COVID-19 Webinar Series Session 14 – Lessons from Home and Abroad: Implementing a Contact Tracing Strategy

12:00 p.m. – 12:05 p.m.     Welcome and Introductions 

Kathryn B. Martucci, MPH, Director of Policy and Programs, Alliance for Health Policy

@allhealthpolicy

12:05 p.m. – 1:00 p.m.           Moderated Discussion

Anand Parekh, M.D., MPH, Chief Medical Advisor, Bipartisan Policy Center

@AParekhBPC

Rudolf Blankart, Dr. rer. pol., Professor of Regulatory Affairs, Center of Competence for Public Management (KPM), University of Bern; Director Promoting Services, sitem-insel AG

@RB_Today

K.J. Seung, M.D., Chief of Strategy and Policy for MA COVID Response, Partners in Health/Commonwealth of Massachusetts; Co-Leader, endTB; Assistant Professor of Medicine, Department of Global Health and Social Medicine, Harvard Medical School; Associate Physician, Division of Global Health Equity, Brigham and Women’s Hospital

@kj_seung

Moderator: Reed Tuckson, M.D., Managing Director, Tuckson Health Connections; Board Chair, Alliance for Health Policy

@DrReedTuckson

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)   0:05 Hello and welcome to session 14 of our covid-19 webinar series. I am Catherine martucci director policy and programmes at the Alliance for Health policy. For those of you who are not familiar with the alliance. We are a nonpartisan resource for the policy Community dedicated to advancing knowledge and understanding of Health policy issues. 0:26 The alliance launched the series to provide insight into the status of the covid-19 response as well as shed light on remaining gaps in the system that must be addressed to limit the severity of the pandemics impact in the United States. 0:40 The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation and the Commonwealth fund for supporting the series you can join today’s conversation on Twitter using the hashtag all Health Live and follow us at all Health policy. 1:00 We want you to be active participants in today’s discussion. So please get your questions ready. Here’s how you can ask them. 1:08 You should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark You can use that speech bubble icon to submit questions you have for the panelists at any time. We will collect these and address them during the broadcast. 1:24 Just you can also use that icon to notify us about any technical issues. You may be experiencing background materials including the slides are available on our website. I’ll Health policy dot-org a recording of today’s webinar will be available there soon. 1:43 As a number of states begin to lift stay-at-home orders questions remain around strategies to curb the continued spread of covid-19. 1:53 Public Health officials are ramping up efforts to Monitor and contain new cases through contact tracing a disease control method used to identify and notify individuals who may have been exposed to the virus. The strategy is a key component of other nations efforts to safely. He’s social distancing measures. 2:12 During this webinar panelists will discuss case studies from abroad and best practices as policymakers looked to implement a contact tracing strategy in the United States. 2:23 And now I’m pleased to introduce the alliance’s board chair. Dr. Reed tuckson to introduce our panelists and moderate today’s briefing. Thank you for being with us today. Dr. Toxin. Well, thank you very much. And we thank all of you for listening in on a very important and obviously timely conversation lessons from home and abroad implementing a contact tracing strategy. 2:45 What we hope you’ll get out of this is that you will learn the importance of contact tracing at this stage in the pandemic that you will have a chance to I’m in case studies from other countries as we learn from their tracing and surveillance efforts. We want to identify successful contact tracing strategies and highlight the infrastructure that is necessary to support this critical activity. 3:07 And finally we want to explore the role of the private sector non-government organizations and Community organizations in doing this and distinguish between what the federal response ought to be and stayed in government response and how these work together, but we have a great panel to Discuss this with us and to start us out. Each of our panelists will have five to seven minutes where they will make comments then we’ll introduce the next one and then the third speaker and then we will have a bit of a moderated question-and-answer period and then we will turn it to you on our last half-hour or your questions and your input to begin. I’m very pleased that a nonparametric has joined us. He is the chief medical officer of the bipartisan policy Center and for a decade he was the HHS. 3:53 Deputy assistant secretary for health clearly a person of great experience in doing important work now, he will discuss the findings from a recent bpc report comparing countries approaches to he’s social distancing measures and how those lessons might be applied to the United States a non. Thank you so much. 4:14 Creed thanks so much for that introduction. It’s great to be with all of you today. And thank you again to the alliance for the invitation as Reed mentioned. I’ll just be summarizing some of the Lessons Learned From A bipartisan policy Center report. I think you have that in your material set. The context here is though we’re still in the midst of the first wave of the pandemic in the United States as we know and here elected officials are poised to open up the economy. 4:44 Most states are in the process or have stated their intention to start this process in the coming days and weeks and so the premise of our recent work was as a nation with 50 states here. Let’s not make policy in a vacuum. Let’s realize that there are dozens of countries around the world that are can pour lie ahead of us or at least in sync all sort of looking at this and trying to figure out how do you he’s social distancing or fiscal distancing interventions? 5:15 And what in the question is what can we learn from them realizing that every country has different size government our notion of federalism culture the extent of personal freedoms. There is no one-size-fits-all pandemic plan, but there are lessons and what are those lessons? 5:32 So our methodology was we looked at 15 countries that ten European countries Austria the Czech Republic Denmark, France Germany, Italy Netherlands, Spain Switzerland and K and we looked at five East Asian countries South Korea Taiwan China Singapore and Hong Kong and the qualitative information. We collected we got from What’s called the health systems response monitor. That’s a collaboration between The Who and the European commission and the European Observatory. We spoke with experts from the Commonwealth funds International Health policy and practice Innovation program. And we also read through published literature as well as media reports. 6:14 And I want to just spend a couple of minutes summarizing the overarching findings of our recent report and then maybe spend an extra minute or so on contact tracing so very quickly. I think the overarching findings when it comes to loosening social distancing interventions. 6:30 Number one there really weren’t too many countries that had explicit transparent quantitative criteria, vis-à-vis loosening social distancing interventions think some countries are Looking at the transmissibility factor are not others are looking at cases. Of course that’s limited be a testing but not too many countries had sort of explicit criteria gating criteria people in terms of sequencing of sectors most countries. Of course, you’re looking at the risk of transmission so sectors that are low risk of transmission opening up first. 7:04 Some countries are actually also taking into account the importance of accompany the economy as well and trying to figure out what’s that sweet spot low risk of Mission plus importance of economy in terms of time frame between bases most countries looking at two to three weeks to assess the impact of infection spread prior to opening up other sectors of their economy in terms of school openings. No real consensus across these countries some countries looking at opening up schools early some late. Some of this is dip is differs based on the level of schooling primary secondary or higher ed make one opportunity here for the u.s. Is to track particularly easy. 7:43 Even countries since they are school year is year-round. And so that might provide some insights for us in the fall in terms of testing. We looked at how many tests are being done in these countries and who was being tested we look at specific regions that have been successful like Venetia and Italy as well as looked at countries that had explicit stated goals. And if you extrapolate that the in the United States sort of the number or range we came up with with is about 4 to 5 million tests per week. 8:13 Week to really be in a good position to loosen social distancing interventions in comparison here in the United States over the last seven days. We’re just under about 2 million, but it’s not just how many you test. It’s who you test and so many of these countries focusing now on vulnerable populations who are asymptomatic whether it’s Frontline workers under sure groups minority populations terms of isolation many countries looking at temporary housing for those who are infected. You can’t recover at home to really break those household. 8:43 Transmission chains in terms of masks really most countries. We looked at are mandating cloth based masks in areas where social distancing is not possible like public transport and grocery stores. And then in terms of communication while loosening countries are being shorter than Switzerland provides a good example of being sure to emphasize the continued importance of hand hygiene respiratory etiquette physical distancing and cloth based mask sort of The New Normal. 9:13 And then finally sort of a minute or two on contact tracing and what we were able to glean based on this cross-country analysis to the extent that countries provided definition of what they mean by contact tracing essentialism a couple of definitions. We found in relation to a confirmed case. We’re really talking about individuals who are within six feet without a mask for 10 to 15 minutes to days prior to a confirmed positive test. 9:42 Two days prior to the start of symptoms in a confirmed case in terms of the process how this is done across countries. 9:50 Most countries are utilizing government employees some using military not as many countries using volunteers really is unclear how many have public health backgrounds but most countries using teams of people at multiple levels local state federal having trainers call centers staff again checking in with these closed contacts over a 14-day period we didn’t find a lot of specificity weather testing was required for these close contacts nor did we find a lot of specificity across countries in terms of for these individuals are they being provided Services over the two-week period of housing or food Etc in terms of quantitative metrics the two countries that that that that that have quantitative metrics one is China particularly Wuhan where they had 1,800 teams of five contact tracers, so essentially one for every Hundred citizens and in Germany five contact tracers for 20,000 population and that roughly relates to sort of what we’re hearing here in the United States for a broad range of perhaps. We need anywhere from a hundred thousand three hundred thousand contact tracers and the 300,000 is sort of more on the range of Wuhan the hundred thousand that we hear about here in the u.s. Is more in the range of Germany. 11:08 And then the last point I’ll just make is there’s been quite it a bit of a tension and I’m using that word very carefully and not saying emphasis on digital contact tracing as a supplementary tool to manual contact tracing certainly in East Asian countries. We’ve seen for the monitoring and surveillance of infected individuals governments mandating some of these tools but I think Singapore is probably the best example with their Trace together act for close contacts. Essentially what that app does is create a log of other smart. 11:42 Bone Bluetooth signals within a 6 foot radius now an individual has to download the app. And then if they become if they turn positive then they have to report that in the app and then that signals other potential individuals who were in close proximity that they may be infected. Of course, there are cons here. There’s been sort of a low uptake rate in Singapore about 12% where experts think you need about sixty percent. There are also some false positives. 12:12 That being said many many European countries. For example, Australia are planning to utilize digital contact tracing. Of course, the key questions are for example, where is the data being stored? Is it centralized? And if so, what are the privacy issues? Is it decentralized? 12:29 In fact many of our of us corporations like Apple and Google are for more focus on the decentralized pathway so many questions there, but but definite evidence that digital contact tracing Says a complimentary or support supported measure the physical manual contact tracing is being used. So any of that is just a high level overview again. What we were trying to do is tease out across European and East Asian countries. What are the pearls the lessons learned that we can hear use here in the United States as we relax the social distancing interventions and a few comments on contact tracing but looking forward to it. 13:12 Writing that discussion in a few minutes. Thank you. So much will will state it in a great lead off that turns us now to Rudolph blank card professor of Regulatory Affairs at the KPM Center for Public management at the University of Bern. He’s also director of a public private partnership in the field of translation translational medicine. 13:32 His research is at the interface of medicine management and law and he will explain for us how Germany is leveraging public health workers for contact tracing and Getting resources into high-risk communities. Welcome Rudolph. Thank you ready for this nice introduction. So I will have I’ve presented some slides and I hope that the next slide will just show up. So I want to show the lessons learned from Germany and the next slide, please. 14:07 And therefore I want to give you some insights or kind of contextual factors about Germany. So Germany is in the middle of Europe and it’s also a federal istic country similar to the us so we have 16 federal states that have a quite a lot of power similar to the United States states. It’s about as large as California with hundred and study 7 square mile. 14:36 Square miles and 83 million people about doubled the size according to population, but we do not have these super cities like New York Paris or London Berlin the largest city. The capital has about 3.4 million and other cities which are larger than a million is Hamburg cologne and Munich and we will see Munich afterwards again from the Healthcare System. We have a compulsion. 15:06 SRI Health Care System health insurance where everybody has to have an insurance across the country. There are almost 2000 hospitals with eight beds per thousand people. This is similar to what the US had in 1970s nowadays the US has about three beds per thousand. However, you have to account that. Germany is said to have a lot of beds almost too much. 15:36 Many beds and if you look at the Intensive Care beds per thousand, we are at 0.34 which is about the number of the US. However, we have increased the number of beds in during the corona crisis to about 0.5. But first how per thousand ways now about 40,000 deaths in total and regarding testing capacity for covid-19. 16:06 Dean we are slightly below a 1 million tests per week or so. You have to say that not all 1 million tests are actually performed. It’s about six to seven hundred thousand that are actually performed and this was kind of effort to increase that number of tests. So next slide, please. 16:25 If you look how they on the map of the different federal states in Germany, you see that the covid-19 cases per capita are pretty Peter Regina’s you see that the covid-19 spread from south to North there were two events. First of all, we see Italy where the virus has spread quite a lot and this pushed. 16:55 Norse to Bavaria and baden-württemberg and then on the other hand from from Austria and they were seeing areas where they have clothes very late the skiing Resorts and many people especially from Bavaria and from Hamburg have been there in places like ish good and they brought the virus to to Germany and spread it there quite a lot on this you can still see on on Map of the covid cases if you look on the right side right top side, you see the new cases per day and you see that about mid-march the heart which directions were in place. We never had a lockdown similar to Spain or Italy where nobody was allowed to go on on the street. 17:46 The people were allowed to go outside, but they were just allowed to have to meet about a maximum of one other person and during the The restrictive phase the number of new cases per day they has the has been reduced substantially and mid-april the was a start of loosening restrictions as an Untold. There are no kind of fixed values that should be reached as nobody knows these values yet. And so it was a kind of a step-by-step approach where every week some more restriction. 18:22 Well loosened you have to You also have to know that the restrictions are not set by the central government as it’s a federal istic country. Each federals. Each of the 16 federal states has to do their own loosening efforts. And so it’s slightly different between the federal states basic control metrics are the reproduction number the doubling time. 18:54 So how long does is it take until the number of infected people doubles that went down from about 2 Days 1 to 2 days to more than a hundred days now A Time times and there is a threshold of 50 cases per hundred thousand people per week where and if one community so Germany has about 300 communities when in one of these Communities that threshold is hit then they will there will be a lockdown measures in place again, but right now they are loosening only if you hit these 50 per hundred thousand cases a week, then you have to to lock down some of the state’s even reducing this number to about 35 to study case because I think that 50 is too much. And another thing is that antibiotics. 19:55 Body, testing will come soon and will be an add-on to to the measures it right now in place next slide please here is a just an overview how the basic reproduction number evolved you the first restrictions kind of no restrictions like forbidding events with more than thousand people social distancing. 20:26 calls for social distancing they reduce already in the beginning of March the number of infections or of the number are the basic reproduction number says basically it says how many people does one infected person generate in how many new infection does one infected person generate and as soon as long as it is below zero the number of infected people stare drops and you can see they are right side where there were the steps of loosening the restrictions that it stayed below 1 which is fine, but during the last four days it increased above one, which is not a good sign, but there is a huge uncertainty. 21:25 And the last two so it was two days above one and now it’s below one again the last two days next slide, please. 21:38 So I told so what what it may be the benefit or what has happened. What is the what are the regulations that would have a major importance in Germany first? It was the national infection protection act that regulates the interaction between the federal state and the state governments and it defines the role of the national Robert Koch Institute. 22:04 They are Ki that’s cop Probably comparable to the US CDC and this institute that gives recommendations to the federal states and to the central government how to act and but the federal States government they are responsible to enact these ordinances and regulations to protect their citizens. 22:30 And the second thing would Germany has done was that they prepared a national pandemic plan in 2005 shortly after the South’s crisis in 2003. They drafted this plan and updated into it in 2017. This was basically based on 99 1999 guidelines of The Who and this resulted in Nash in company and institution pandemic plans that all institutions are often narges nursing homes schools. 23:06 They had to have Pandemic plan which says for example that on hundred beds in a nursing home. You need 15 rooms two separate people or what Germany also had is a special telephone number to call for covid cases that you had. This was a hundred 1617 and compared to other countries where it was kind of the 9-1-1 number. 23:31 These numbers were kind of overcrowded which caused other problems of Who have kind of Mark Abalone factions they could come through. So this was a very important thing as well next slide, please. I just wanted to give you one inside how contact tracing actually works here in the city of Munich. The city of Munich has is a part of the federal state of Bavaria. 23:59 And the City of Munich has probably the largest public health authority in Germany and is responsible for 1.4 million people basically Physicians hospitals and public health authorities May prescribe tests, which which results are then reported to a state database and this state database is going then to the robot Koch Institute to the National Database that derives their things but the public has Authority is also informed about the infected individual shown in red and they Contact the red in infected individual and they infect. 24:44 The individual has to report all their contacts which they had over 15 minutes. And also this infected integral is put into current time at home or in a Corona hotel which are four-star actually or it has to go in hospital. Then the public health authority also contacts of contact person’s one which the infected individual reported. They in fact is this suspected in infected people. 25:11 They have to go to currently in as well for 14 days whether they have symptoms or not whether the test is negative or not. They have to go for 14 days and I was there also and if they have the suspected infected people are infected as well. Then the tall Circle starts again, so next slide, please. 25:35 So just as you probably know Germany can pretty good out of the crisis until now. We don’t know what happens. But what are the success factors what we see now is probably preparation. So they had a national pandemic plan on The Good Health Care System. The Germany had also luck. It was not the first to be hit and had some experiences from other countries. Like Italy. They also had experiences in spotlights like BMW who was hit by the skiing Resort cry. 26:04 Says and the bus so they have access to a Health Care system and testing a which is a pretty good so tests are free in Germany. So everybody actually wants to who wants to have a test gets a test. There is excessive testing capacity. And the population is used to access the healthcare system and last there is a fast and comprehensive testing where special groups they get their results within two hours and general population. 26:34 See Stu eight hours. The infection is also infection prevention is also done first put first. So in the key is they involve key people to have access to a minorities and they wave prosecution of kind of illegal immigrants Etc. 26:51 And a large role is also playing that you go to the physician and the that you go to current Gene is the Social Security system, which is important to have that you have an unemployment assistance and that you also Short time work which is subsidized by the federal state. So you’re not losing your your your job just because you are in current time. So that’s my slide for now and I can override I think I’m out of time and I hand over to read thank you so much Rudolph appreciate it. 27:27 And now for our third speaker KJ song who is assistant professor of medicine at Brigham and Women’s Hospital, but he’s particularly really important for us on this particular conversation because he’s the project leader and observational study principal investigator for Partners in Health Partners in Health has really been bolstering Massachusetts contact tracing Workforce and is has the Lessons Learned on best practices that state and federal policymakers can utilize KJ. 27:56 Thank you Reid. Can you go to the next slide slide, please? I am part of the Massachusetts Community tracing collaborative and I want to present some of the experiences that we’ve had here so far. I hear a lot of feels a lot of calls from other States cities in in in our country trying to you know, maybe we are you know for six weeks ahead of everybody else. 28:25 But we’re really not that far ahead in the grand scheme of things next slide, please one of the things that you know contact tracing is not anything new. 28:40 It’s not even you in the United States and I think that certainly the public health nurses, they all understand and have been doing this for years with other diseases and I think even a lot of the patients a lot of the people that our community have and have have also have experience with contact tracing to but you know, this is just part of a larger Community response to covid and you know, this is what we were discussing before is that when you’re looking at the other countries and the other other countries that have been effective all of them have used social distancing testing contact tracing isolation and quarantine and if you can’t do Do the all of these things in an effective efficient and Rapid manner that you really have no chance against covid that slide, please. 29:36 so here you really you know, we what we talked about in Massachusetts a lot is really the four elements and the contact tracing I absolutely is important but I think sometimes people misunderstand that contact tracing alone isn’t useful unless you have anybody to trace and that’s you know, if you don’t really have if you don’t have your testing structures or systems in place if there aren’t people who ooh, ooh who are able to get tested without State without waiting in line, you know those times, you know that in Germany that’s really impressive, you know to get your results back in in two to four hours. 30:18 If you’re a first responder and in 68 hours, if you’re the general public that’s something that is a right now is is mostly a a dream in most of the United States and after you trace if you don’t really have anything for people to do If they can’t prevent infection to other people then again, you know, you’re testing and tracing use just a empty exercise people need to be supported to isolate in home or in a facility and that support, you know, there are many many people I think in our experience up to 20% of the people that we call need support to isolated home and really would welcome if there were isolation. 31:05 Facilities that were set up in their towns next slide, please. 31:11 So if we really say that all four of these these elements, you know, all four of these activities are important to combine covid. We also have to Target them and we need to outreach into specific communities and we know the covid by this time. I think everybody knows that covid doesn’t hit everybody equally, it’s our poor communities. It’s our communities of color. 31:40 Color that are disproportionately affected. So how are you going to get into these communities with with with all of these interventions next slide, please, you know, one of the things that we have learned in Massachusetts and is that there are you know, there are local, you know to reach into these communities you have to use the organizations that have experience in those communities and the obvious ones here. 32:10 Are the local Boards of health and this in different states? These are called these may be called call differently, but these Public Health departments, which are local they have, you know, Decades of experience working with communities working with people making sure that they are linked into services and the other the other major group. I think that is important to to to work with are the community health centers. 32:40 So there’s networks National really networks of federally qualified community health centers that really are their mandate to work in specific communities to work with different languages and have very personal relationships. 32:54 And and so when you’re you know, when you’re number one when you’re calling and you know, you’re talking to somebody, you know, who who has gotten a diagnosis of covid to be able you know for For a community health center to say that they are a you know that we’re in this community. This is a this is a name. That’s that there’s name recognition there and that sort of name recognition that sort of reputation is priceless. I will give you some round numbers, you know, we could say maybe the local Boards of Health. There are maybe three hundred at least 300 nurses. 33:40 That are doing contact tracing ch-ch-ch see staff close to us. Also 300 staff now in Massachusetts that are doing contact tracing and the the the for the CTC. These are dou Pi H employees that have been newly hired there’s about 1500 of them. So we’re talking over 2,000 people now in Massachusetts all were using the same system and doing contact tracing for covid. 34:09 It is not just about being culturally competent. It’s it’s about providing high-quality high-quality services in it’s clear at this time, even though we’ve been doing this for just a few weeks that you know, simply advising people that they need to isolate advising people that they need to quarantine the classic public health education. This is inadequate. 34:39 you know people cannot isolate when they’re living six people in in a single house if there are people who are elderly in their house and who are really vulnerable to covid and if you can’t provide any sort of support whether that’s food delivery, whether that’s a referral to a facility whether that’s child care, whether it’s delivering medications, then the likelihood that you’re going to It’s a transmission within the home and even you know in the workplace if this person is such a worker is is really close to 0 so, you know, and I think that one the local Boards of health and the chcs they do have that experience. They do have that understanding about and about how to link people to local support. But overall the project as a whole has to have that Vision. 35:36 The contact tracing project is not just Just a epidemiological exercise. If you want to you know, it’s not a data collection exercise. If you want to have an epidemiological impact that you have to think about the dot that the downstream activities after the call. How are you going to support people to do isolation and quarantine and my last slide here, you know, I think once you have very experienced contact tracing systems. 36:09 Then you’re able to do even more creative sorts of contact tracing. It’s a gration with testing. Can you go to the next slide please? One of the things that just came out yesterday or a couple days ago was a new recommendation by the Department of Public Health that all contacts in Massachusetts should be tested. 36:30 So now instead of just going so and what I’m saying here is that this is not just symptomatic context is asymptomatic context to And we know that covid even before the onset of symptoms can be very very infectious. And this is the Department of Public Health attempt to get ahead of it. So you can see there that normally we think of contact tracing coming after the testing. 36:57 So a patient who is tested positive is now referred to contact tracing and and then there’s an effort to look at the context but now with the new Dacians with a new fast-track among testing sites, then those contests can get rapidly tested as well which can lead to new cases which can lead to the discovery of new chains of transmission that that that need to be broken. 37:28 I’m going to start stop here read thank you very much. Well, thank you all very much the through the three of you and let’s start to get right down to some of the key questions and and I wonder whether you could start out you mentioned a little bit about variability. I think in the criteria for determining whether a contact is significant or not, clinically and requires, you know secondary intervention. 37:57 Could you Elaborate a little bit more on on what you have seen around the country and then maybe KJ you might be able to again drill down again on on what you’re seeing in terms of consistency or lack ther