outbreak response, no matter whether it’s the pandemic today or Ebola or other diseases that occur periodically. The public must understand how to protect themselves and how to protect each other and we’ve gone into that before, it’s just really understanding that the public needs to continue to physically distance, wash their hands, and make sure that they don’t go to mass gatherings, if governments are still permitting them. So, they need to take responsibility themselves to make sure that they protect themselves, but at the same time, protecting others by wearing a mask, if they cannot physically distance, and this is everybody should be wearing a mask, if they’re not able to physically distance from the elderly or also, in a closed environment, and this is what WHO recommends. So, the public has to be at the bottom of this, and they also have to understand the importance of contact tracing.
You know, if you go back to the Ebola outbreak, the modellers were all saying that what was necessary was safe burials and an increase in the number of hospital beds, so that people could be isolated. They forgot about the communities and they forgot about the importance of contact tracing and in fact, many times when WHO was suggested to begin contact tracing, the response from the Director General at that time was, “Oh, there are too many – too much community transmission, we can’t do that.” And Bill Foege, who was the Head of the smallpox activities in Asia, continued to remind her that in smallpox eradication, even in Calcutta, which was the major metropolis at that time, contact tracing was used to stop smallpox transmission. So, contact tracing is very important in all outbreaks and this one, that the public must also participate in that. Once the public began to understand the importance of outbreak case – contact tracing, in the Ebola outbreak, they began to participate and the outbreak could be stopped, and many times the hospital beds that were being built were not even ready by the time the outbreak ended. So, the power of contact tracing and community involvement with that is very important, and I think, Oliver, that’s what the theme of today’s consultation is, is that correct?
Dr Oliver Morgan
Yes, that’s correct, David, we’ve got to focus actually two issues really, the community engagement and also the digital tools. I mean, I think the way to see contact tracing is that it’s really an activity to support communities. It should not be seen as a top down approach. It’s really an approach to support communities to take the actions that they need to take and a critical part of the contact tracing is that, especially if we’re recommending quarantine, is to provide support to those individuals who have to quarantine. Now, that can come in many different ways and it’s very context specific. It could be providing basic necessities, such as food and water. It could be providing individuals with the medications that they need. It could be a whole host of different things, but it’s really about supporting communities to implement the measures that they need to implement and informing members of the community if they have been exposed. There’s an important role of contact tracing in communicating people’s risk, you know, if they have been exposed.
I think the role of engaging the community is the elemental piece of public health and, especially with contact tracing, it’s extremely difficult. David’s really highlighted a good example where if you don’t go into it with that approach, then it would be very difficult, and we do have something – you know, several examples where we’ve been able to do contact tracing in extremely difficult settings. David mentioned the smallpox example. WHO has been working, for the last two years with the government of the Democratic Republic of the Congo, to control an Ebola outbreak in the eastern parts of that country, where, at the height of our response, we were contact tracing 20,000 people every day in the middle of a conflict zone. It’s extremely challenging, but with the engagement of the community, you can achieve it and I think that’s a – it’s really important when we hear the feedback from the different groups during our consultation. We had a great presentation yesterday from Argentina about working in marginalised communities and how the community itself rallied around to support the activities of contact tracing, and it can work if the engagement of the community is positive.
Emma Ross
And are you seeing any indicators, maybe because that’s your topic today on the consultation, it’s too early, but are you seeing that the communities are co-operating with quarantine in COVID-19, or is it an issue that needs to be tackled? Is it all sorted and going well, as far as the community engagement in quarantine and contact tracing?
Dr Oliver Morgan
I mean, engagement with communities is an ongoing process in every aspect of every outbreak and disease control effort. Public health is an active process of engaging and intervening with the community to control the situation in their communities, in their populations. So, we can see a mixed – you know, we see a number of different contexts and we see some successes, some challenges. I think the other thing that we’ve learned over the years with contact tracing is, it’s not a one-way street. Even when you do face community resistance, you can re-engage with communities and have that community trust rebuilt. It’s tough. It’s not straightforward. You have to work very closely with members of the local community and the local opinion leaders, but it’s – it is definitely achievable. So, what I would say, in situations where there isn’t community trust, is that you can regain that trust, if it’s somehow not there or lost.
Professor David Heymann CBE
Emma, I may just want to add a little bit to that, because I fully agree with what Oliver has said and, you know, governments that try to do centralised contact tracing have been less effective and less successful than those that have done – that have delegated this to the local level, where the communities can be involved, and it’s about an up approach rather than a top down approach. Because contact tracing in the local area, people have trust in each other and if you’re contact tracing with someone who you know or someone who you know is in your living area, it’s much easier to give them the confidence as you do contact tracing. And many governments have made the mistake of trying to centralise this, rather than decentralising it to the most – the basic element – the basic level where communities can be fully involved. I just wanted to emphasis again what Oliver had said, moving forward.
Emma Ross
Okay, thank you. I’m going to turn to the questions now, but I will kind of intervene, with a few to get started on contact tracing apps. The most upvoted question at the moment is from Dimitris Monioudis, “If contact tracing smartphone apps are accurate, as proven in a number of countries, why does the UK demand the necessity to quarantine incoming travellers, even from low risk countries? Couldn’t they simply be obliged to carry a smartphone with the app at all times?”
Dr Oliver Morgan
Is – do – is that for me, Emma, or…?
Emma Ross
Yes, I guess we could – you could answer that as far as if, instead of quarantine, if incoming visitors could be obliged to carry a smartphone app for contact tracing, would that be as effective as quarantining, or is there a role for something like that?
Dr Oliver Morgan
Well, I think the best way to see the role of technology in – certainly in contact tracing, is the opportunity to augment the process of contact tracing. If – it’s actually very exciting to see these new technologies coming into many different aspects of public health. We’re really excited to see them, but I think it’s, like most parts of life, there isn’t a magic bullet solution to many problems and once we see, even in countries which have really used technology quite extensively, we had a great presentation yesterday from South Korea, who have really been at the leading edge of many technology engagements for public health, but even in South Korea, the human interaction between the contact tracing teams and the individuals who are cases and contacts is absolutely essential. A lot of the processes that they use are still, let’s say, fairly traditional, tried and tested approaches, and they’re trying to use technology to augment rather than replace the human endeavour of contact tracing, or the human interaction between the contacts and cases and the contact tracing teams.
So, I think it’s a very important message coming out of this consultation that in no country has – have they been able to replace humans with smartphone apps, in order to do effective contact tracing. So, I think that’s a very clear message coming from our – from many countries and from our partners. I think where we’ve seen the best use of apps is to target very specific activities, for example, reporting symptoms on a daily basis. We’ve seen examples where countries have had apps that allow contacts to report their symptoms on a daily basis to the contact tracing team, which reduces the amount of travel the contact tracing teams need to do to check up or to see how the contacts are doing. But even with that, we’ve heard that the contact tracing teams still do a face-to-face visit throughout the 14-day quarantine period. So, it’s not a process of registering somebody and leaving them to do their 14 days without interaction, it’s using those apps to augment the existing process.
Emma Ross
Well, how – that’s a segue to a question I’ve had is how accurate are these apps at identifying a real contact, so a potential contact, just in terms of meaningful proximity, let alone the other factors, such as whether it was face-to-face, outside, inside, I mean, what’s the contact they’re picking up? If it’s Bluetooth, is it coming within ten metres of someone, 100 metres, what – how – what are you learning about how accurate they are at picking up real contacts and cutting out the noise and what does that mean for the contact tracing workforce? Surely that’s going to give them a huge num – extra number to follow up on. What are we seeing with that panning out?
Dr Oliver Morgan
Well, we still don’t know. We haven’t seen many robust evaluations of using proximity tracking apps for contact tracing. There are different types of proximity apps. There are some that use GPS locations, and some that use Bluetooth for the relative proximity to other people, and then, within that, there are other features, such as centralised data storage and decentralised data storage, and a number of other aspects to these apps. So, they’re not all the same. What we’ve seen is that, in the end, the actual discussion with the case about their potential contacts is the most important, because the setting, it’s also pretty important. So, being within close proximity of somebody inside a building where there’s limited ventilation is a bit different from being at close proximity to somebody outside, on a windy day. I think we’ll learn some of these – the effectiveness – we’ll learn about the effectiveness, as we go forwards. But the initial indications is that they do need to be used carefully, because they can produce quite a lot of, let’s say, digital noise and create additional work for the contact tracing teams to sift through who are the real contacts and who are not.
The other aspect that we’re learning from many other countries that are trying to implement these is that if – there’s a risk of systematically excluding some members of the population. Not everybody has a smartphone, not everybody will have the app that’s being used. Also, some people, like children, may be systematically excluded, if you rely too heavily on the apps. So, there are a number of aspects that we’re learning, which we have to do more evaluation on.
Emma Ross
And are you, or David, seeing any concerning issues, in terms of the degree to which countries are relying on these apps, or planning to rely on them, you know, to supplement or prop up or – you know, their shoe leather epidemiology, is that going – I mean, I would imagine it would be quite tempting, if there is a technology, to kind of, you know, heavily rely on that, is that going on? Is that a concern and is – are there any indications emerging of to what extent that might be going on, or you think it might pan out that way?
Professor David Heymann CBE
Maybe, Oliver, I’ll start off by saying that all new technologies have to be very well vetted and studied and it would be wrong not to be studying to see whether or not there is a way to use this in the future as a contact tracing supplement to other face-to-face activities. But at present all these are are just tests to see whether or not it can be effective and they should never replace real contact tracing as we understand it today, which involves human interaction in order to gain confidence and understand from people who are infected where they might have had contact with someone else. Now, I’ll turn over to Oliver, because he’s done a lot more thinking on this than I have, Oliver.
Dr Oliver Morgan
Yes, thanks, David. I completely agree, we wouldn’t recommend that contact tracing is done through new technology alone, and we really do have to do some more rigorous evaluations. I think it – I think there are some very positive aspects to this. I think it is definitely worth pursuing, but there is a risk that if seen as a replacement of a properly trained workforce and then, the contact tracing will not be very effective. Again, you know, we’ve spoken quite a lot about the community engagement aspect, the – you know, that’s really important. You know, apps can also help with engagement of communities, but they can also be a barrier if – the technology can sometimes be a barrier to engaging in communities. So, I think these things have to be weighed up, as we go forwards, and evaluated in real time.
Emma Ross
Okay, thank you. Here is a question from Prashant Rao from The Atlantic, and it is a most upvoted question, “How quickly and easily can newly hired contact tracers be skilled up to the necessary level? If a layperson were hired, what training would they require and how long would that take? And do any countries have reserve forces of contact tracers and is that a feasible solution?”
Dr Oliver Morgan
Well, maybe I’ll answer just quickly, based on some great presentations we heard yesterday. The quick answer is yes. I mean, there are countries that have put in place a scalable, flexible contact tracing workforce that, at the core, has trained public health professionals and then has a, let’s say, an extendable workforce that can be drawn upon, you know, if a surge is needed, and those surge – that surge capacity can come from Teachers, other government public sector workers, medical students, other students, community workers, and non-governmental organisations. So, while contact tracing does require training and it does require some practice and close supervision actually to ensure that, you know, that the quality remains high, it is something that a number of different people can do. So, yes, we’re definitely seeing that scalable approach being implemented in different countries.
Emma Ross
Okay, thank you. Here’s another most upvoted question by Marie Crackett, “In the work environment, is the 15 minutes, I guess of contact, a cumulative figure? I’m thinking of Teachers in the classroom with children and other staff.” David, do you want to start with that?
Professor David Heymann CBE
Yes, well, certainly contact is cumulative and if you’re in touch – in contact intermittently in the morning with someone, it maybe increase your risk of being infected, if that person is infected. So, the number of contacts would be important and also, the duration of those contacts is important. But to say one is more important than the other would be very difficult, because an event when someone gets infected is really a random event. We don’t understand exactly what might cause people to get infected, but certainly, if you’re next to someone who’s infected and doesn’t know it, and if they speak to you in a loud voice, or if they shout at you, or if they do something else, it may be that the droplets that they create would cause an infection. So, it’s a whole series of things that determines this interaction and, in schools, I think the way that the UK is approaching this is quite a sound way of putting children into what they call bubbles, I believe, in the UK, a group that stays together throughout their school day, so that if they – one does become infected, they can all be put under a surveillance system in isolation, so that they don’t infect others and at the same time, Teachers are understanding how they must isolate themselves from their students as they speak. So, I think it’s a learning experience that everyone is going through. No-one’s ever had to go through this before, in this generation of people, and there will be trial and error and there have been cases, for example, in Singapore, where they thought they had everything right in the schools and then they found that they were having transmission and they had to close them down for a time until they figured out what had been going on, and then they opened them up again with a new set of standards in that school. So, it’s all about trial and error now that this will occur, and we really have to work together on this and not criticise or not say we’re not doing it because we don’t believe in it. We have to all work together to make sure that we can come out of this situation in a way that we’ve equalised the risk and equalised the response capacities.
Emma Ross
So, on the cumulative 15 minutes thing though, is two bouts of seven and a half minutes with the same person the same risk as 15 minutes on a trot with that person, or is it less if you, you know, leave before the 15 minutes and come back to them?
Professor David Heymann CBE
Yeah, I would say it is, but remember that during that cumulative 15 minutes, there may be no exposure whatsoever, but if during that cumulative 15 minutes someone is infected and speaks and shouts and causes droplets, then there is a risk. So, you know, risks are – there are many different levels of risk and, you know, to take 15 minutes as a standard is the way some groups are doing it. And, yes, I believe it would be cumulative, but Oliver may have a different view, and I’m turning to Oliver now because he’s had a lot more experience recently with this outbreak. So, Oliver, what’s your view on this?
Dr Oliver Morgan
Yeah, thanks, David, I – you know, I think this is, you know, an important question, I think these are, you know, these are not, you know, 14 minutes versus 16 minutes, it might not be a – you know, all the difference in the world, but, you know, I think it really does require an assessment, as David indicated, that, you know, you have different things happening. You have the individual who’s the case, understanding what their clinical situation is, you know, are they extremely unwell, are they coughing, are they mildly unwell, are they early in their disease, what activities are they undertaking during that exposure, window? All of those things can – are important and need to be understood.
Similarly, from the contact side, there are a number of activities, which is important to understand, you know, are they providing care to the individual? Are they just happen to be sitting, you know, in close proximity? Are they, you know, talking, are they singing in a choir? What sorts of actions and activities, both from the case and the contact, are really important to understand, and, you know, the idea that it can be simplified into kind of hard and fast cut-offs is probably not that helpful. It does take a little bit of further enquiry, and so I think this is what’s at the heart of this, is this is why it’s actually a pretty difficult thing to assess people’s exposure risks, and what we experience and, you know, I’ve experienced myself, is that if you work at this and you’re doing this regularly for a disease and a setting, with the community, you start to really understand what those interactions are and you’re better able to make those assessments and over time, they get better and better and better. So, I think the – you know, these recommendations, these guidelines should be seen as guidelines rather than rules and if it’s not a rule, it’s a guideline, and that further assessment to really understand both the case and the exposure dynamics is really important.
Emma Ross
Thank you. Here’s a question actually about the ethics and the rights issues, from Andrea JCL Downey, from Digital Health, “Any thoughts about the moral, ethical and/or lawful misuse of technology for this purpose, with civil rights inevitably violated in the process?”
Professor David Heymann CBE
Maybe I’ll start with that, in saying that it’s really always difficult to determine which is more important, an individual right or the right of the community, and especially when there’s an infectious disease. You know, is it right for someone who has an infection to knowingly go out in the community and expose others to that infection, or is it the right of the community to know when someone is infected, so that they can not be exposed to that infection? So, it’s always a problem in issues like this and gradually, as we begin to work and understand how we can move together in solidarity as a global community, the answers will come, if they’re not already there. It’s very simple to say, well, it’s a human right and therefore, nobody can tell me what to do when I’m sick. Yet, on the other hand, there’s a whole group of people out in the public who could be exposed to me, if I do go out when I’m sick, and is that their right to prevent me from coming out there, or is it my right to go into that community? It’s a very, very difficult issue and it surfaces every time there’s a major outbreak, such as this.
Generally, what people believe is that the public right is more important than the human right in certain instances and therefore, people should be able to be ensured when they’re in the public that they are at least being protected, that’s a government’s job to protect them. That doesn’t mean that a government can blatantly interfere with human rights, but it must work with people who might be causing a threat to the community, to help them understand that they might be a threat to the community and how they can prevent that community from becoming infected. So, it’s a long answer, it’s an answer that’s perplexed public health for many, many years, is it right to make somebody – to force someone to have a vaccination, for example, to protect the other students in their classroom? And so, these are issues which will go on and on and be discussed in many different fora, but at present, it’s felt that in some instances, you should be able to protect the public by having a law which says, for example, that a student who goes to school must be vaccinated against measles to protect the others in that school. So, things are evolving over time, but it’s not an easy issue to resolve, and I know WHO’s thinking a lot about this as well, and maybe Oliver has some other views on this as well, Oliver.
Dr Oliver Morgan
Yes, thanks, David, and very tricky questions. I think, there, lots of issues that are being raised, certainly around data privacy, and a lot of concerns about the use of our individual, you know, electronic data for disease control. I think there are quite a lot of guidance in place in many countries around the use of individual’s data. I think, as we go forward, certainly on the technology side, we’ll see better ways for each of us to be bet – be able to be better custodians of our own data and take better decisions about how we use our own data for whether it’s in, you know, public health and disease control, or any other aspects of our lives. I think we do need to be a little bit mindful though that we’re not, you know, we’re not proposing to do a kind of – have a Big Brother approach to contact tracing or disease surveillance, I think, you know, as we’ve repeated many times during our conversation, that engagement with the community is vital. So, approaches need to be – and need to resonate with communities and that includes the use of digital data. So, those conversations need to happen in – with different communities in different countries to figure out what balance they wish to have, especially when it comes to their digital data.
Emma Ross
Thank you. I think almost the last question. This is the most upvoted at the moment, from Chris Gannett, “With many citizens keen to travel during the summer period, do you think that differing contact tracing systems in different countries will result in a rise in cases through tourists not downloading the host country’s app, or not engaging with contact tracers there, or not following the rules?” So, I guess, that’s really about how contact tracing efforts might be frustrated by travel and tourism. Is that being discussed this week, has that come up, Oliver?
Dr Oliver Morgan
You know, it hasn’t come up yet, but it’s on the billing for, I think, tomorrow. You know, I think this is a really – another great example where, you know, we can manage risks and we need to look for ways to manage risks, not only within our own communities and countries, but internationally. And so, while we don’t yet have a global system, and I – you know, to support international travel in terms of contact tracing, I think it’s something that’s – you know, we’re definitely looking at. At the moment, we see different policies from different countries about how they wish to manage international travellers. I know that, for example, in Australia, if you travel to Australia, you need to have a 14-day quarantine, you know, on arrival in a designated place, and they’re managing their risks in that way. But I – there are other countries where they’re using contact tracing approaches, so that people who do international travel participate in those contact tracing programmes and countries are managing the risks in that way. Maybe to echo a little bit of a comment that David said, I think it’s also each individual’s responsibility to think about this. If we’re travelling to other places and other people’s communities, you know, how do we want to conduct ourselves and what contribution can we make to managing that risk for that community, if we go on holiday somewhere? So, I think these are interesting conversations and, again, I think we’ll all be working through these, over the next few months, for sure.
Professor David Heymann CBE
Emma, maybe I’ll just add that Oliver mentioned contact tracing for tuberculosis earlier, and there have been some glimpses of how that might be done when there have been people with resistant tuberculosis who have travelled in one country and been on an airplane and then got off in another, there have been some efforts, cross border, to do contact tracing and to notify other governments and, of course, the European Union is doing that continuously with diseases, such as Legionnaires disease and others, where there is contact tracing that goes on from hospitals. So, what Oliver says is right, there’s a – we’re beginning to see that occurring and I know that WHO will be looking in this, because they play a major role whenever that does occur across international borders, they’re involved in the actual tracing and notification. So, yes, I think in the future these things will be happening, and Oliver just reminded us again, it’s the individual’s responsibility to make sure that they protect others.
Emma Ross
So, that brings me to the last question I want to squeeze in for a quick answer from both of you, and that is about these contact tracing apps being voluntary and should everybody in the community consider it their civic duty to download it and participate in it? Are we not protecting others, if we don’t want to have anything to do with the apps? And the final parting question is, do we actually need the apps to successfully do contact tracing? Are they necessary? Whether they’re helpful is a different question, but if you could each answer briefly, quickly, to finish up. First of all, are we selfish by not downloading it and do we really need them?
Dr Oliver Morgan
Necessary, no. We’ve been doing contact tracing for decades without them. Helpful, potentially, if we’re doing it at large scale. Obligatory, I would say, again, no, but I would obviously highly encourage everybody to participate in contact tracing, if they’re asked to do so.
Emma Ross
David, your view on whether…
Professor David Heymann CBE
And I would just – go ahead.
Emma Ross
…everybody should download it? Your views on whether it’s selfish not to download these apps, or not to want to participate?
Professor David Heymann CBE
Well, as both Oliver and I have said, these are new technologies, which need to be evaluated, and certainly, myself, I would download it and use it as a volunteer because I know how important it really is to get a database, to understand whether there is any application for these in contact tracing, not at present so much as in the future. We do know though, that you can’t replace that human element of contact with people who are sick to identify their contacts and then contact face-to-face with those contacts to make sure they understand what their responsibilities are and also, to identify contacts of them should they become sick. So, apps are going to be important to evaluate, I would volunteer to do it, but in the future, they may have more of a role than they do now. Now, they cannot replace the contact tracing that’s face-to-face or telephone-to-telephone.
Emma Ross
Okay, that’s pretty clear. We’re going to wrap up now. Thank you so much both of you, and for our listeners, the full recording is on the Chatham House website this afternoon, or on YouTube, in case you missed the beginning, and thank you for joining us and please join us the same time next week, when David and I will be talking with Professor Gabriel Leung from the University of Hong Kong about what’s going on in Asia and insights for the rest of the world. So, thank you all very much for joining us.
