Pandemic Surveillance and Racialized Subpopulations: Mitigating Vulnerabilities in COVID-19 Apps

Short- and Long-Term Predicted and Witnessed Consequences of Digital Surveillance During the COVID-19 Pandemic: Scoping Review

BACKGROUND

The COVID-19 pandemic has prompted the deployment of digital technologies for public health surveillance globally. The rapid development and use of these technologies have curtailed opportunities to fully consider their potential impacts (eg, for human rights, civil liberties, privacy, and marginalization of vulnerable groups).

OBJECTIVE

We conducted a scoping review of peer-reviewed and gray literature to identify the types and applications of digital technologies used for surveillance during the COVID-19 pandemic and the predicted and witnessed consequences of digital surveillance.

METHODS

Our methodology was informed by the 5-stage methodological framework to guide scoping reviews: identifying the research question; identifying relevant studies; study selection; charting the data; and collating, summarizing, and reporting the findings. We conducted a search of peer-reviewed and gray literature published between December 1, 2019, and December 31, 2020. We focused on the first year of the pandemic to provide a snapshot of the questions, concerns, findings, and discussions emerging from peer-reviewed and gray literature during this pivotal first year of the pandemic. Our review followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) reporting guidelines.

RESULTS

We reviewed a total of 147 peer-reviewed and 79 gray literature publications. Based on our analysis of these publications, we identified a total of 90 countries and regions where digital technologies were used for public health surveillance during the COVID-19 pandemic. Some of the most frequently used technologies included mobile phone apps, location-tracking technologies, drones, temperature-scanning technologies, and wearable devices. We also found that the literature raised concerns regarding the implications of digital surveillance in relation to data security and privacy, function creep and mission creep, private sector involvement in surveillance, human rights, civil liberties, and impacts on marginalized groups. Finally, we identified recommendations for ethical digital technology design and use, including proportionality, transparency, purpose limitation, protecting privacy and security, and accountability.

CONCLUSIONS

A wide range of digital technologies was used worldwide to support public health surveillance during the COVID-19 pandemic. The findings of our analysis highlight the importance of considering short- and long-term consequences of digital surveillance not only during the COVID-19 pandemic but also for future public health crises. These findings also demonstrate the ways in which digital surveillance has rendered visible the shifting and blurred boundaries between public health surveillance and other forms of surveillance, particularly given the ubiquitous nature of digital surveillance.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-https://doi.org/10.1136/bmjopen-2021-053962.

Changes to Public Health Surveillance Methods Due to the COVID-19 Pandemic: Scoping Review

BACKGROUND

Public health surveillance plays a vital role in informing public health decision-making. The onset of the COVID-19 pandemic in early 2020 caused a widespread shift in public health priorities. Global efforts focused on COVID-19 monitoring and contact tracing. Existing public health programs were interrupted due to physical distancing measures and reallocation of resources. The onset of the COVID-19 pandemic intersected with advancements in technologies that have the potential to support public health surveillance efforts.

OBJECTIVE

This scoping review aims to explore emergent public health surveillance methods during the early COVID-19 pandemic to characterize the impact of the pandemic on surveillance methods.

METHODS

A scoping search was conducted in multiple databases and by scanning key government and public health organization websites from March 2020 to January 2022. Published papers and gray literature that described the application of new or revised approaches to public health surveillance were included. Papers that discussed the implications of novel public health surveillance approaches from ethical, legal, security, and equity perspectives were also included. The surveillance subject, method, location, and setting were extracted from each paper to identify trends in surveillance practices. Two public health epidemiologists were invited to provide their perspectives as peer reviewers.

RESULTS

Of the 14,238 unique papers, a total of 241 papers describing novel surveillance methods and changes to surveillance methods are included. Eighty papers were review papers and 161 were single studies. Overall, the literature heavily featured papers detailing surveillance of COVID-19 transmission (n=187). Surveillance of other infectious diseases was also described, including other pathogens (n=12). Other public health topics included vaccines (n=9), mental health (n=11), substance use (n=4), healthy nutrition (n=1), maternal and child health (n=3), antimicrobial resistance (n=2), and misinformation (n=6). The literature was dominated by applications of digital surveillance, for example, by using big data through mobility tracking and infodemiology (n=163). Wastewater surveillance was also heavily represented (n=48). Other papers described adaptations to programs or methods that existed prior to the COVID-19 pandemic (n=9). The scoping search also found 109 papers that discuss the ethical, legal, security, and equity implications of emerging surveillance methods. The peer reviewer public health epidemiologists noted that additional changes likely exist, beyond what has been reported and available for evidence syntheses.

CONCLUSIONS

The COVID-19 pandemic accelerated advancements in surveillance and the adoption of new technologies, especially for digital and wastewater surveillance methods. Given the investments in these systems, further applications for public health surveillance are likely. The literature for surveillance methods was dominated by surveillance of infectious diseases, particularly COVID-19. A substantial amount of literature on the ethical, legal, security, and equity implications of these emerging surveillance methods also points to a need for cautious consideration of potential harm.

Pandemic Racism: Lessons on the Nature, Structures, and Trajectories of Racism During COVID-19

The COVID-19 pandemic has been one of the most acute global crises in recent history, which profoundly impacted the world across many dimensions. During this period, racism manifested in ways specifically related to the pandemic, including xenophobic sentiments, racial attacks, discriminatory policies, and disparate outcomes across racial/ethnic groups. This paper examines some of the pressing questions about pandemic racism and inequity. We review what research has revealed about the nature and manifestations of racism, the entrenchment of structural racism, and trajectories of racism during COVID-19.

An online platform for COVID-19 diagnostic screening using a machine learning algorithm

OBJECTIVE

COVID-19 has brought emerging public health emergency and new challenges. It configures a complex panorama that has been requiring a set of coordinated actions and has innovation as one of its pillars. In particular, the use of digital tools plays an important role. In this context, this study presents a screening algorithm that uses a machine learning model to assess the probability of a diagnosis of COVID-19 based on clinical data.

METHODS

This algorithm was made available for free on an online platform. The project was developed in three phases. First, an machine learning risk model was developed. Second, a system was developed that would allow the user to enter patient data. Finally, this platform was used in teleconsultations carried out during the pandemic period.

RESULTS

The number of accesses during the period was 4,722. A total of 126 assistances were carried out from March 23, 2020, to June 16, 2020, and 107 satisfaction survey returns were received. The response rate to the questionnaires was 84.92%, and the ratings obtained regarding the satisfaction level were higher than 4.8 (on a 0-5 scale). The Net Promoter Score was 94.4.

CONCLUSION

To the best of our knowledge, this is the first online application of its kind that presents a probabilistic assessment of COVID-19 using machine learning models exclusively based on the symptoms and clinical characteristics of users. The level of satisfaction was high. The integration of machine learning tools in telemedicine practice has great potential.

Navigating social and academic isolation: a qualitative exploration of American university students' perspectives and experiences early in the COVID-19 pandemic

Objective: To qualitatively explore the multifaceted impacts of the early months of the COVID-19 pandemic on the lives of American university students.Method: Undergraduate students in general education courses at a mid-sized public Western U.S. university were recruited to complete a Qualtrics survey that evaluated their perceptions, beliefs, and behaviours towards COVID-19. Thematic analysis identified prevailing themes regarding the positive and negative changes to students' lives during the pandemic.Results: Participants included undergraduate students (N = 241) between the ages of 18 and 24 (74.7% women), with 49.4% identifying as White. Thematic analysis of the survey identified several codes encompassed by six key themes: (1) shifting social interactions; (2) wellness; (3) school; (4) financial changes; (5) loss of experiences; and (6) political turmoil.Conclusion: Some students identified positive consequences (e.g., more family time, more flexible schedule), while almost all students reported negative consequences (e.g., difficulty with time management and organisation, loss of job or income) of the COVID-19 pandemic. University communities should consider providing additional academic, financial, and mental health resources to students to further mitigate the lasting consequences of the pandemic.

Use of digital technologies for public health surveillance during the COVID-19 pandemic: A scoping review

Throughout the COVID-19 pandemic, a variety of digital technologies have been leveraged for public health surveillance worldwide. However, concerns remain around the rapid development and deployment of digital technologies, how these technologies have been used, and their efficacy in supporting public health goals. Following the five-stage scoping review framework, we conducted a scoping review of the peer-reviewed and grey literature to identify the types and nature of digital technologies used for surveillance during the COVID-19 pandemic and the success of these measures. We conducted a search of the peer-reviewed and grey literature published between 1 December 2019 and 31 December 2020 to provide a snapshot of questions, concerns, discussions, and findings emerging at this pivotal time. A total of 147 peer-reviewed and 79 grey literature publications reporting on digital technology use for surveillance across 90 countries and regions were retained for analysis. The most frequently used technologies included mobile phone devices and applications, location tracking technologies, drones, temperature scanning technologies, and wearable devices. The utility of digital technologies for public health surveillance was impacted by factors including uptake of digital technologies across targeted populations, technological capacity and errors, scope, validity and accuracy of data, guiding legal frameworks, and infrastructure to support technology use. Our findings raise important questions around the value of digital surveillance for public health and how to ensure successful use of technologies while mitigating potential harms not only in the context of the COVID-19 pandemic, but also during other infectious disease outbreaks, epidemics, and pandemics.

A Value-centered Exploration of Data Privacy and Personalized Privacy Assistants

In the current post-GDPR landscape, privacy notices have become ever more prevalent on our phones and online. However, these notices are not well suited to their purpose of helping users make informed decisions. I suggest that instead of utilizing notice to elicit informed consent, we could repurpose privacy notices to create the space for more meaningful, value-centered user decisions. Value-centered privacy decisions, or those that accurately reflect who we are and what we value, encapsulate the intuitive role of personal values in data privacy decisions. To explore how we could design for such decisions, I utilize Suzy Killmister’s Four-Dimensional Theory of Autonomy (4DT) to operationalize value-centered privacy decisions. I then utilize 4DT to help design a system—called a value-centered privacy assistant (VcPA)—that could help create the space for value-centered data privacy decisions using privacy notices. Using this 4DT lens, I further assess the degree that an existing technology, personalized privacy assistants (PPAs), use notices in a manner that allows for value-centered decision-making. I lastly utilize insights from the PPA assessment to inform the design of a VcPA, concluding that a VcPA could utilize notices to assist users in value-centered app selection and in other data privacy decisions.

In the shadow of privacy: Overlooked ethical concerns in COVID-19 digital epidemiology

The COVID-19 pandemic witnessed a surge in the use of health data to combat the public health threat. As a result, the use of digital technologies for epidemic surveillance showed great potential to collect vast volumes of data, and thereby respond more effectively to the healthcare challenges. However, the deployment of these technologies raised legitimate concerns over risks to individual privacy. While the ethical and governance debate focused primarily on these concerns, other relevant issues remained in the shadows. Leveraging examples from the COVID-19 pandemic, this perspective article aims to investigate these overlooked issues and their ethical implications. Accordingly, we explore the problem of the digital divide, the role played by tech companies in the public health domain and their power dynamics with the government and public research sector, and the re-use of personal data, especially in the absence of adequate public involvement. Even if individual privacy is ensured, failure to properly engage with these other issues will result in digital epidemiology tools that undermine equity, fairness, public trust, just distribution of benefits, autonomy, and minimization of group harm. On the contrary, a better understanding of these issues, a broader ethical and data governance approach, and meaningful public engagement will encourage adoption of these technologies and the use of personal data for public health research, thus increasing their power to tackle epidemics.

Tracing app technology: an ethical review in the COVID-19 era and directions for post-COVID-19

We conducted a systematic literature review on the ethical considerations of the use of contact tracing app technology, which was extensively implemented during the COVID-19 pandemic. The rapid and extensive use of this technology during the COVID-19 pandemic, while benefiting the public well-being by providing information about people's mobility and movements to control the spread of the virus, raised several ethical concerns for the post-COVID-19 era. To investigate these concerns for the post-pandemic situation and provide direction for future events, we analyzed the current ethical frameworks, research, and case studies about the ethical usage of tracing app technology. The results suggest there are seven essential ethical considerations-privacy, security, acceptability, government surveillance, transparency, justice, and voluntariness-in the ethical use of contact tracing technology. In this paper, we explain and discuss these considerations and how they are needed for the ethical usage of this technology. The findings also highlight the importance of developing integrated guidelines and frameworks for implementation of such technology in the post- COVID-19 world.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10676-022-09659-6.

How is “solidarity” understood in discussions about contact tracing apps? An overview

Background

In the context of the COVID-19 pandemic, there is much discussion about contact tracing apps, their use to contain the spread of the virus as well as the ethical, legal, and social aspects of their development, implementation, acceptance, and use. In these discussions, authors frequently mention “solidarity” when making key points in arguments. At the same time, authors rarely specify how they understand “solidarity”. This lack of specification about how they understand “solidarity” can lead to misunderstandings in discussions.

Objective

To prevent such misunderstandings, it is important to specify how one understands “solidarity” when mentioning it in the discussions on contact tracing apps. Therefore, the aim of this paper is to elaborate how “solidarity” is understood in the context of contact tracing apps, i.e., how different authors understand “solidarity” when using it in discussions about these apps.

Methods

In order to find out how different authors understand “solidarity” when discussing contact tracing apps, I conduct a literature review. I collect papers from several databases, inductively work out central differences and similarities between the different uses of “solidarity”, and use them to code and analyze relevant passages.

Results

In the final sample, five different understandings of “solidarity” in the context of contact tracing apps can be identified. These understandings differ in how different authors (1) imagine the basic concept of solidarity, i.e., what “solidarity” refers to, (2) how they temporally relate solidarity to contact tracing apps, and (3) how they perceive the causal interactions between solidarity and contact tracing apps, i.e., the different ways in which solidarity and contact tracing apps influence each other.

Conclusions

The five understandings of “solidarity” in the context of contact tracing apps presented here can serve as guidance for how “solidarity” can be understood in discussions—thus contributing to a better mutual understanding and preventing communicative misunderstandings.

Data privacy during pandemics: a systematic literature review of COVID-19 smartphone applications

BACKGROUND

On January 8, 2020, the Centers for Disease Control and Prevention officially announced a new virus in Wuhan, China. The first novel coronavirus (COVID-19) case was discovered on December 1, 2019, implying that the disease was spreading quietly and quickly in the community before reaching the rest of the world. To deal with the virus' wide spread, countries have deployed contact tracing mobile applications to control viral transmission. Such applications collect users' information and inform them if they were in contact with an individual diagnosed with COVID-19. However, these applications might have affected human rights by breaching users' privacy.

METHODOLOGY

This systematic literature review followed a comprehensive methodology to highlight current research discussing such privacy issues. First, it used a search strategy to obtain 808 relevant papers published in 2020 from well-established digital libraries. Second, inclusion/exclusion criteria and the snowballing technique were applied to produce more comprehensive results. Finally, by the application of a quality assessment procedure, 40 studies were chosen.

RESULTS

This review highlights privacy issues, discusses centralized and decentralized models and the different technologies affecting users' privacy, and identifies solutions to improve data privacy from three perspectives: public, law, and health considerations.

CONCLUSIONS

Governments need to address the privacy issues related to contact tracing apps. This can be done through enforcing special policies to guarantee users privacy. Additionally, it is important to be transparent and let users know what data is being collected and how it is being used.

Contact Tracing Apps: Lessons Learned on Privacy, Autonomy, and the Need for Detailed and Thoughtful Implementation

The global and national response to the COVID-19 pandemic has been inadequate due to a collective lack of preparation and a shortage of available tools for responding to a large-scale pandemic. By applying lessons learned to create better preventative methods and speedier interventions, the harm of a future pandemic may be dramatically reduced. One potential measure is the widespread use of contact tracing apps. While such apps were designed to combat the COVID-19 pandemic, the time scale in which these apps were deployed proved a significant barrier to efficacy. Many companies and governments sprinted to deploy contact tracing apps that were not properly vetted for performance, privacy, or security issues. The hasty development of incomplete contact tracing apps undermined public trust and negatively influenced perceptions of app efficacy. As a result, many of these apps had poor voluntary public uptake, which greatly decreased the apps' efficacy. Now, with lessons learned from this pandemic, groups can better design and test apps in preparation for the future. In this viewpoint, we outline common strategies employed for contact tracing apps, detail the successes and shortcomings of several prominent apps, and describe lessons learned that may be used to shape effective contact tracing apps for the present and future. Future app designers can keep these lessons in mind to create a version that is suitable for their local culture, especially with regard to local attitudes toward privacy-utility tradeoffs during public health crises.

Considerations for the Design and Implementation of COVID-19 Contact Tracing Apps: Scoping Review

BACKGROUND

Given the magnitude and speed of SARS-CoV-2 transmission, achieving timely and effective manual contact tracing has been a challenging task. Early in the pandemic, contact tracing apps generated substantial enthusiasm due to their potential for automating tracing and reducing transmission rates while enabling targeted confinement strategies. However, although surveys demonstrate public interest in using such apps, their actual uptake remains limited. Their social acceptability is challenged by issues around privacy, fairness, and effectiveness, among other concerns.

OBJECTIVE

This study aims to examine the extent to which design and implementation considerations for contact tracing apps are detailed in the available literature, focusing on aspects related to participatory and responsible eHealth innovation, and synthesize recommendations that support the development of successful COVID-19 contact tracing apps and related eHealth technologies.

METHODS

Searches were performed on five databases, and articles were selected based on eligibility criteria. Papers pertaining to the design, implementation, or acceptability of contact tracing apps were included. Articles published since 2019, written in English or French, and for which the full articles were available were considered eligible for analysis. To assess the scope of the knowledge found in the current literature, we used three complementary frameworks: (1) the Holistic Framework to Improve the Uptake and Impact of eHealth Technologies, (2) the Montreal model, and (3) the Responsible Innovation in Health Assessment Tool.

RESULTS

A total of 63 articles qualified for the final analysis. Less than half of the selected articles cited the need for a participatory process (n=25, 40%), which nonetheless was the most frequently referenced item of the Framework to Improve the Uptake and Impact of eHealth Technologies. Regarding the Montreal model, stakeholder consultation was the most frequently described level of engagement in the development of contact tracing apps (n=24, 38%), while collaboration and partnership were cited the least (n=2, 3%). As for the Responsible Innovation in Health framework, all the articles (n=63, 100%) addressed population health, whereas only 2% (n=1) covered environmental considerations.

CONCLUSIONS

Most studies lacked fundamental aspects of eHealth development and implementation. Our results demonstrate that stakeholders of COVID-19 contact tracing apps lack important information to be able to critically appraise this eHealth innovation. This may have contributed to the modest uptake of contact tracing apps worldwide. We make evidence-informed recommendations regarding data management, communication, stakeholder engagement, user experience, and implementation strategies for the successful and responsible development of contact tracing apps.

Early Perceptions of COVID-19 Contact Tracing Apps in German-Speaking Countries: Comparative Mixed Methods Study

Background

The main German-speaking countries (Germany, Austria, and Switzerland) have implemented digital contact tracing apps to assist the authorities with COVID-19 containment strategies. Low user rates for these apps can affect contact tracing and, thus, its usefulness in controlling the spread of the novel coronavirus.

Objective

This study aimed to assess the early perceptions of people living in the German-speaking countries and compare them with the frames portrayed in the newspapers during the first wave of the COVID-19 pandemic.

Methods

We conducted qualitative interviews with 159 participants of the SolPan project. Of those, 110 participants discussed contact tracing apps and were included in this study. We analyzed articles regarding contact tracing apps from 12 newspapers in the German-speaking countries.

Results

Study participants perceived and newspaper coverage in all German-speaking countries framed contact tracing apps as governmental surveillance tools and embedded them in a broader context of technological surveillance. Participants identified trust in authorities, respect of individual privacy, voluntariness, and temporary use of contact tracing apps as prerequisites for democratic compatibility. Newspapers commonly referenced the use of such apps in Asian countries, emphasizing the differences in privacy regulation among these countries.

Conclusions

The uptake of digital contact tracing apps in German-speaking countries may be undermined due to privacy risks that are not compensated by potential benefits and are rooted in a deeper skepticism towards digital tools. When authorities plan to implement new digital tools and practices in the future, they should be very transparent and proactive in communicating their objectives and the role of the technology—and how it differs from other, possibly similar, tools. It is also important to publicly address ethical, legal, and social issues related to such technologies prior to their launch.