How do countries structure contact tracing operations and what is the role of apps?

Cross-Country Analysis

How do countries structure contact tracing operations and what is the role of apps?

In this policy snapshot we provide a comparative analysis of how 30 countries in the World Health Organization (WHO) European Region structure their contact tracing operations.

The WHO has highlighted the importance of testing, contact tracing and isolation in order to stem the spread of COVID-19. This policy snapshot is part of a series of linked posts looking at public health capacity and the test, trace, isolate strategy. 

The WHO defines contact tracing as “the process of identifying, assessing and managing people who have been exposed to a disease to prevent onward transmission”. According to the WHO, critical elements of contact tracing include: community engagement and public support; careful planning and consideration of local contexts, communities, and cultures; a workforce of trained contact tracers and supervisors; logistics support to contact tracing teams; and a system to collate, compile, and analyse data in real-time. 

The information presented here is based on evidence available in the COVID-19 Health Systems Response Monitor (HSRM) (up to 5 June 2020). As most countries in the European Region begin to experience a decrease in the number of newly infected people, contact tracing remains an essential tool for societies’ transition back to normal life. In our analysis, we identified two main approaches in which countries structure their contact tracing operations: centralized and decentralized.

Who performs contact tracing?

In the majority of countries, trained staff conduct phone interviews to identify everyone who has been in contact with infected or suspected cases. Although contact tracing has been around for decades, the increased demand due to COVID-19 has led to an immediate and substantial need for trained workers (who do not necessarily need a background in public health). Contact tracing could also be supported by the use of apps (see below); however, apps do not replace qualified contact tracers who work with the population as a whole. 

Countries using a centralized approach for contact tracing have one agency to lead operations

A range of countries implement centralized contact tracing at national level (e.g. BelarusCyprusIsraelKyrgyzstanLatviaLithuaniaLuxemburgMaltaPolandPortugalRepublic of MoldovaRussian Federation). Often, the Ministry of Health or a subordinate agency leads these operations. For example, in Portugal, contact tracing is coordinated by the Directorate-General of Health; in Poland, the National Sanitary Inspection is in charge. 

Decentralized contact tracing puts the responsibility on regions or districts

A number of countries use a more decentralized approach by implementing contact tracing at regional/district level (e.g. Albania, BelgiumBosnia and HerzegovinaBulgariaEstoniaFinlandItalythe NetherlandsNorth MacedoniaNorwaySlovenia RomaniaSerbiaSloveniaSpain). For example, in Romania, the dedicated staff in the 42 district public health authorities are in charge of calling all the contacts of those infected (i.e. from home and work) and asking specific questions (i.e. date of the most recent contact, duration of their interaction) to investigate which ones are close contacts, in order to establish isolation measures or offer testing, if they have symptoms. In Spain, contact tracers at the regional level track down people who were closer than 2 meters to either suspected or confirmed cases for more than 15 minutes in the two days before the onset of symptoms or a positive test. In the United Kingdom, plans under development for the test, trace, isolate strategy will operate at 3 levels: centrally, regionally and locally, with separate contact tracing strategies in England, Scotland, Wales and Northern Ireland.

Figure 1 below illustrates the different approaches. 

For some countries using a decentralised approach, GPs are part of contact tracing 

In some countries, the responsibility for contact tracing relies on general practitioners (GPs). For example, in Serbia, the physician attending a possible or probable COVID-19 case is responsible for recording the patient’s close contacts after the onset of symptoms of COVID-19, and then sending it to the epidemiologist of the territory’s public health institute. Afterwards, the epidemiologist contacts all the people on the list and requests that they self-isolate for 14 days.

In Norway, GPs in the municipalities are responsible for tracing contacts for all patients with confirmed COVID-19, in cooperation with the Norwegian Institute of Public Health. 

Many countries are making more funding and employment opportunities available for contact tracing teams 

Most countries have invested in additional human resources in public health to strengthen their tracing teams. This is the case in Romania, where several measures have been taken to increase the availability of human resources, not only to increase the number of staff but also to retain existing health workers. In Serbia, the Minister of Health stated that 4,500 health workers were employed during the state of emergency period, including 1,500 doctors, with newly employed staff being trained on basic aspects of coping with the COVID-19 outbreak, including using contact tracing tools. In the United Kingdom, 25,000 contact tracers were recruited in England and started work at the end of May. An upcoming policy snapshot will look at how countries are increasing their public health capacity in working towards implementing an effective ‘find, test, trace, isolate and support’ system.

Contact tracing apps are being developed and used to help contain the spread of the virus

As countries have begun to lift lockdown measures, several countries have identified apps as a potential way to effectively trace contacts of infected persons and get any subsequent outbreaks under control (Belgium, Bulgaria, Denmark, Finland, France, Russian Federation, Spain, Ukraine, the United Kingdom). The specific technical details and capabilities of the apps can vary substantially, which affects how individuals use them and what data are collected. This policy snapshot specifically focuses on apps designed for contact tracing, while apps used for self-diagnosis, monitoring active cases and communications are outside of the scope of this post. A previous policy snapshot on digital health tools provides a primer on some of these topics.

Contact tracing apps employed in the surveyed countries can either rely on Bluetooth or GPS. Contact tracing apps based on Bluetooth work by logging every device whose Bluetooth connection has been nearby. If a person on that history list self-reports to have tested positive for COVID-19, people who have been near that device would be notified and can take measures to self-isolate. Contact tracing apps which monitor the movement of COVID-19 patients are based on geolocation and can also take the form of monitoring bracelets, or they could be mobile apps downloaded to phones. 

Most apps developed so far can be downloaded voluntarily, and how much they allow users to opt-in on different features (e.g., geolocation, data sharing) varies. For example, Denmark is developing an app which will track citizens who voluntarily decide to use the app. If a citizen using the app is diagnosed with COVID-19, all citizens who have been close to the patient will be informed that they may have been exposed to COVID-19, but the identity of the patient will not be revealed to them.

In most cases, these different apps anonymously record other phones within the vicinity via Bluetooth on the basis of anonymous data, although a few countries have developed apps which analyse movements and gatherings taking into account the geolocation of the individual.

Countries have uneven development and implementation of contact tracing apps

A few countries have developed apps earlier in the pandemic (Israel, Lithuania, Norway, Russian Federation, Spain, Ukraine), while other countries have plans to roll them out soon (Belgium, Denmark, Finland, France, Italy, the Netherlands, North Macedonia, the United Kingdom). Italy selected the app “Immuni” out of a total of over 300 proposals.

Governments grapple with the difficult balance between effectively tracing contacts and ensuring data privacy

Several countries explicitly mention that privacy concerns, data storage, governance considerations, and partnerships with private industry players impact the speed of adoption of these apps (Belgium, France, the Netherlands, Spain), as governments weigh these implications. For example, in Spain there is an order that regulates the use of anonymized and aggregated data provided by mobile operators in order to analyse the population movements prior and during the lockdown, with a view to identify hotspots and improve the management and coordination of health care resources. In Belgium, the technology has to be open source, use only anonymized data, and rely on Bluetooth technology as opposed to geolocation technologies. Moreover, Belgium has specified that if different regions use different applications, they should be compatible with each other and with the federal eHealth platform. 

All countries have developed strategies for contact tracing

Contact tracing has been identified as a key element to control the spread of COVID-19. In our analysis, we have found that all countries have developed some strategy to put contact tracing in place. Further, most countries have invested additional resources into this task by hiring new personnel and developing apps that could help support the re-opening of the economy. 

We have also found that most countries tend to implement a decentralised approach for contact tracing through regional/district public health services. While this approach facilitates closeness to the population and its needs, it may result in uneven contact tracing across the country.   

This is particularly relevant for the use of apps. We found that some countries have developed different contact tracing apps to broaden their ability to undertake early detection of potential new COVID-19 infections. However, there is heterogeneity in the characteristics of these apps: some apps are voluntary (e.g. Denmark) while others are compulsory (e.g. Russian Federation); some countries also regulate access to private data (e.g. Spain) while others would only use anonymized data (e.g. Belgium). Independently of their characteristics, there should be transparency regarding how the information is gathered and for what purpose. While some think that the use of apps can help make the contact tracing operation faster and more effective, a limited uptake by citizens may mean that apps may not be the only solution. For example, in Singapore, which developed its own contact tracing app, only about one in six people in the country had actually downloaded the app a few weeks after it was available, despite the government’s public campaign. 

To conclude, we understand that further analysis will be useful to understand how much contact tracing is supported by other strategies such as the reinforcement of early detection in primary care (by PCR or any other equivalent test), and closer coordination with the epidemiological surveillance services. 

Cristina Hernández-Quevedo, Giada Scarpetti, Erin Webb