Facilitators and barriers to engagement with contact tracing during infectious disease outbreaks: A rapid review of the evidence

COVID-19 contact tracing and quarantine policies in the Indo-Pacific Region: A mixed-methods study of experiences of public health professionals

Contact tracing and quarantine are valuable public health tools to prevent the transmission of SARS-CoV-2 and control the epidemic. Many low-and middle-income countries (LMICs) adopted global contact tracing and quarantine guidelines but were unable to contextualise the guidance into policies and practices that were relevant to their setting. Therefore, we examine contact tracing policies and practices in the Indo-Pacific region and the need to design context-specific policies. We conducted a mixed-methods study, including a cross-sectional online survey followed by key-informant interviews (KIIs). Using convenience snowball sampling, we invited public health professionals primarily involved in COVID-19 pandemic response from the Indo-Pacific region. We undertook descriptive analyses using counts and percentages for survey data and framework analysis for qualitative data. Seventy-seven public health professionals participated in the survey, of whom ten also participated in the KIIs. The study identified significant gaps between policies and the local contexts. Factors that broaden the gaps were limited knowledge of the changing dynamics of COVID-19 transmission, poor leadership, and coordination, little or no formal training on contact tracing, poor understanding of the guideline recommendations, limited resources, community resistance and mistrust, social stigmatisation and fear of being ostracised, and discrimination. This study revealed substantial disparities between policies and local contexts, significantly influencing policy implementation at national, provincial, and district levels across the studied countries. To bridge these gaps, we advocate for national contact tracing and quarantine guidelines explicitly addressing the quarantine needs of specific demographics, including children, pregnant women, prisoners, and individuals affected by social exclusion issues. Furthermore, we propose strengthening contact tracing training programs, urging revised guidelines to account for social, cultural, and infrastructural nuances influencing contact tracing and quarantine implementation. We also recommend engaging local NGOs, faith-based organisations, and local administrations to reinforce community connections and strengthen contact tracing.

Contact tracing in Austria, Georgia, Kyrgyzstan, Ukraine, and Kosovo† during the COVID-19 pandemic: response review and good practices

BACKGROUND

During the COVID-19 pandemic, effective contact tracing was recognized as a crucial public health response to mitigate the spread of SARS-CoV-2 and reduce COVID-19-related morbidity and mortality, particularly before widespread vaccination. The World Health Organization (WHO) recommended implementing active surveillance strategies to trace and quarantine contacts of confirmed or suspected COVID-19 cases.

METHODS

A detailed review and analysis of the COVID-19 contact tracing responses was conducted in five European countries and territories, between March 2021 and August 2022. The countries and territories were selected to ensure geographical representation across the WHO European Region and applied a mixed-methods approach of in-depth interviews with various stakeholders across different administrative levels to identify good practices in COVID-19 contact tracing. The interviews covered 12 themes, including methods and procedures for COVID-19 contact tracing, information technology, quality assurance and key performance indicators.

RESULTS

The findings demonstrate that the policy approach, digitalization capabilities and implementation approach varied in the countries and territories and were dynamic throughout the pandemic. The analysis revealed that some practices were applicable across all countries and territories, while others were context-specific, catering to each country's and territory's unique needs. The study highlighted a need for all countries to institutionalize contact tracing as an essential function of existing health systems, to digitalize contact tracing practices and processes, and to build and retain contact tracing capacities for better pandemic preparedness.

CONCLUSION

The lessons related to COVID-19 contact tracing should be utilized to strengthen future outbreak response operations as part of epidemic and pandemic preparedness.

Evaluation of the implementation of a community health worker-led COVID-19 contact tracing intervention in Chiapas, Mexico, from March 2020 to December 2021

BACKGROUND

Mexico is one of the countries with the greatest excess death due to COVID-19. Chiapas, the poorest state in the country, has been particularly affected. Faced with an exacerbated shortage of health professionals, medical supplies, and infrastructure to respond to the pandemic, the non-governmental organization Compañeros En Salud (CES) implemented a COVID-19 infection prevention and control program to limit the impact of the pandemic in the region. We evaluated CES's implementation of a community health worker (CHW)-led contact tracing intervention in eight rural communities in Chiapas.

METHODS

Our retrospective observational study used operational data collected during the contract tracing intervention from March 2020 to December 2021. We evaluated three outcomes: contact tracing coverage, defined as the proportion of named contacts that were located by CHWs, successful completion of contact tracing, and incidence of suspected COVID-19 among contacts. We described how these outcomes changed over time as the intervention evolved. In addition, we assessed associations between these three main outcomes and demographic characteristics of contacts and intervention period (pre vs. post March 2021) using univariate and multivariate logistic regression.

RESULTS

From a roster of 2,177 named contacts, 1,187 (54.5%) received at least one home visit by a CHW and 560 (25.7%) had successful completion of contact tracing according to intervention guidelines. Of 560 contacts with complete contact tracing, 93 (16.6%) became suspected COVID-19 cases. We observed significant associations between sex and coverage (p = 0.006), sex and complete contact tracing (p = 0.049), community of residence and both coverage and complete contact tracing (p < 0.001), and intervention period and both coverage and complete contact tracing (p < 0.001).

CONCLUSIONS

Our analysis highlights the promises and the challenges of implementing CHW-led COVID-19 contact tracing programs. To optimize implementation, we recommend using digital tools for data collection with a human-centered design, conducting regular data quality assessments, providing CHWs with sufficient technical knowledge of the data collection system, supervising CHWs to ensure contact tracing guidelines are followed, involving communities in the design and implementation of the intervention, and addressing community member needs and concerns surrounding stigmatization arising from lack of privacy.

User feedback on the NHS test & Trace Service during COVID-19: The use of machine learning to analyse free-text data from 37,914 England adults

Objectives

The UK government's approach to the pandemic relies on a test, trace and isolate strategy, mainly implemented via the digital NHS Test & Trace Service. Feedback on user experience is central to the successful development of public-facing Services. As the situation dynamically changes and data accumulate, interpretation of feedback by humans becomes time-consuming and unreliable. The specific objectives were to 1) evaluate a human-in-the-loop machine learning technique based on structural topic modelling in terms of its Service ability in the analysis of vast volumes of free-text data, 2) generate actionable themes that can be used to increase user satisfaction of the Service.

Methods

We evaluated an unsupervised Topic Modelling approach, testing models with 5-40 topics and differing covariates. Two human coders conducted thematic analysis to interpret the topics. We identified a Structural Topic Model with 25 topics and metadata as covariates as the most appropriate for acquiring insights.

Results

Results from analysis of feedback by 37,914 users from May 2020 to March 2021 highlighted issues with the Service falling within three major themes: multiple contacts and incompatible contact method and incompatible contact method, confusion around isolation dates and tracing delays, complex and rigid system.

Conclusions

Structural Topic Modelling coupled with thematic analysis was found to be an effective technique to rapidly acquire user insights. Topic modelling can be a quick and cost-effective method to provide high quality, actionable insights from free-text feedback to optimize public health Services.

Evaluating the Added Value of Digital Contact Tracing Support Tools for Citizens: Framework Development

BACKGROUND

The COVID-19 pandemic revealed that with high infection rates, health services conducting contact tracing (CT) could become overburdened, leading to limited or incomplete CT. Digital CT support (DCTS) tools are designed to mimic traditional CT, by transferring a part of or all the tasks of CT into the hands of citizens. Besides saving time for health services, these tools may help to increase the number of contacts retrieved during the contact identification process, quantity and quality of contact details, and speed of the contact notification process. The added value of DCTS tools for CT is currently unknown.

OBJECTIVE

To help determine whether DCTS tools could improve the effectiveness of CT, this study aims to develop a framework for the comprehensive assessment of these tools.

METHODS

A framework containing evaluation topics, research questions, accompanying study designs, and methods was developed based on consultations with CT experts from municipal public health services and national public health authorities, complemented with scientific literature.

RESULTS

These efforts resulted in a framework aiming to assist with the assessment of the following aspects of CT: speed; comprehensiveness; effectiveness with regard to contact notification; positive case detection; potential workload reduction of public health professionals; demographics related to adoption and reach; and user experiences of public health professionals, index cases, and contacts.

CONCLUSIONS

This framework provides guidance for researchers and policy makers in designing their own evaluation studies, the findings of which can help determine how and the extent to which DCTS tools should be implemented as a CT strategy for future infectious disease outbreaks.

Adoption of a COVID-19 Contact Tracing App by Czech Youth: Cross-Cultural Replication Study

BACKGROUND

During the worldwide COVID-19 pandemic crisis, the role of digital contact tracing (DCT) intensified. However, the uptake of this technology expectedly differed among age cohorts and national cultures. Various conceptual tools were introduced to strengthen DCT research from a theoretical perspective. However, little has been done to compare theory-supported findings across different cultural contexts and age cohorts.

OBJECTIVE

Building on the original study conducted in Belgium in April 2020 and theoretically underpinned by the Health Belief Model (HBM), this study attempted to confirm the predictors of DCT adoption in a cultural environment different from the original setting, that is, the Czech Republic. In addition, by using brief qualitative evidence, it aimed to shed light on the possible limitations of the HBM in the examined context and to propose certain extensions of the HBM.

METHODS

A Czech version of the original instrument was administered to a convenience sample of young (aged 18-29 y) Czech adults in November 2020. After filtering, 519 valid responses were obtained and included in the quantitative data analysis, which used structural equation modeling and followed the proposed structure of the relationships among the HBM constructs. Furthermore, a qualitative thematic analysis of the free-text answers was conducted to provide additional insights about the model's validity in the given context.

RESULTS

The proposed measurement model exhibited less optimal fit (root mean square error of approximation=0.065, 90% CI 0.060-0.070) than in the original study (root mean square error of approximation=0.036, 90% CI 0.033-0.039). Nevertheless, perceived benefits and perceived barriers were confirmed as the main, statistically significant predictors of DCT uptake, consistent with the original study (β=.60, P<.001 and β=-.39; P<.001, respectively). Differently from the original study, self-efficacy was not a significant predictor in the strict statistical sense (β=.12; P=.003). In addition, qualitative analysis demonstrated that in the given cohort, perceived barriers was the most frequent theme (166/354, 46.9% of total codes). Under this category, psychological fears and concerns was a subtheme, notably diverging from the original operationalization of the perceived barriers construct. In a similar sense, a role for social influence in DCT uptake processes was suggested by some respondents (12/354, 1.7% of total codes). In summary, the quantitative and qualitative results indicated that the proposed quantitative model seemed to be of limited value in the examined context.

CONCLUSIONS

Future studies should focus on reconceptualizing the 2 underperforming constructs (ie, perceived severity and cues to action) by considering the qualitative findings. This study also provided actionable insights for policy makers and app developers to mitigate DCT adoption issues in the event of a future pandemic caused by unknown viral agents.

COVID-19 contact tracing at work in Belgium - how tracers tweak guidelines for the better

BACKGROUND

When conducting COVID-19 contact tracing, pre-defined criteria allow differentiating high-risk contacts (HRC) from low-risk contacts (LRC). Our study aimed to evaluate whether contact tracers in Belgium followed these criteria in practice and whether their deviations improved the infection risk assessment.

METHOD

We conducted a retrospective cohort study in Belgium, through an anonymous online survey, sent to 111,763 workers by email. First, we evaluated the concordance between the guideline-based classification of HRC or LRC and the tracer's classification. We computed positive and negative agreements between both. Second, we used a multivariate Poisson regression to calculate the risk ratio (RR) of testing positive depending on the risk classification by the contact tracer and by the guideline-based risk classification.

RESULTS

For our first research question, we included 1105 participants. The positive agreement between the guideline-based classification in HRC or LRC and the tracer's classification was 0.53 (95% CI 0.49-0.57) and the negative agreement 0.70 (95% CI: 0.67-0.72). The type of contact tracer (occupational doctors, internal tracer, general practitioner, other) did not significantly influence the results. For the second research question, we included 589 participants. The RR of testing positive after an HRC compared to an LRC was 3.10 (95% CI: 2.71-3.56) when classified by the contact tracer and 2.24 (95% CI: 1.94-2.60) when classified by the guideline-based criteria.

CONCLUSION

Our study indicates that contact tracers did not apply pre-defined criteria for classifying high and low risk contacts. Risk stratification by contact tracers predicts who is at risk of infection better than guidelines only. This result indicates that a knowledgeable tracer can target testing better than a general guideline, asking for a debate on how to adapt the guidelines.

Facilitators and barriers to COVID-19 testing in community and clinical settings: Lessons learned from Lesotho and Zambia

The sudden emergence of the coronavirus disease 2019 (COVID-19) had a devastating impact on health systems and population health globally. To combat the spread of COVID-19, countries enacted guidelines and safety measures, including testing, contact tracing, and quarantine. It was unclear the extent to which uptake of COVID-19 testing and other health initiatives would be accepted in countries with a history of dealing with widespread communicable disease transmission such as HIV or Tuberculosis. The objective of this study was to understand and compare the facilitators and barriers to COVID-19 testing at hospital sites in two rural communities in Lesotho and community spaces (referred to as hubs) in one urban community in Zambia during active phases of COVID-19 pandemic. Individual interviews and focus group discussions (FGDs) were held during March-October 2021 to explore facilitators and barriers to COVID-19 testing. FGDs with 105 community members and health care workers, and 16 individual interviews with key informants and four mystery shoppers were conducted across the two countries. In Zambia, four mystery shopper observations, and eight hub observations were also conducted. Individual country codebooks were developed and combined; thematic analyses were then conducted using the combined codebook. Findings were compared across the two countries, and most were consistent across the two countries. Two primary themes emerged that related to both barriers and facilitators: (1) structural conditions; (2) social implications and attitudes. The structural conditions that operated as barriers in both countries included public health isolation measures and misinformation. In Lesotho, the cost of tests was an additional barrier. The only structural facilitators were in Zambia where the community hubs were found to be accessible and convenient. The social implication barriers related to fear of isolation, stigma, and mental health implications because of quarantine, perceived pain of the test, and compromised privacy. Social facilitators that led to people testing included experiencing COVID-19 firsthand and knowing people who had died because of COVID-19. Across both countries, primary barriers and facilitators to COVID-19 related to structural conditions and social implications and attitudes. Public health measures can be at odds with social and economic realities; pandemic response should balance public health control and the socio-economic needs. Data from Zambia revealed that community-based settings have the potential to increase uptake of testing services. Community-based campaigns to normalize and reduce stigma for COVID-19 testing services are needed.

Antecedents predicting digital contact tracing acceptance: a systematic review and meta-analysis

An awareness of antecedents of acceptance of digital contact tracing (DCT) can enable healthcare authorities to design appropriate strategies for fighting COVID-19 or other infectious diseases that may emerge in the future. However, mixed results about these antecedents are frequently reported. Most prior DCT acceptance review studies lack statistical synthesis of their results. This study aims to undertake a systematic review and meta-analysis of antecedents of DCT acceptance and investigate potential moderators of these antecedents. By searching multiple databases and filtering studies by using both inclusion and exclusion criteria, 76 and 25 studies were included for systematic review and meta-analysis, respectively. Random-effects models were chosen to estimate meta-analysis results since Q, I 2, and H index signified some degree of heterogeneity. Fail-safe N was used to assess publication bias. Most DCT acceptance studies have focused on DCT related factors. Included antecedents are all significant predictors of DCT acceptance except for privacy concerns and fear of COVID-19. Subgroup analysis showed that individualism/collectivism moderate the relationships between norms/privacy concerns and intention to use DCT. Based on the results, the mean effect size of antecedents of DCT acceptance and the potential moderators may be more clearly identified. Appropriate strategies for boosting the DCT acceptance rate can be proposed accordingly.

Communication to promote and support physical distancing for COVID-19 prevention and control

BACKGROUND

This review is an update of a rapid review undertaken in 2020 to identify relevant, feasible and effective communication approaches to promote acceptance, uptake and adherence to physical distancing measures for COVID-19 prevention and control. The rapid review was published when little was known about transmission, treatment or future vaccination, and when physical distancing measures (isolation, quarantine, contact tracing, crowd avoidance, work and school measures) were the cornerstone of public health responses globally. This updated review includes more recent evidence to extend what we know about effective pandemic public health communication. This includes considerations of changes needed over time to maintain responsiveness to pandemic transmission waves, the (in)equities and variable needs of groups within communities due to the pandemic, and highlights again the critical role of effective communication as integral to the public health response.

OBJECTIVES

To update the evidence on the question 'What are relevant, feasible and effective communication approaches to promote acceptance, uptake and adherence to physical distancing measures for COVID-19 prevention and control?', our primary focus was communication approaches to promote and support acceptance, uptake and adherence to physical distancing.

SECONDARY OBJECTIVE

to explore and identify key elements of effective communication for physical distancing measures for different (diverse) populations and groups.

SEARCH METHODS

We searched MEDLINE, Embase and Cochrane Library databases from inception, with searches for this update including the period 1 January 2020 to 18 August 2021. Systematic review and study repositories and grey literature sources were searched in August 2021 and guidelines identified for the eCOVID19 Recommendations Map were screened (November 2021).

SELECTION CRITERIA

Guidelines or reviews focusing on communication (information, education, reminders, facilitating decision-making, skills acquisition, supporting behaviour change, support, involvement in decision-making) related to physical distancing measures for prevention and/or control of COVID-19 or selected other diseases (sudden acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), influenza, Ebola virus disease (EVD) or tuberculosis (TB)) were included. New evidence was added to guidelines, reviews and primary studies included in the 2020 review.

DATA COLLECTION AND ANALYSIS

Methods were based on the original rapid review, using methods developed by McMaster University and informed by Cochrane rapid review guidance. Screening, data extraction, quality assessment and synthesis were conducted by one author and checked by a second author. Synthesis of results was conducted using modified framework analysis, with themes from the original review used as an initial framework.

MAIN RESULTS

This review update includes 68 studies, with 17 guidelines and 20 reviews added to the original 31 studies. Synthesis identified six major themes, which can be used to inform policy and decision-making related to planning and implementing communication about a public health emergency and measures to protect the community. Theme 1: Strengthening public trust and countering misinformation: essential foundations for effective public health communication Recognising the key role of public trust is essential. Working to build and maintain trust over time underpins the success of public health communications and, therefore, the effectiveness of public health prevention measures. Theme 2: Two-way communication: involving communities to improve the dissemination, accessibility and acceptability of information Two-way communication (engagement) with the public is needed over the course of a public health emergency: at first, recognition of a health threat (despite uncertainties), and regularly as public health measures are introduced or adjusted. Engagement needs to be embedded at all stages of the response and inform tailoring of communications and implementation of public health measures over time. Theme 3: Development of and preparation for public communication: target audience, equity and tailoring Communication and information must be tailored to reach all groups within populations, and explicitly consider existing inequities and the needs of disadvantaged groups, including those who are underserved, vulnerable, from diverse cultural or language groups, or who have lower educational attainment. Awareness that implementing public health measures may magnify existing or emerging inequities is also needed in response planning, enactment and adjustment over time. Theme 4: Public communication features: content, timing and duration, delivery Public communication needs to be based on clear, consistent, actionable and timely (up-to-date) information about preventive measures, including the benefits (whether for individual, social groupings or wider society), harms (likewise) and rationale for use, and include information about supports available to help follow recommended measures. Communication needs to occur through multiple channels and/or formats to build public trust and reach more of the community. Theme 5: Supporting behaviour change at individual and population levels Supporting implementation of public health measures with practical supports and services (e.g. essential supplies, financial support) is critical. Information about available supports must be widely disseminated and well understood. Supports and communication related to them require flexibility and tailoring to explicitly consider community needs, including those of vulnerable groups. Proactively monitoring and countering stigma related to preventive measures (e.g. quarantine) is also necessary to support adherence. Theme 6: Fostering and sustaining receptiveness and responsiveness to public health communication Efforts to foster and sustain public receptiveness and responsiveness to public health communication are needed throughout a public health emergency. Trust, acceptance and behaviours change over time, and communication needs to be adaptive and responsive to these changing needs. Ongoing community engagement efforts should inform communication and public health response measures.

AUTHORS' CONCLUSIONS

Implications for practice Evidence highlights the critical role of communication throughout a public health emergency. Like any intervention, communication can be done well or poorly, but the consequences of poor communication during a pandemic may mean the difference between life and death. The approaches to effective communication identified in this review can be used by policymakers and decision-makers, working closely with communication teams, to plan, implement and adjust public communications over the course of a public health emergency like the COVID-19 pandemic. Implications for research Despite massive growth in research during the COVID-19 period, gaps in the evidence persist and require high-quality, meaningful research. This includes investigating the experiences of people at heightened COVID-19 risk, and identifying barriers to implementing public communication and protective health measures particular to lower- and middle-income countries, and how to overcome these.

'We are not here to enforce; we are here for the people' Factors influencing performance of contact tracing during the COVID-19 pandemic: A qualitative study

Background

Provider-initiated contact tracing (CT) is an important measure to slow down the spread of infectious diseases such as COVID-19. However, carrying out effective CT depends on the collaboration between the patient and the contact tracer. To improve CT, it is important to understand which factors influence contact tracers in being able to carry out CT during large pandemics.

Methods

We performed individual semi-structured interviews with nine contact tracers working for the COVID-19 unit of the Public Health Service (PHS) Rotterdam-Rijnmond, the Netherlands, to explore their experiences with carrying out CT. Data were collected between July 2020 and December 2020. The interview protocol was structured based on the CT tasks and guided by the literature and the framework explaining adherence to clinical practice guidelines.

Results

In general, CT seemed to be carried out satisfactorily. Individual factors (interviewing techniques and skills, attitude towards the patient and attitude towards CT), factors related to the patient (cooperativeness and engagement, emotions, language and culture and (mis)information), guideline-related factors (characteristics) and factors related to the organisation (interactions with colleagues, support from management, workload and training) were found to influence the carrying out of CT.

Conclusion

To be well prepared for future pandemics, it is important to explore strategies that can be effective to support the contact tracer in performing CT, support patients in feeling comfortable to be engaged and ways to reach more consistency in policies and protocols.

Socioeconomic disadvantage and engagement with digital contact tracing for COVID-19 in Western Sydney: A secondary analysis of surveillance data

OBJECTIVE

COVID-19 outcomes were highly inequitably distributed in Australia and worldwide. The digitalisation of public health interventions offers resource-efficiency and increased capacity for pandemic responses, but risks excluding the elderly and disadvantaged, reinforcing existing inequalities. Despite this, there has been little evaluation of the determinants of uptake of digital contact tracing. This paper describes the use of digital contact tracing for COVID-19 in a population in metropolitan Sydney and the determinants of engagement in this population.

METHODS

Routinely collected surveillance data for residents of Western Sydney Local Health District, returning a positive SARS-CoV-2 result between 1st August 2021 and 12th February 2022, were extracted including responses to a digital contact tracing questionnaire. Individual records were linked to area-level socioeconomic indices of disadvantage. Descriptive analyses explored characteristics of non-responders and geospatial variation. Logistic regression was undertaken to evaluate the effect of age, sex and socioeconomic disadvantage on the odds of response.

RESULTS

Of the 133 055 individuals included, 130 645 (98%) were issued a digital contact tracing questionnaire, and 106 432 (81%) responded. Odds of responding were lower in males (odds ratio: 0.79), individuals aged 80+ (odds ratio: 0.17) and the most disadvantaged communities (odds ratio: 0.32).

CONCLUSIONS

Digital data collection for contact tracing was a scalable and efficient tool in the context of the Western Sydney Local Health District COVID-19 response. However, older people and individuals in disadvantaged communities were less likely to engage.

IMPLICATIONS FOR PUBLIC HEALTH

Responses to future pandemics should leverage the resource-efficiency of digital interventions but should avoid compounding existing health inequalities.

Citizen involvement in COVID-19 contact tracing with digital tools: a qualitative study to explore citizens' perspectives and needs

BACKGROUND

Contact tracing (CT) is a key strategy when dealing with outbreaks of infectious diseases such as COVID-19. The scale of the COVID-19 pandemic has often left public health professionals (PHPs), who are responsible for the execution of CT, unable to keep up with the rapid and largescale spread of the virus. To enhance or support its execution, and potentially lower the workload for PHPs, citizens may be more actively involved in CT-tasks that are commonly executed by PHPs (referred to as 'self-led CT'). There is limited insight into citizens' perspectives on and needs for self-led CT for COVID-19. This study aims to explore the perspectives and needs of Dutch citizens on taking more responsibilities in the execution of CT for COVID-19, potentially through the use of digital tools.

METHODS

An exploratory qualitative study was performed, in which online semi-structured interviews were conducted. Questions were based on the Reasoned Action Approach and Health Belief Model. Interviews were audio-recorded and transcribed verbatim. A thematic analysis was conducted to identify citizens' perspectives and needs to participate in self-led CT.

RESULTS

We conducted 27 interviews with Dutch citizens. Seven main themes were identified from the interviews: 1) 'Citizens' perspectives on self-led CT are influenced by prior experiences with regular CT', 2) 'Citizens' felt responsibilities and the perceived responsibilities of the PHS in CT shape their perspectives on self-led CT', 3) 'Anticipated impacts of self-led CT on the CT-process', 4) 'Citizens' attitude towards the application of self-led CT depends on their own perceived skills and the willingness and skills of others', 5) 'Shame and social stigma may hamper participation in self-led CT', 6) 'Concerns about privacy and data security: a barrier for self-led CT', and 7) 'Citizens' perspectives and anticipated needs for the implementation and application of self-led CT in practice'.

CONCLUSIONS

Most interviewees hold a positive attitude towards self-led CT and using digital tools for this purpose. However, their intention for self-led CT may depend on various factors, such as prior experiences with regular CT, and their perceived self-efficacy to participate. Perspectives and needs of citizens should be considered for the future implementation of self-led CT in practice.

Barriers to and facilitators of populational adherence to prevention and control measures of COVID-19 and other respiratory infectious diseases: a qualitative evidence synthesis

AIMS

To summarise the evidence on barriers to and facilitators of population adherence to prevention and control measures for coronavirus disease 2019 (COVID-19) and other respiratory infectious diseases.

METHODS

A qualitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis and the Cochrane Effective Practice and Organization of Care: Qualitative Evidence Synthesis. We performed an electronic search on MEDLINE, Embase and PsycINFO from their inception to March 2023.

RESULTS

We included 71 studies regarding COVID-19, pneumonia, tuberculosis, influenza, pertussis and H1N1, representing 5966 participants. The measures reported were vaccinations, physical distancing, stay-at-home policy, quarantine, self-isolation, facemasks, hand hygiene, contact investigation, lockdown, infection prevention and control guidelines, and treatment. Tuberculosis-related measures were access to care, diagnosis and treatment completion. Analysis of the included studies yielded 37 barriers and 23 facilitators.

CONCLUSIONS

This review suggests that financial and social support, assertive communication, trust in political authorities and greater regulation of social media enhance adherence to prevention and control measures for COVID-19 and infectious respiratory diseases. Designing and implementing effective educational public health interventions targeting the findings of barriers and facilitators highlighted in this review are key to reducing the impact of infectious respiratory diseases at the population level.

Community outbreak of COVID-19 among people who use drugs attending a harm reduction centre in Barcelona, Spain

BACKGROUND

The COVID-19 pandemic particularly affected the health of vulnerable population, such as people who use drugs. Due to compromised baseline health status, certain drug uses and settings and socioeconomic deprivation related to poverty and homelessness, drug users faced higher risk of COVID-19 infection. They had difficulty in adhering to the public health measures (i.e. physical distancing, hand hygiene and mask use). Also, the struggle to implement non-pharmaceutical actions (i.e. test-trace-isolate-quarantine strategy) among SARS-COV-2-infected drug users and their close contacts challenged the public health response. Therefore, this study aimed to describe a community COVID-19 outbreak and its approach among drug users of a harm reduction programme in an outpatient drug treatment centre in Barcelona, Spain.

METHODS

We conducted an observational descriptive study of an outbreak of COVID-19 among people who use drugs attending the harm reduction programme of an outpatient drug treatment centre in the city of Barcelona, between July and October 2021 (n = 440). A passive search for cases was carried out with rapid antigens tests targeting symptomatic users who attended the facilities.

RESULTS

Nineteen positive COVID-19 cases were identified among symptomatic drug users, between July and October 2021, with an attack rate of 4.3%. Specific measures were taken to control the outbreak, such as offering accommodation to self-isolate in a low-threshold residential resource to homeless drug users who tested positive and intensifying the vaccination strategy. The management of the outbreak was carried out in close collaboration between the outpatient centre and the main public health stakeholders in the city of Barcelona.

CONCLUSIONS

This study shows the complexity of managing and investigating COVID-19 outbreaks in vulnerable population groups. Epidemiological control measures, such as the test-trace-isolate-quarantine strategy, were challenging to implement due to technology-related barriers and socioeconomic vulnerabilities, especially homelessness. Community-based interventions, cooperation among stakeholders and housing-related policies were helpful in tackling outbreaks among people who use drugs. When addressing vulnerable and hidden populations, the perspective of inequalities should be included in epidemiological surveillance and outbreak control strategies.

Challenges of COVID-19 Case Investigation and Contact Tracing in School Settings: An Initial Investigation

BACKGROUND

Case investigation and contact tracing (CI/CT) are important public health tools to interrupt COVID-19 transmission. Our study aims to understand how parents and school staff perceive COVID-19 CI/CT.

METHODS

Using a mixed methods approach, we distributed a community survey and conducted 15 focus group discussions (FGDs) in English and Spanish between December 2020 and March 2021 with 20 parents and 22 staff from schools in San Diego County ZIP Codes with COVID-19 rates in the top quintile as of August 2020.

RESULTS

One in 4 survey respondents reported that they would be reluctant to participate in CI/CT. FGDs revealed themes of mistrust in government authorities, overburdened institutions, unfamiliarity with CI/CT, and uncertainty about its reliability. School community members emphasized that parents trust schools to be involved in CI/CT efforts, but schools are overwhelmed with this added responsibility.

CONCLUSIONS

Investing in schools as community hubs is necessary so they can become important partners in prevention and mitigation in public health.

Resident Willingness to Participate in Digital Contact Tracing in a COVID-19 Hotspot: Findings From a Detroit Panel Study

BACKGROUND

Digital surveillance tools and health informatics show promise in counteracting diseases but have limited uptake. A notable illustration of the limits of such tools is the general failure of digital contact tracing in the United States in response to COVID-19.

OBJECTIVE

We investigated the associations between individual characteristics and the willingness to use app-based contact tracing in Detroit, a majority-minority city that experienced multiple waves of COVID-19 outbreaks and deaths since the start of the pandemic. The aim of this study was to examine variations among residents in the willingness to download a contact tracing app on their phones to provide public health officials with information about close COVID-19 contact during summer 2020.

METHODS

To examine residents' willingness to participate in digital contact tracing, we analyzed data from 2 waves of the Detroit Metro Area Communities Study, a population-based survey of Detroit, Michigan residents. The data captured 1873 responses from 991 Detroit residents collected in June and July 2020. We estimated a series of multilevel logit models to gain insights into differences in the willingness to participate in digital contact tracing across a variety of individual attributes, including race/ethnicity, degree of trust in the government, and level of education, as well as interactions among these variables.

RESULTS

Our results reflected widespread reluctance to participate in digital contact tracing in response to COVID-19, as less than half (826/1873, 44.1%) of the respondents said they would be willing to participate in app-based contact tracing. Compared to White respondents, Black (odds ratio [OR] 0.45, 95% CI 0.23-0.86) and Latino (OR 0.32, 95% CI 0.11-0.99) respondents were significantly less willing to participate in digital contact tracing. Trust in the government was positively associated with the willingness to participate in digital contact tracing (OR 1.17, 95% CI 1.07-1.27), but this effect was the strongest for White residents (OR 2.14, 95% CI 1.55-2.93). We found similarly divergent patterns of the effects of education by race. While there were no significant differences among noncollege-educated residents, White college-educated residents showed greater willingness to use app-based contact tracing (OR 6.12, 95% CI 1.86-20.15) and Black college-educated residents showed less willingness (OR 0.46, 95% CI 0.26-0.81).

CONCLUSIONS

Trust in the government and education contribute to Detroit residents' wariness of digital contact tracing, reflecting concerns about surveillance that cut across race but likely arise from different sources. These findings point to the importance of a culturally informed understanding of health hesitancy for future efforts hoping to leverage digital contact tracing. Though contact tracing technologies have the potential to advance public health, unequal uptake may exacerbate disparate impacts of health crises.

A Novel Bayesian Spatial-Temporal Approach to Quantify SARS-CoV-2 Testing Disparities for Small Area Estimation

Objectives. To propose a novel Bayesian spatial-temporal approach to identify and quantify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing disparities for small area estimation. Methods. In step 1, we used a Bayesian inseparable space-time model framework to estimate the testing positivity rate (TPR) at geographically granular areas of the census block groups (CBGs). In step 2, we adopted a rank-based approach to compare the estimated TPR and the testing rate to identify areas with testing deficiency and quantify the number of needed tests. We used weekly SARS-CoV-2 infection and testing surveillance data from Cameron County, Texas, between March 2020 and February 2022 to demonstrate the usefulness of our proposed approach. Results. We identified the CBGs that had experienced substantial testing deficiency, quantified the number of tests that should have been conducted in these areas, and evaluated the short- and long-term testing disparities. Conclusions. Our proposed analytical framework offers policymakers and public health practitioners a tool for understanding SARS-CoV-2 testing disparities in geographically small communities. It could also aid COVID-19 response planning and inform intervention programs to improve goal setting and strategy implementation in SARS-CoV-2 testing uptake. (Am J Public Health. 2023;113(1):40-48. https://doi.org/10.2105/AJPH.2022.307127).

Local initiative supports case isolation and contact tracing during a SARS-CoV-2 surge in summer 2020: a community case study in Antwerp, Belgium

In Antwerp, Belgium's second largest city, a COVID-19 surge in July 2020 predominantly affected neighborhoods with high ethnic diversity. Local volunteers reacted and set up an initiative to support contact tracing and self-isolation. We describe the origin, implementation, and transfer of this local initiative, based on semi-structured interviews of five key informants and document review. The initiative started in July 2020, when family physicians signaled a surge of SARS-CoV-2 infections among people of Moroccan descent. Family physicians feared that the mainstream contact tracing organized by the Flemish government through centralized call centers would not be efficient in halting this outbreak. They anticipated language barriers, mistrust, inability to investigate case clusters, and practical problems with self-isolation. It took 11 days to start up the initiative, with logistical support from the province and city of Antwerp. Family physicians referred SARS-CoV-2-infected index cases with complex needs (including language and social situation) to the initiative. Volunteer COVID coaches contacted cases, got a contextualized understanding of their living conditions, assisted with backward and forward contact tracing, offered support during self-isolation, and checked if infected contacts also needed support. Interviewed coaches were positive about the quality of the interaction: they described extensive open conversations with cases. The coaches reported back to referring family physicians and coordinators of the local initiative, who took additional action if necessary. Although interactions with affected communities were perceived as good, respondents considered that the number of referrals by family physicians was too low to have a meaningful impact on the outbreak. In September 2020, the Flemish government assigned the tasks of local contact tracing and case support to the local health system level (primary care zones). While doing so, they adopted elements of this local initiative, such as COVID coaches, tracing system, and extended questionnaires to talk with cases and contacts. This community case study illustrates how urgency can motivate people to action yet support from people with access to resources and coordination capacity is vital for effective organization and transition to long-term sustainability. From their conception, health policies should consider adaptability of new interventions to local contexts.

Dutch public health professionals’ perspectives and needs regarding citizen involvement in COVID-19 contact tracing through digital support tools: an exploratory qualitative study

Background

Contact tracing (CT) is an important, but resource-intensive tool to control outbreaks of communicable diseases. Under pandemic circumstances, public health services may not have sufficient resources at their disposal to effectively facilitate CT. This may be addressed by giving cases and their contact persons more autonomy and responsibility in the execution of CT by public health professionals, through digital contact tracing support tools (DCTS-tools). However, the application of this approach has not yet been systematically investigated from the perspective of public health practice. Therefore, we investigated public health professionals’ perspectives and needs regarding involving cases and contact persons in CT for COVID-19 through DCTS-tools.

Methods

Between October 2020 and February 2021, we conducted online semi-structured interviews (N = 17) with Dutch public health professionals to explore their perspectives and needs regarding the involvement of cases and contact persons in CT for COVID-19 through DCTS-tools, in the contact identification, notification, and monitoring stages of the CT-process. Interviews were audio recorded and transcribed verbatim. A thematic analysis was performed.

Results

Four main themes related to Dutch public health professionals’ perspectives and needs regarding involving cases and contact persons in CT for COVID-19 through DCTS-tools emerged from the data: ‘Distinct characteristics of CT with DCTS-tools’; ‘Anticipated benefits and challenges of CT for COVID-19 with DCTS- tools’; ‘Circumstances in CT for COVID-19 that permit or constrain the application of DCTS-tools’; and ‘Public health professionals’ needs regarding the development and application of DCTS-tools for CT’. Public health professionals seem to have a positive attitude towards involving cases and contact persons through DCTS-tools. Public health professionals’ (positive) attitudes seem conditional on the circumstances under which CT is performed, and the fulfilment of their needs in the development and application of DCTS-tools.

Conclusions

Dutch public health professionals seem positive towards involving cases and contact persons in CT for COVID-19 through DCTS-tools. Through adequate implementation of DCTS-tools in the CT-process, anticipated challenges can be overcome. Future research should investigate the perspectives and needs of cases and contact persons regarding DCTS-tools, and the application of DCTS-tools in practice.

Individual costs and community benefits: Collectivism and individuals' compliance with public health interventions

Differences in national responses to COVID-19 have been associated with the cultural value of collectivism. The present research builds on these findings by examining the relationship between collectivism at the individual level and adherence to public health recommendations to combat COVID-19 during the pre-vaccination stage of the pandemic, and examines different characteristics of collectivism (i.e., concern for community, trust in institutions, perceived social norms) as potential psychological mechanisms that could explain greater compliance. A study with a cross-section of American participants (N = 530) examined the relationship between collectivism and opting-in to digital contact tracing (DCT) and wearing face coverings in the general population. More collectivistic individuals were more likely to comply with public health interventions than less collectivistic individuals. While collectivism was positively associated with the three potential psychological mechanisms, only perceived social norms about the proportion of people performing the public health interventions explained the relationship between collectivism and compliance with both public health interventions. This research identifies specific pathways by which collectivism can lead to compliance with community-benefiting public health behaviors to combat contagious diseases and highlights the role of cultural orientation in shaping individuals' decisions that involve a tension between individual cost and community benefit.

Factors Influencing the Results of COVID-19 Case Outreach-Results From a California Case Investigation/Contact Tracing Program

CONTEXT

Considerable research has examined impacts of case investigation and contact tracing (CI/CT) programs on the spread of infectious diseases such as COVID-19, but there are few reports on factors affecting the ability of these programs to obtain interviews and acquire key information.

OBJECTIVE

To investigate programmatic and case-specific factors associated with CI outcomes using data from the Public Health Institute's Tracing Health CI/CT program. Analyses were designed to detect variability in predictors of whether interviews and key information were obtained rather than quantify specific relationships.

DESIGN

Logistic regression models examined variability in the predictive value of interview timeliness and respondent characteristics on outreach outcomes and interview results.

SETTING AND PARTICIPANTS

Participants were members of a large California health care network with a positive laboratory test for COVID-19 and outreach from January 1 to July 31, 2021.

MAIN OUTCOME MEASURES

The primary outcome was the result of outreach attempts: completed interview, refused interview, or failure to reach the infected person. Secondary outcomes considered whether respondents provided information on symptom onset, employment, and contact information or a reason for declining to provide information, and whether resource support was requested or accepted.

RESULTS

Of 9391 eligible records, 65.6% were for completed interviews, 6.0% were refusals, and 28.3% were failed outreach. One-third of respondents (36.7%) provided information on contacts (mean = 0.97 contacts per respondent, 2.6 for those naming at least 1). Privacy concerns were the most common reasons for not providing contact information. Among respondent characteristics and interview timeliness, only race and number of symptoms showed statistically significant effects in all adjusted analyses.

CONCLUSIONS

Significant variation existed in outreach outcomes by subject characteristics and interview timeliness. CI/CT programs carefully focused to characteristics and needs of specific communities will likely have the greatest impact on the spread of COVID-19 and other communicable diseases.

"I can't do it": A qualitative study exploring case and contact experiences with COVID-19 contact tracing

BACKGROUND

Low engagement in contact tracing for COVID-19 dramatically reduces its impact, but little is known about how experiences, environments and characteristics of cases and contacts influence engagement.

METHODS

We recruited a convenience sample of COVID-19 cases and contacts from the New Haven Health Department's contact tracing program for interviews about their contact tracing experiences. We analyzed transcripts thematically, organized themes using the Capability, Opportunity, Motivation, Behavior (COM-B) model, and identified candidate interventions using the linked Behavior Change Wheel Framework.

RESULTS

We interviewed 21 cases and 12 contacts. Many felt physically or psychologically incapable of contact tracing participation due to symptoms or uncertainty about protocols. Environmental factors and social contacts also influenced engagement. Finally, physical symptoms, emotions and low trust in and expectations of public health authorities influenced motivation to participate.

CONCLUSION

To improve contact tracing uptake, programs should respond to clients' physical and emotional needs; increase clarity of public communications; address structural and social factors that shape behaviors and opportunities; and establish and maintain trust. We identify multiple potential interventions that may help achieve these goals.

Strengthening government’s response to COVID-19 in Indonesia: A modified Delphi study of medical and health academics

The Indonesian government has issued various policies to control COVID-19. However, COVID-19 new cases continued to increase, and there remain uncertainties as to the future trajectory. We aimed to investigate how medical and health academics view the Indonesian government’s handling of COVID-19 and which areas of health systems need to be prioritized to improve the government’s response to COVID-19. We conducted a modified Delphi study adapting the COVID-19 assessment scorecard (COVID-SCORE) as the measurement criteria. We invited medical and health academics from ten universities across Indonesia to take part in the two-round Delphi study. In the first round, participants were presented with 20 statements of COVID-SCORE and asked to rate their agreement with each statement using a five-point Likert scale. All participants who completed the first cycle were invited to participate in the second cycle. They had the opportunity to revise their answers based on the previous cycle’s results and ranked a list of actions to improve government response. We achieved a moderate consensus level for five statements, a low consensus level for 13 statements and no consensus for two statements. The prioritization suggested that top priorities for improving the government’s response to COVID-19 in Indonesia encompass: (1) strengthening capacity to ensure consistent, credible and targeted communication while adopting a more inclusive and empathic communication style to address public concerns; (2) ensuring universal access to reliable COVID-19 testing by expanding lab infrastructure, facilitating operational readiness, and scaling up implementation of proven alternative/complementary tests to RT-PCR; and (3) boosting contact tracing implementation capacity and facilitating contact tracing for all positive cases, involving key stakeholders in further development of the existing contact tracing system (i.e. PeduliLindungi) as well as its evaluation and quality assurance. Ultimately, our study highlights the importance of strengthening health system functions during the pandemic and improving health system resilience for dealing with future public health emergencies.

The public sector and co-creation in turbulent times: A systematic literature review on robust governance in the COVID-19 emergency

The capacity of public sector of co-creating with other stakeholders is challenged by the increasing presence of disruptive turbulent events, such as the COVID-19. At this regard, robustness has been identified as a suitable response to deal with this kind of events. Through a systematic literature review, we analyzed how public sector organizations have co-created with other actors during the COVID-19 and what have been the contribution of robust governance strategies. Our findings point firstly to the empirical validity of the robustness concept, providing evidence of the extensive use of robust governance strategies into the co-creation processes. Second, we identified a configurational approach to robustness, with governments co-creating by simultaneously employing several robust strategies. Thirdly, we observed a more active involvement of societal stakeholders, with emergence of proto-institutions and potential threats to the political system.

The Relative Importance of Vulnerability and Efficiency in COVID-19 Contact Tracing Programmes: A Discrete Choice Experiment

Objectives: This study aims to assess the trade-offs between vulnerability and efficiency attributes of contact tracing programmes based on preferences of COVID-19 contact tracing practitioners, researchers and other relevant stakeholders at the global level.

Methods: We conducted an online discrete choice experiment (DCE). Respondents were recruited globally to explore preferences according to country income level and the prevailing epidemiology of COVID-19 in the local setting. The DCE attributes represented efficiency (timeliness, completeness, number of contacts), vulnerability (vulnerable population), cooperation and privacy. A mixed-logit model and latent class analysis were used.

Results: The number of respondents was 181. Timeliness was the most important attribute regardless of country income level and COVID-19 epidemiological condition. Vulnerability of contacts was the second most important attribute for low-to-lower-middle-income countries and third for upper-middle-to-high income countries. When normalised against conditional relative importance of timeliness, conditional relative importance of vulnerability ranged from 0.38 to 0.42.

Conclusion: Vulnerability and efficiency criteria were both considered to be important attributes of contact tracing programmes. However, the relative values placed on these criteria varied significantly between epidemiological and economic context.

COVID-19 Testing: A Qualitative Study Exploring Enablers and Barriers in the Greater Accra Region, Ghana

Introduction

The COVID-19 pandemic is a global crisis and has reaffirmed that extensive testing along with effective tracing is still crucial to slowing transmission of the COVID-19 virus despite the rolling out of vaccines. This study explored enablers and barriers to COVID-19 testing in the Greater Accra region of Ghana. We envision lessons learned from this study could serve as a road map to strengthen the current response to COVID-19 and preparedness for future outbreaks, particularly in low- and middle-income countries.

Methods

A qualitative design was undertaken to explore the phenomenon. Data collection methods included in-depth interviews with key informants with a purposively selected sample of 20 participants. Interviews were conducted using flexible semi-structured interview guides. Depending on the participant's position and involvement in COVID-19 testing, the guides were modified, and key elements were drawn from a tailored version of the WHO Health System Framework, incorporating the Essential Public Health Functions (EPHF). The interview findings were augmented by reviewing published literature.

Results

Better health governance through political leadership, community participation, multisectoral collaboration, effective resource management, and information systems played a crucial role in catalyzing COVID-19 testing. The primary barriers to testing were mainly COVID-19 infodemic, inadequacy of material resources to meet growing health needs, and a lack of opportunities to have equal and easy access to testing services. Furthermore, although human resources were adequate, they were unevenly distributed across settings.

Conclusion

Despite rolling out vaccines against COVID-19, testing remains an important measure to control the virus. To effectively be prepared for extensive COVID-19 testing and respond to future outbreaks, the following are recommended: there should be improved political commitments, coordination, and communication with diverse actors to ensure even distribution of all resources across the country; empowerment of community members should be encouraged to develop community-oriented pandemic preparedness and management of COVID-19 infodemic; investment in strengthening capacity of Good Manufacturing Practice (GMP); incorporation of health policy and systems research (HPSR) into the post-COVID-19 pandemic recovery process and future pandemic preparedness.

What Went Wrong with the IMMUNI Contact-Tracing App in Italy? A Cross-Sectional Survey on the Attitudes and Experiences among Healthcare University Students

The adoption of digital contact-tracing apps to limit the spread of SARS-CoV-2 has been sup-optimal, but studies that clearly identify factors associated with the app uptake are still limited. In April 2021, we administered a questionnaire to healthcare university students to investigate their attitudes towards and experiences of the IMMUNI app. A multivariable logistic regression model was built to identify app download predictors. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. We surveyed 247 students. Most respondents (65.6%) had not downloaded IMMUNI, reporting as the main reason the perceived app uselessness (32.7%). In the multivariable analysis, being advised to use the app (aOR: 3.21, 95%CI: 1.80-5.73), greater fear of infecting others (aOR: 1.50, 95%CI: 1.01-2.23), and greater trust in the institutional response to the emergency (aOR: 1.33, 95%CI: 1.00-1.76) were positively associated with the outcome, whereas greater belief in the "lab-leak theory" of COVID-19 was a negative predictor (aOR: 0.75, 95%CI: 0.60-0.93). Major technical issues were reported by app users. Targeted strategies aimed at improving awareness of digital health applications should be devised. Furthermore, institutions should invest in the development of these technologies, to minimize technical issues and make them accessible to the entire population.

Contact Tracing: Barriers and Facilitators

Contact tracing-the process of identifying, isolating, and managing infected persons and their contacts-is a recognized public health measure for controlling the transmission of infectious diseases. In the context of the COVID-19 pandemic, contact tracing has received intense attention. We provide a brief overview of the history of contact tracing during several major disease outbreaks in the past century: syphilis and other sexually transmitted infections, HIV infection, tuberculosis, Ebola virus disease, and COVID-19. Our discussion on the barriers to and facilitators of contact tracing offers a perspective on societal and institutional roles and dynamics, stigma as a major barrier to effective tracing efforts, and how the nature and epidemiology of the infection itself can affect its success. We explore the evolution and adaptation of contact tracing and provide insights for future programming and research. (Am J Public Health. Published online ahead of print June 2, 2022: e1-e9. https://doi.org/10.2105/AJPH.2022.306842).

The psychological reassurance effect of mobile tracing apps in Covid-19 Era

As part of their public health policies, most countries have launched mobile tracing applications (apps) to reduce the spread of the COVID-19 virus and reassure their citizens. To the best of our knowledge, no study has explored the importance of 'well-being' and 'trust in the future' in the context of digital contact-tracing apps. This is an important gap, especially given the importance of citizens' acceptance of a mobile tracing app and its role in reassuring citizens. Therefore, we study the French government's tracing app-StopCovid-as experienced by a sample of 832 participants from France. The results establish strong links between perceived value and trust in government, well-being, and trust in the future, which are considered the key features of the reassurance effect in a pandemic context. In addition, a multigroup analysis (MGA) allows us to compare the effect of several moderators on the overall model, such as the users versus nonusers of tracking apps or infected versus noninfected with COVID-19. The study provides practical implications by highlighting how governments should deploy mobile tracing apps to contribute to public health and reassure their citizens during the pandemic.

African Americans views of COVID-19 contact tracing and testing

Increasing COVID-testing and contact tracing is necessary to control the COVID-19 pandemic considering suboptimal vaccine rates. We conducted semi-structured interviews to explore views towards contact tracing and testing among 62 African Americans. Based on our findings, participants identified COVID-19 testing and contact tracing as beneficial, yet medical and governmental mistrust, stigma associated with SARS-CoV-2, lack of access, poor communication, and costs as major barriers. This study also highlights intervention targets to improve COVID-testing and contact tracing.

Delineating privacy aspects of COVID tracing applications embedded with proximity measurement technologies & digital technologies

As the COVID-19 pandemic expanded over the globe, governments implemented a series of technological measures to prevent the disease's spread. The development of the COVID Tracing Application (CTA) was one of these measures. In this study, we employed bibliometric and topic-based content analysis to determine the most significant entities and research topics. Additionally, we identified significant privacy concerns posed by CTAs, which gather, store, and analyze data in partnership with large technology corporations using proximity measurement technologies, artificial intelligence, and blockchain. We examined a series of key privacy threats identified in our study. These privacy risks include anti-democratic and discriminatory behaviors, politicization of care, derogation of human rights, techno governance, citizen distrust and refusal to adopt, citizen surveillance, and mandatory legislation of the apps' installation. Finally, sixteen research gaps were identified. Then, based on the identified theoretical gaps, we recommended fourteen prospective study strands. Theoretically, this study contributes to the growing body of knowledge about the privacy of mobile health applications that are embedded with cutting-edge technologies and are employed during global pandemics.

Estimates of Cases and Hospitalizations Averted by COVID-19 Case Investigation and Contact Tracing in 14 Health Jurisdictions in the United States

CONTEXT

The implementation of case investigation and contact tracing (CICT) for controlling COVID-19 (caused by SARS-CoV-2 virus) has proven challenging due to varying levels of public acceptance and initially constrained resources, especially enough trained staff. Evaluating the impacts of CICT will aid efforts to improve such programs.

OBJECTIVES

Estimate the number of COVID-19 cases and hospitalizations averted by CICT and identify CICT processes that could improve overall effectiveness.

DESIGN

We used data on the proportion of cases interviewed, contacts notified or monitored, and days from testing to case and contact notification from 14 jurisdictions to model the impact of CICT on cumulative case counts and hospitalizations over a 60-day period. Using the Centers for Disease Control and Prevention's COVIDTracer Advanced tool, we estimated a range of impacts by assuming either contacts would quarantine only if monitored or would do so upon notification of potential exposure. We also varied the observed program metrics to assess their relative influence.

RESULTS

Performance by jurisdictions varied widely. Jurisdictions isolated between 12% and 86% of cases (including contacts that became cases) within 6 to 10 days after infection. We estimated that CICT-related reductions in transmission ranged from 0.4% to 32%. For every 100 remaining cases after other nonpharmaceutical interventions were implemented, CICT averted between 4 and 97 additional cases. Reducing time to case isolation by 1 day increased averted case estimates by up to 15 percentage points. Increasing the proportion of cases interviewed or contacts notified by 20 percentage points each resulted in at most 3 or 6 percentage point improvements in averted cases.

CONCLUSIONS

We estimated that CICT reduced the number of COVID-19 cases and hospitalizations among all jurisdictions studied. Reducing time to isolation produced the greatest improvements in impact of CICT.

Complementation of contact tracing by mass testing for successful containment of beta COVID-19 variant (SARS-CoV-2 VOC B.1.351) epidemic in Hong Kong

BACKGROUND

Global dissemination of SARS-CoV-2 Variants of Concern (VOCs) remains a concern. The aim of this study is to describe how mass testing and phylogenetic analysis successfully prevented local transmission of SARS-CoV-2 VOC in a densely populated city with low herd immunity for COVID-19.

METHODS

In this descriptive study, we conducted contact tracing, quarantine, and mass testing of the potentially exposed contacts with the index case. Epidemiological investigation and phylogeographic analysis were performed.

FINDINGS

Among 11,818 laboratory confirmed cases of COVID-19 diagnosed till 13th May 2021 in Hong Kong, SARS-CoV-2 VOCs were found in 271 (2.3%) cases. Except for 10 locally acquired secondary cases, all SARS-CoV-2 VOCs were imported or acquired in quarantine hotels. The index case of this SARS-CoV-2 VOC B.1.351 epidemic, an inbound traveler with asymptomatic infection, was diagnosed 9 days after completing 21 days of quarantine. Contact tracing of 163 contacts in household, hotel, and residential building only revealed 1 (0.6%) secondary case. A symptomatic foreign domestic helper (FDH) without apparent epidemiological link but infected by virus with identical genome sequence was subsequently confirmed. Mass testing of 0.34 million FDHs identified two more cases which were phylogenetically linked. A total of 10 secondary cases were identified that were related to two household gatherings. The clinical attack rate of household close contact was significantly higher than non-household exposure during quarantine (7/25, 28% vs 0/2051, 0%; p<0.001).

INTERPRETATION

The rising epidemic of SARS-CoV-2 VOC transmission could be successfully controlled by contact tracing, quarantine, and rapid genome sequencing complemented by mass testing.

FUNDING

Health and Medical Research Fund Commissioned Research on Control of Infectious Disease (see acknowledgments for full list).

An Evaluation of the Text Illness Monitoring (TIM) Platform for COVID-19: A Cross-Sectional Online Survey of Public Health Users

Background

The US public health response to the COVID-19 pandemic has required contact tracing and symptom monitoring at an unprecedented scale. The US Centers for Disease Control and Prevention and several partners created the Text Illness Monitoring (TIM) platform in 2015 to assist US public health jurisdictions with symptom monitoring for potential novel influenza virus outbreaks. Since May 2020, 142 federal, state, and local public health agencies have deployed TIM for COVID-19 symptom monitoring.

Objective

The aim of this study was to evaluate the utility, benefits, and challenges of TIM to help guide decision-making for improvements and expansion to support future public health emergency response efforts.

Methods

We conducted a brief online survey of previous and current TIM administrative users (admin users) from November 28 through December 21, 2020. Closed- and open-ended questions inquired about the onboarding process, decision to use TIM, groups monitored with TIM, comparison of TIM to other symptom monitoring systems, technical challenges and satisfaction with TIM, and user support. A total of 1479 admin users were invited to participate.

Results

A total of 97 admin users from 43 agencies responded to the survey. Most admin users represented the Indian Health Service (35/97, 36%), state health departments (26/97, 27%), and local or county health departments (18/97, 19%), and almost all were current users of TIM (85/94, 90%). Among the 43 agencies represented, 11 (26%) used TIM for monitoring staff exclusively, 13 (30%) monitored community members exclusively, and 19 (44%) monitored both staff and community members. Agencies most frequently used TIM to monitor symptom development in contacts of cases among community members (28/43, 65%), followed by symptom development among staff (27/43, 63%) and among staff contacts of cases (24/43, 56%). Agencies also reported using TIM to monitor patients with COVID-19 for the worsening of symptoms among staff (21/43, 49%) and community members (18/43, 42%). When asked to compare TIM to previous monitoring systems, 78% (40/51) of respondents rated TIM more favorably than their previous monitoring system, 20% (10/51) said there was no difference, and 2% (1/51) rated the previous monitoring system more favorably than TIM. Most respondents found TIM favorable in terms of time burden, staff burden, timeliness of the data, and the ability to monitor large population sizes. TIM compared negatively to other systems in terms of effort to enroll participants (ie, persons TIM monitors) and accuracy of the data. Most respondents (76/85, 89%) reported that they would highly or somewhat recommend TIM to others for symptom monitoring.

Conclusions

This evaluation of TIM showed that agencies used TIM for a variety of purposes and rated TIM favorably compared to previously used monitoring systems. We also identified opportunities to improve TIM; for example, enhancing the flexibility of alert deliveries would better meet admin users’ varying needs. We also suggest continuous program evaluation practices to assess and respond to implementation gaps.

Designing Better Exposure Notification Apps: The Role of Persuasive Design

BACKGROUND

Digital contact tracing apps have been deployed worldwide to limit the spread of COVID-19 during this pandemic and to facilitate the lifting of public health restrictions. However, due to privacy-, trust-, and design-related issues, the apps are yet to be widely adopted. This calls for an intervention to enable a critical mass of users to adopt them.

OBJECTIVE

The aim of this paper is to provide guidelines to design contact tracing apps as persuasive technologies to make them more appealing and effective.

METHODS

We identified the limitations of the current contact tracing apps on the market using the Government of Canada's official exposure notification app (COVID Alert) as a case study. Particularly, we identified three interfaces in the COVID Alert app where the design can be improved. The interfaces include the no exposure status interface, exposure interface, and diagnosis report interface. We propose persuasive technology design guidelines to make them more motivational and effective in eliciting the desired behavior change.

RESULTS

Apart from trust and privacy concerns, we identified the minimalist and nonmotivational design of exposure notification apps as the key design-related factors that contribute to the current low uptake. We proposed persuasive strategies such as self-monitoring of daily contacts and exposure time to make the no exposure and exposure interfaces visually appealing and motivational. Moreover, we proposed social learning, praise, and reward to increase the diagnosis report interface's effectiveness.

CONCLUSIONS

We demonstrated that exposure notification apps can be designed as persuasive technologies by incorporating key persuasive features, which have the potential to improve uptake, use, COVID-19 diagnosis reporting, and compliance with social distancing guidelines.

Use of clinical data to augment healthcare worker contact tracing during the COVID-19 pandemic

OBJECTIVE

This work examined the secondary use of clinical data from the electronic health record (EHR) for screening our healthcare worker (HCW) population for potential exposures to patients with coronavirus disease 2019.

MATERIALS AND METHODS

We conducted a cross-sectional study at a free-standing, quaternary care pediatric hospital comparing first-degree, patient-HCW pairs identified by the hospital's COVID-19 contact tracing team (CTT) to those identified using EHR clinical event data (EHR Report). The primary outcome was the number of patient-HCW pairs detected by each process.

RESULTS

Among 233 patients with COVID-19, our EHR Report identified 4,116 patient-HCW pairs, including 2,365 (30.0%) of the 7,890 pairs detected by the CTT. The EHR Report also revealed 1,751 pairs not identified by the CTT. The highest number of patient-HCW pairs per patient was detected in the inpatient care venue. Nurses comprised the most frequently identified HCW role overall.

CONCLUSION

Automated methods to screen HCWs for potential exposure to patients with COVID-19 using clinical event data from the EHR are likely to improve epidemiologic surveillance by contact tracing programs and represent a viable and readily available strategy which should be considered by other institutions.

Exploring the drivers and barriers to uptake for digital contact tracing

Digital contact tracing has been deployed as a public health intervention to help suppress the spread of Covid-19 in many jurisdictions. However, most governments have struggled with low uptake and participation rates, limiting the effectiveness of the tool. This paper characterises a number of systems developed around the world, comparing the uptake rates for systems with different technology, data architectures, and mandates. The paper then introduces the MAST framework (motivation, access, skills, and trust), adapted from the digital inclusion literature, to explore the drivers and barriers that influence people's decisions to participate or not in digital contact tracing systems. Finally, the paper discusses some suggestions for policymakers on how to influence those drivers and barriers in order to improve uptake rates. Examples from existing digital contact tracing systems are presented throughout, although more empirical experimentation is required to support more concrete conclusions on effective interventions.

Understanding racial differences in attitudes about public health efforts during COVID-19 using an explanatory mixed methods design

Efforts to mitigate the spread of COVID-19 rely on trust in public health organizations and practices. These practices include contact tracing, which requires people to share personal information with public health organizations. The central role of trust in these practices has gained more attention during the pandemic, resurfacing endemic questions about public trust and potential racial trust disparities, especially as they relate to participation in public health efforts. Using an explanatory mixed methods design, we conducted quantitative analysis of state-level survey data in the United States from a representative sample of Michigan residents (n = 1000) in May 2020. We used unadjusted and adjusted linear regressions to examine differences in trust in public health information and willingness to participate in public health efforts by race. From July to September 2020, we conducted qualitative interviews (n = 26) to further explain quantitative results. Using unadjusted linear regression, we observed higher willingness to participate in COVID-19 public health efforts among Black survey respondents compared to White respondents. In adjusted analysis, that difference disappeared, yielding no statistically significant difference between Black and White respondents in either trust in public health information sources or willingness to participate. Qualitative interviews were conducted to explain these findings, considering their contrast with assumptions that Black people would exhibit lower trust in public health organizations during COVID-19. Altruism, risk acknowledgement, trust in public health organizations during COVID-19, and belief in efficacy of public health efforts contributed to willingness to participate in public health efforts among interviewees. Our findings underscore the contextual nature of trust, and the importance of this context when analyzing protective health behaviors among communities disproportionately affected by COVID-19. Assumptions about mistrust among Black individuals and communities may be inaccurate because they overlook the specific context of the public health crisis. These findings are important because they indicate that Black respondents are exhibiting strategic trust during COVID-19 despite systemic, contemporary, and historic barriers to trust. Conceptual specificity rather than blanket generalizations is warranted, especially given the harms of stereotyping and discrimination.

Public perception on the use of digital contact tracing tools post COVID-19 lockdown: Sentiment analysis and opinion mining (Preprint)

Background

Singapore’s national digital contact-tracing (DCT) tool—TraceTogether—attained an above 70% uptake by December 2020 after a slew of measures. Sentiment analysis can help policymakers to assess public sentiments on the implementation of new policy measures in a short time, but there is a paucity of sentiment analysis studies on the usage of DCT tools.

Objective

We sought to understand the public’s knowledge of, concerns with, and sentiments on the use of TraceTogether over time and their preferences for the type of TraceTogether tool.

Methods

We conducted a cross-sectional survey at a large public hospital in Singapore after the COVID-19 lockdown, from July 2020 through February 2021. In total, 4097 respondents aged 21-80 years were sampled proportionately by sex and 4 age groups. The open-ended responses were processed and analyzed using natural language processing tools. We manually corrected the language and logic errors and replaced phrases with words available in the syuzhet sentiment library without altering the original meaning of the phrases. The sentiment scores were computed by summing the scores of all the tokens (phrases split into smaller units) in the phrase. Stopwords (prepositions and connectors) were removed, followed by implementing the bag-of-words model to calculate the bigram and trigram occurrence in the data set. Demographic and time filters were applied to segment the responses.

Results

Respondents’ knowledge of and concerns with TraceTogether changed from a focus on contact tracing and Bluetooth activation in July-August 2020 to QR code scanning and location check-ins in January-February 2021. Younger males had the highest TraceTogether uptake (24/40, 60%), while older females had the lowest uptake (8/34, 24%) in the first half of July 2020. This trend was reversed in mid-October after the announcement on mandatory TraceTogether check-ins at public venues. Although their TraceTogether uptake increased over time, older females continued to have lower sentiment scores. The mean sentiment scores were the lowest in January 2021 when the media reported that data collected by TraceTogether were used for criminal investigations. Smartphone apps were initially preferred over tokens, but the preference for the type of TraceTogether tool equalized over time as tokens became accessible to the whole population. The sentiments on token-related comments became more positive as the preference for tokens increased.

Conclusions

The public’s knowledge of and concerns with the use of a mandatory DCT tool varied with the national regulations and public communications over time with the evolution of the COVID-19 pandemic. Effective communications tailored to subpopulations and greater transparency in data handling will help allay public concerns with data misuse and improve trust in the authorities. Having alternative forms of the DCT tool can increase the uptake of and positive sentiments on DCT.

COVID-19 pandemic and reasons to prioritize the needs of the health care system to ensure its sustainability: A scoping review from January to October 2020 (Review)

The worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led the World Health Organization to characterize the pandemic as a public health emergency of international concern. National health care systems in countries during the initial surge of the pandemic were unable to handle the sanitarian crisis that had emerged. Thus, the prevention and control of future global health emergencies must be a priority. The present scoping review aimed to retrieve articles that summarize the current experience on issues related to historical knowledge, and epidemiology, clinical features and overall burden of SARS-CoV-2 on health care services. In summary, a comprehensive overview of the information that has been learnt during this period is presented in the current review. Furthermore, taking into account the global experience, the need for planning cohesive and functional health services before similar pandemic events occur in the future is highlighted. The next public health issue should be prevented rather than treated. In spite of the vaccination benefits, a number of sporadic cases of SARS-CoV-2infections will persist. Information collected remains relevant for appraising how similar threats can be faced in the future. Overall, collaborative health care plans need to be rethought to increase preparedness.

COVID-19 Prevention and Control Measures in Workplace Settings: A Rapid Review and Meta-Analysis

Workplaces can be high-risk environments for SARS-CoV-2 outbreaks and subsequent community transmission. Identifying, understanding, and implementing effective workplace SARS-CoV-2 infection prevention and control (IPC) measures is critical to protect workers, their families, and communities. A rapid review and meta-analysis were conducted to synthesize evidence assessing the effectiveness of COVID-19 IPC measures implemented in global workplace settings through April 2021. Medline, Embase, PubMed, and Cochrane Library were searched for studies that quantitatively assessed the effectiveness of workplace COVID-19 IPC measures. The included studies comprised varying empirical designs and occupational settings. Measures of interest included surveillance measures, outbreak investigations, environmental adjustments, personal protective equipment (PPE), changes in work arrangements, and worker education. Sixty-one studies from healthcare, nursing home, meatpacking, manufacturing, and office settings were included, accounting for ~280,000 employees based in Europe, Asia, and North America. Meta-analyses showed that combined IPC measures resulted in lower employee COVID-19 positivity rates (0.2% positivity; 95% CI 0–0.4%) than single measures such as asymptomatic PCR testing (1.7%; 95% CI 0.9–2.9%) and universal masking (24%; 95% CI 3.4–55.5%). Modelling studies showed that combinations of (i) timely and widespread contact tracing and case isolation, (ii) facilitating smaller worker cohorts, and (iii) effective use of PPE can reduce workplace transmission. Comprehensive COVID-19 IPC measures incorporating swift contact tracing and case isolation, PPE, and facility zoning can effectively prevent workplace outbreaks. Masking alone should not be considered sufficient protection from SARS-CoV-2 outbreaks in the workplace.

Digital Contact Tracing Applications during COVID-19: A Scoping Review about Public Acceptance

Digital contact tracing applications (CTAs) have been one of the most widely discussed technical methods of controlling the COVID-19 outbreak. The effectiveness of this technology and its ethical justification depend highly on public acceptance and adoption. This study aims to describe the current knowledge about public acceptance of CTAs and identify individual perspectives, which are essential to consider concerning CTA acceptance and adoption. In this scoping review, 25 studies from four continents across the globe are compiled, and critical topics are identified and discussed. The results show that public acceptance varies across national cultures and sociodemographic strata. Lower acceptance among people who are mistrusting, socially disadvantaged, or those with low technical skills suggest a risk that CTAs may amplify existing inequities. Regarding determinants of acceptance, eight themes emerged, covering both attitudes and behavioral perspectives that can influence acceptance, including trust, privacy concerns, social responsibility, perceived health threat, experience of and access to technologies, performance expectancy and perceived benefits, and understanding. Furthermore, widespread misconceptions about the CTA function are a topic in need of immediate attention to ensure the safe use of CTAs. The intention-action gap is another topic in need of more research.

A case for location based contact tracing

We present an evaluation of the effectiveness of manual contact tracing compared to bulletin board contact tracing. Classical contact tracing relies on reaching individuals who have been in proximity to an infectious person. A bulletin board approach focuses on identifying locations visited by an infectious person, and then contacting those who were at those locations. We present results comparing their effects on the overall reproductive number as well as the incidence and prevalence of disease. We evaluate them by building a new agent based simulation (ABS) model using the Susceptible Exposed Infectious and Recovered (SEIR) framework for disease spread. We conduct simulation experiments to quantify the effectiveness of these two models of contact tracing by calibrating the model to be compatible with SARS-CoV-2. We find that bulletin board contact tracing gives comparable results in terms of the reproductive number, duration, prevalence and incidence but is less resource intensive, easier to implement and offers a wider range of privacy options. Our experiments show that location-based bulletin board contact tracing can improve manual contact tracing.

Quality and Adoption of COVID-19 Tracing Apps and Recommendations for Development: Systematic Interdisciplinary Review of European Apps

BACKGROUND

Simulation study results suggest that COVID-19 contact tracing apps have the potential to achieve pandemic control. Concordantly, high app adoption rates were a stipulated prerequisite for success. Early studies on potential adoption were encouraging. Several factors predicting adoption rates were investigated, especially pertaining to user characteristics. Since then, several countries have released COVID-19 contact tracing apps.

OBJECTIVE

This study's primary aim is to investigate the quality characteristics of national European COVID-19 contact tracing apps, thereby shifting attention from user to app characteristics. The secondary aim is to investigate associations between app quality and adoption. Finally, app features contributing to higher app quality were identified.

METHODS

Eligible COVID-19 contact tracing apps were those released by national health authorities of European Union member states, former member states, and countries of the European Free Trade Association, all countries with comparable legal standards concerning personal data protection and app use voluntariness. The Mobile App Rating Scale was used to assess app quality. An interdisciplinary team, consisting of two health and two human-computer interaction scientists, independently conducted Mobile App Rating Scale ratings. To investigate associations between app quality and adoption rates and infection rates, Bayesian linear regression analyses were conducted.

RESULTS

We discovered 21 national COVID-19 contact tracing apps, all demonstrating high quality overall and high-level functionality, aesthetics, and information quality. However, the average app adoption rate of 22.9% (SD 12.5%) was below the level recommended by simulation studies. Lower levels of engagement-oriented app design were detected, with substantial variations between apps. By regression analyses, the best-case adoption rate was calculated by assuming apps achieve the highest ratings. The mean best-case adoption rates for engagement and overall app quality were 39.5% and 43.6%, respectively. Higher adoption rates were associated with lower cumulative infection rates. Overall, we identified 5 feature categories (symptom assessment and monitoring, regularly updated information, individualization, tracing, and communication) and 14 individual features that contributed to higher app quality. These 14 features were a symptom checker, a symptom diary, statistics on COVID-19, app use, public health instructions and restrictions, information of burden on health care system, assigning personal data, regional updates, control over tracing activity, contact diary, venue check-in, chats, helplines, and app-sharing capacity.

CONCLUSIONS

European national health authorities have generally released high quality COVID-19 contact tracing apps, with regard to functionality, aesthetics, and information quality. However, the app's engagement-oriented design generally was of lower quality, even though regression analyses results identify engagement as a promising optimization target to increase adoption rates. Associations between higher app adoption and lower infection rates are consistent with simulation study results, albeit acknowledging that app use might be part of a broader set of protective attitudes and behaviors for self and others. Various features were identified that could guide further engagement-enhancing app development.

Usability, inclusivity, and content evaluation of COVID-19 contact tracing apps in the United States

We evaluated the usability of mobile COVID-19 contact tracing apps, especially for individuals with barriers to communication and limited digital literacy skills. We searched the Apple App Store, Google Play, peer-reviewed literature, and lay press to find contact tracing apps in the United States. We evaluated apps with a framework focused on user characteristics and user interface. Of the final 26 apps, 77% were on both iPhone and Android. 69% exceeded 9th grade readability, and 65% were available only in English. Only 12% had inclusive illustrations (different genders, skin tones, physical abilities). 92% alerted users of an exposure, 42% linked to a testing site, and 62% linked to a public health website within 3 clicks. Most apps alert users of COVID-19 exposure but require high English reading levels and are not fully inclusive of the U.S. population, which may limit their reach as public health tools.

Implementation of close contact elicitation at the time of COVID-19 testing-Atlanta, GA, October-November 2020

BACKGROUND

Contact tracing during the Coronavirus Disease 2019 (COVID-19) pandemic in the USA has been met with various challenges. In an attempt to improve the yield of close contact collection, the Fulton County Board of Health implemented a pilot approach to contact elicitation at the time of testing.

METHODS

Between October and November 2020, close contacts were elicited from persons under investigation (PUIs) at one COVID-19 testing site in Fulton County, GA. Secure online data collection forms were used to record PUI demographic data, close contact information and reasons for not providing contacts.

RESULTS

Of 1238 PUIs, 48% reported at least one contact. Among the 66 people who tested positive, 16 (24%) reported contacts compared to 578/1165 (50%) who tested negative. PUIs of increasing age were less likely to provide contacts; Black and Hispanic PUIs were also less likely to report any contacts compared to White and Asian PUIs.

CONCLUSIONS

Our study revealed that PUIs testing positive were less likely to provide contacts compared to PUIs testing negative. Age and racial differences were also noted in the provision of contacts. Further investigation is needed to understand these discrepancies in order to devise more effective strategies for contact elicitation.

Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries

Health systems resilience is key to learning lessons from country responses to crises such as coronavirus disease 2019 (COVID-19). In this perspective, we review COVID-19 responses in 28 countries using a new health systems resilience framework. Through a combination of literature review, national government submissions and interviews with experts, we conducted a comparative analysis of national responses. We report on domains addressing governance and financing, health workforce, medical products and technologies, public health functions, health service delivery and community engagement to prevent and mitigate the spread of COVID-19. We then synthesize four salient elements that underlie highly effective national responses and offer recommendations toward strengthening health systems resilience globally.

The barriers and enablers to downloading the COVIDSafe app - a topic modelling analysis

Objective: We report a survey in regional Queensland to understand the reasons for suboptimal uptake of the COVIDSafe app.

Methods: A short five‐minute electronic survey disseminated to healthcare professionals, mining groups and school communities in the Central Queensland region. Free text responses and their topics were modelled using natural language processing and a latent Dirichlet model.

Results: We received a total of 723 responses; of these, 69% had downloaded the app and 31% had not. The respondents’ reasons for not downloading the app were grouped under four topics: lack of perceived risk of COVID‐19/lack of perceived need and privacy issues; phone‐related issues; tracking and misuse of data; and trust, security and credibility. Among the 472 people who downloaded the app and provided text amenable to text mining, the two topics most commonly listed were: to assist with contact tracing; and to return to normal.

Conclusions: This survey of a regional population found that lack of perceived need, concerns around privacy and technical difficulties were the major barriers to users downloading the application.

Implications for public health: Health promotion campaigns aimed at increasing the uptake of the COVIDSafe app should focus on promoting how the app will assist with contact tracing to help return to ‘normal’. Additionally, health promotors should address the app's impacts on privacy, people's lack of perceived need for the app and technical barriers.