COVID-19 Webinar Series Session 12 – From Data to Decisions: Mobilizing a Surveillance Infrastructure

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

 

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Good afternoon, everybody.

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Good afternoon, everybody.

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Hello.

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All right. Hey, sorry about that little technical problem to get started. But I’m here we are. I’m Sarah – president and CEO of the Alliance Health policy and I want to welcome you to the sixth week of our covid-19 webinar series for those who are not familiar with the alliance welcome. We are a non partisan resource for the policy Community dedicated to advancing knowledge and understanding of Health policy issues. We launched this series to provide insight into the status of a covid-19 response and shed light on remaining gaps in the system that must be addressed.

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To limit the severity in the United States The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation and the Commonwealth fund for supporting our covid-19 webinar series. You can join the conversation on Twitter using the hashtag. I’ll help live and follow us at all Health policy. We want you all to be active participants in today’s very important discussion. So please do get your questions ready. Here’s how you do it.

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As policymakers way options to he’s social distancing measures a robust surveillance infrastructure is critical to prevent another surge in cases. This system will require close collaboration between the federal government States localities and many facets of the healthcare system as well as individual behavior during this webinar panelists will explore options policymakers can pursue to strengthen our surveillance infrastructure as we move from mitigation to containment of the covid-19 pandemics.

2:26

Day, I’m pleased to be joined by a group of distinguished panelists first. We’ll hear from Erin Murray the Chief Information officer for the University of Texas at Austin Dell medical school and UT Health Boston. Next is dr. Joseph Eisenberg the janji Cyril endowed chair and professor of epidemiology at the University of Michigan School of Public Health. And finally, I’d like to welcome Jim blumenstock who is the chief program officer for health security at the association of state and territorial health.

2:56

Officials asked. Oh, thank you so much to all of you for joining us today. I’m going to turn it over to each of you for some opening remarks starting with Erin Erin Mary. Go ahead. Hello and thank you all for listening and then the tuning in some of the big things that we have going on here at the University of Texas at Austin particularly as it relates to contact tracing and home monitoring and whatnot. As we battle covid.

3:17

We have found a tremendous willingness and the community to partner and want to get in front of this the outpouring of support from both patients and from just a General has been phenomenal, but with that as you leverage in them and layering technology and whatnot. You always learned some important lessons. So hopefully today I’ll walk you through some of those real time. I walk you through some of the things that we have over common challenges and some of the partnership’s that we’ve done both with local and state authorities and National authorities on trying to advance care and dealing with covid-19 and all Dimensions particularly as it relates to contact tracing and home monitoring. So, thank you.

3:54

Great. Thanks so much, Aaron. All right, and next Joe. Would you like to offer some quick opening remarks? Yeah, I want to just talk a little bit about the role of testing in the midst of an epidemic like we have here in the US just has been much talk about the need for testing. We’ve been told about the success of early on in the pandemics and countries like South Korea and Germany with a testing was talked about his keys.

4:24

Senses to controlling the under the hammock and we’ve also been told that how far behind we are in the number of tests were performing. Although we are certainly observing Civic ramp up Cindy and various States on testing. So I just wanted to touch upon you know, what are we what’s the role of testing and why is it so important to move forward on testing and testing me increasing testing numbers. There’s really two major roles for testing. I can play in controlling the spread of the epidemic first. It’s a essential.

4:54

surveillance tool know without this information about cases of infection and disease were pretty much Flying Blind with respect to developing appropriate intervention and control procedures and there’s two types of test that we can use for surveillance in the first is what we really been talking about quite a bit and that’s a testing for the the presence of the virus in the individual to assessment person who’s infected and the second is to test to see if a person has antibodies against the virus person has antibodies this means that they’ve been Those to the virus and they’ve either experienced symptoms milder severe they didn’t asymptomatic Theory symptomatic infections. And so this provides valuable information on the extensiveness of the transmission missed that’s occurred because it’s capturing these mild and asymptomatic cases that we otherwise would have missed through the conventional testing. And so it’s a really important part of a complement to our surveillance tool box.

5:55

But the second important role of testing and I think we’ve been you know, when we talk about testing numbers is what we’re really focused on is the importance of testing is a tool for control of viral spread.

6:07

So by isolating those tested as well as their contacts, we can contain the spread in a much more efficient way than broad-scale social distancing that we’re doing we’re seeing right now so we can really think about the testing and contact tracing and isolation as a The social distancing approach to control the disease effectively Advocate and as we relax social distancing, we need to increase that testing detainment activity. Ideally, we’re testing all suspected cases regardless of severity and the contacts and in this way, we’re able to prevent case clusters from developing and a way to move forward.

6:47

So these two testing activities provide the essential information needed to again move forward over the next Year or even two and allow us to relax social distancing in a very strategic method on men methodical manner that ensures that we keep the case is low in their numbers and not increasing.

7:08

So tragically we should be relaxing social distancing slowly first allowing work sectors that only result in low probability events, and then by providing appropriate guidance of the work sectors on mitigation, we can maximize You have the economy. So increasing testing and containment allows us to increase the relax your social distancing and maximize again this opening of the economy. So the next major question is really about how much testing is needed and we hear numbers all over the map of wide range some saying 5 to 20 million tests per day in the US. Hello lower-end.

7:50

We’re hearing things like that suggests that we need to increase our capacity like threefold and Michigan and from our capacity is steadily increasing now on the order of a thousand tests. So reaching 15 thousand tests is actually quite doable and largely a simple supply chain problem 2% test positive is an important metric here. So that’s two percent of tests that are positive and Michigan where about 20% and we’d like to see that number decrease attend.

8:24

Some more published studies on testing are used most published studies on testing are used to forecast models to estimate the testing numbers needed to move forward and needless to say these forecasts from these models are highly uncertain and they contain many assumptions about efficacy of social distancing about and contact tracing and isolation. And there’s also a lot of uncertainty about the amount of transmission that has already occurred.

8:51

So this really explains that a wide range of estimates on what testing Ray we need to move forward the more cases the more testing that’s needed. Hence.

9:01

We can move, you know, the percent positive metric is useful indicator on how many test we actually need syndromic surveillance can also do a lot in helping contain and again, you can make our testing much more efficient information on symptom based surveillance provides a quicker response than On a surveillance and case identification and we’re currently lots of people are developing apps now. Our people are beginning to develop apps that are make this even more efficient.

9:36

And lastly, I just wanted to mention that you know population immunity is important piece of this puzzle, but there’s a lot of uncertainty associated with how much protection somebody has its when they do recover and this is likely to be a function of their health status whether or not they had a mild or severe disease and also a function of the virus. So there’s like there’s also a lot of question of how long protection will last. So ultimately, I believe that population immunity will play an important role in protection.

10:06

Initially established it as the virus established herself as an endemic disease and herd immunity is this important concept and number of people needed to prove that were protected and the virus can’t really transmitted and we use this concept in developing vaccines strategies at all the time, you know many people have estimated this level to be a statistic 60 percent of the population, but I you know this point we can only speculate on all these these kind of numbers.

10:36

So that with that that kind of gives a hopefully an overview of the role of testing why it’s important why we need to really ramp testing up in moving forward in the senate in this pandemic as we relax social distancing.

10:53

Great. Thank you so much Joe that was that was a real tour de force. I feel like I was back in epidemiology class and I think you gave us a lot of food for thought. So again for the audience if you have questions follow-up questions, feel free to just go ahead and send those in using your question mark icon. So now I’m happy to turn this over to Jim blumenstock from asked o Dem go ahead. Well, thank you so much and good day everybody, you know first allow me to State the obvious.

11:21

That the nation’s public health system is really on the front lines in this war against covid-19 with our principal Focus right now being I containment and mitigation and as I see it really our work is in for specific tracks or phases that would include response restoration or what’s also be referred to as reopening of Commerce recovery, which we cannot lose sight of and certainly begin to have a vision for and overall Community resilience.

11:51

Just to remind you a quick snapshot of really what our immediate and longer-term response objectives are in the context of covid-19 your state territorial public health and needed to tribal Health agencies or health entities conduct such activities as aggressive an integrated Incident Management maintaining an emergency Operation Center in coordination with other components of their government including Emergency Management and Homeland Security.

12:20

They’re responsible for the health and safety of responders and critically important to any public health emergency, but I think it’s certainly rearing its ugly head it with covid-19 is the issue of Health Equity and that risk and vulnerable populations and trying developing strategies and tactics to address their immediate and unique needs clearly, which I’m sure we’ll talk about in a few moments is the issue of information-sharing not a date not only data as part of analysis intelligence for decision support, but also public information.

12:52

hooting warnings and effective risk Communications another key part which I think is related to Joe’s rebars is around countermeasures and other types of mitigation non-pharmaceutical interventions such as times when we don’t have a vaccine or proven therapeutic as critically important for such things as social distancing quarantine and isolation as not only legal tools, but also effective tactics is a role that state and territorial Health agencies play in issuing monitoring and encouraging voluntary compliance and lastly is around the medical material a lot of discussion about local jurisdictions asking for receiving and distributing the Strategic National stockpile many jurisdictions maintain their own State caches and will probably continue to do so throughout this campaign of covid-19 response and already the the public health system is looking look, forward looking ahead to what a national vaccination campaign can be, you know those of us who are in the field and work during H1N1 10 years ago of a full appreciation for what it’s like to distribute medical countermeasures antivirals when available as well as vaccine when it comes available that has to go above and beyond what is typically available through the capacity of traditional Health Care Systems, whether it be your private physician your pharmacist Or even places of employment so that is certainly a planning effort underway right now as we’re managing this response search staff. I’m not only in the public health field, but also helping their HealthCare Partners navigate some of the licensing and legal requirements and other types of barriers that may exist to ensure an all-hands-on-deck i Mutual a type of environment and obviously infection control. Not only is it work force protection effort, but certainly in high risk.

14:51

So these like nursing homes that were infection control is a critically important aspect is a role where Health Department’s play Not only as Educators, but sometimes as regulators and the last two areas again is biosurveillance, like which I know we’ll talk about it in Great length and during the course of the hour and again getting back to the issue of recovery as you can imagine.

15:14

And for those of you that can sort of draw the analog between major natural disasters like hurricanes Katrina Sandy the Deep Horizon oil spill you can imagine that a recovery of a community certainly measured in months. If not years. Well, you know covid as an infectious disease has a different set of manifestations but the impact on our on our human infrastructure is I think equally equally as vulnerable as our heart infrastructure would be during natural disasters.

15:45

So what does this mean to the Health Care Workforce the public health Workforce the met the emotional Hey Bureau, mental health of our society as we continue through this the programs and services that may be somewhat neglected as a sort of a second-order consequence because we’re moving all of our resources and focus on covid-19. So clearly that’s the only a planning effort but it’s also a long-term longitudinal, you know Community resilience Focus as well. You know before I close I really want to pick up on a point.

16:21

Aunt Jo did an outstanding job overviewing the importance of testing not only what it means to the case to his or her contacts but also the community that’s impacted for the purposes of not only patient care individual counseling but also determining interventions that may be necessary for specific communities being driven by the data that’s available from testing but the second part of that strategy if you will is the issue of tracing and as Joe had mentioned that that is critically important following testing so that you know individuals who are ill can be isolated and individuals who’ve been directly exposed to sit cases can be quarantined and monitored all is it as an effective strategy to contain and basically suppress any outbreaks that may take place in a community and you know, if I asking everybody to go back to two or three months ago when we were in the tainment phase that was all about trying to keep the virus out of our country and when it got here trying to contain it in small pockets of communities for as long as possible in order to allow to sort of ramp up the infrastructure that was where we were on the on the other side of the curve where we’re starting to increase now, we’re sort of approaching that point. We’re going on the back side of the car. So, you know moving across from moving from MIT.

17:51

Asian back to a containment strategy state by state county by county community by Community is becoming a another phase of that type of containment or outbreak suppression effort. So to have sufficient Workforce to go in and respond to cases that have been identified speak an interview and counsel their contacts. So they don’t continue to spread. It’s actually with the community is the success to not only you know full on.

18:21

Reopening but also sort of that Tipping Point of getting into more normal societal activities. So how do we accomplish that? Well, you know again different models different projections, but one thing everyone agrees with that the current Public Health Workforce in this country is woefully insufficient to meet the the labor demands of having contact tracers or disease intervention specialist.

18:49

Do the amount of work that is Necessary to achieve that goal of suppressing future outbreaks as there was pleads pleased to contribute to a product at the Johns Hopkins Center for Health security released two weeks ago which puts that an estimate of a hundred thousand individuals to be Nationwide contact tracers for the next 12 months is a reasonable projection of need that we have to Rally around and basically, you know ramp up that component of our Workforce.

19:21

At a cost estimated to be three point six billion dollars so that that sort of the the sobering point.

19:29

I want to leave you with but I think you know, it’s also critically important to recognize that you know with the emphasis on testing contact tracing is an equal partner in that overall strategy to suppress future disease transmission and to protect the public health matter what the fate of covid-19 is whether you know, whether it’s It just becomes an endemic disease. It becomes a roaring seasonal disease with a second wave the fact that testing and contact tracing contact tracing look still be an integral part of our response platform regardless, so, thank you very much.

20:10

Great. Thank you so much. Jim and Joe and erinite we’re gonna have a great discussion. There’s a lot to talk about here. Alright, so the first thing I want to do is for those who maybe you know are hearing this term surveillance for the first time applied in a public health infrastructure. And you guys have done a great job of laying out some of the components of it, but maybe gem I’ll just start with you surveillance. A lot of people may think of that as like a totally different thing from public health. So what are the essential elements of surveillance? You could just quickly kind of bullet point them out.

20:40

Sure, Well, you certainly it’s all about the structured collection and Analysis of data to basically paint a picture of what’s going on that would basically Drive decisions for for Action that could be ranging from ongoing monitoring to aggressive interventions, you know and everything in between. So in the in the context of covid-19, there are there are multiple surveillance.

21:10

Methods or Pathways that are being used, you know, the one thing that that my observation is that we have.

21:17

We have taken existing Legacy surveillance systems and put them into very effective use with some modification the capture the type of data that we need to really get a fuller picture of how covid-19 is spreading impacting and affecting the health and safety of our community and that would include With everything from obviously the reporting of cases to the reporting of deaths through the existing systems that that exists syndromic surveillance looking at the influenza-like illness platforms that are out there and using them and possibly enhancing that little bit to sort of capture the covid 19 issue another project. I’d like to share, you know on public opinion polling ask though is working with CDC and Harvard to ramp up.

22:10

A fairly significant public opinion polling around public opinion polling effort around covid-19, you know, someone might not think of that as being traditional Public Health surveillance, but I do because you know in capturing through its through a methodology through a structured method of proven approach capturing the data on the Public’s beliefs in values and that how that influences their processing and accepting of messaging around covid.

22:40

Is is important and to me that’s just one sort of offshoot surveillance effort that the Public Health System is using to really try to use data to inform this is decision and action great. Thanks. So I want to turn to Aaron Aaron you’ve written a health Affairs blog about how do we really strengthen and accelerate the data infrastructure around covid-19 or valence? So can say a few words?

23:10

What are some of the key elements that we need as Jim said a surveillance is the structured collection and Analysis of the data? What do we need to do to make it what it what it needs to be to really get back to containing? Covid-19 Aaron. Absolutely. Yeah. No, I appreciate the question and it’s great question and great overview for my co-panelists here with James and Joseph.

23:33

So the degree of a couple things and without getting into too much of the nuances number one, there is not A readily adopted framework nationally for the bulk of the data that we need to be shared amongst the states at a national level at a state level what not.

23:50

There are certain criteria, especially with the new US CDI standards corporate interoperability and others that you know, we must modernize our Frameworks around that our electronic medical record systems are using our syndromic surveillance systems are using so that we’re all talking the same language on a national level to be able to share today if I want to share information with say Awesome public health or I want to share information with a state or even the federal government. Each of those are different types of criteria different types of datasets phenotypes, whatever else there’s not one set criteria for sort of a national superhighway. A lot of that was addressed to 21st century cures, but now as you know, as you all know it’s been delayed a little bit in terms of information blocking and whatnot. But those standards Nations must occur. So that’s number one standards. Number two. We need to make sure that we are really looking at you know, how do we deal with?

24:40

With national provider data submission and points for electronic lab in case reports. How do how do these how are these case reports and lab reports in put it into a central common system as you saw the White House spun up, you know a pretty much a work around saying hey email us every day. You know with what your lab tests are with your volumes are what you’re seeing. You know you low in PPE that’s not the way this is supposed to work that over email, right?

25:03

We need a we need to be able to suss out that data on a national level and be able to ingest it into some sort of central repository so we can Click get actual in size. So we’ve talked about standards. We talked about coding and that we’ve talked about obviously being able to submit data from again lab and case Report perspective. Another one is being able to look at all of the dimensions of care. We focus tremendous amount of time on the inpatient acute setting totally makes sense.

25:28

We understand a lot of patience for covid are presenting in the Ed and then thus going up to ICU or whatever else for recovery, but to the degree of it, there’s a number of ambulatory Health Systems El tax Have facilities Primary Care Facilities in the middle of everywhere America. And those were sort of left out from the American Recovery and reinvestment act and have not got on to Modern electronic medical records or if they are those records systems don’t really necessarily talk to the others. So when we’re looking at and trying to say, okay how many people in Austin Texas potentially could be at risk for covid or what are the demographics there that’s even hard on a local level much less a national level to say. What is the true extrapolation of risk?

26:10

Keep hearing about you know, what are we ever going to achieve herd immunity? Are we ever going to get to this end number and we really don’t even know what that is due to a lack of testing like a data availability and a lack of Standards. So to the degree of it, if you look at those Dimensions as being some of the key criteria that sort of built itself around a framework so that when you’re trying to do something like contact tracing and I’m trying to call air and say hey Aaron who have you encountered at the local hair salon or Barbershop or the mall or you know, you went to buy a new pair of sneakers today and you you know, where symptomatic who were you around?

26:40

And it’s tough to get that data because at the end of the day, we’re only as good as the data is and right now our national infrastructure a public health infrastructure is woefully inadequate. So I implore folks listening to go back look at standards modernization. Look at being able to way to be able to suss out this data from the community and input in a central repository partnering with your local public health authorities and making sure that data is commonly exchange and commonly denominated format and understanding how do we get back to?

27:10

Realizing what’s valuable here, which is the patient at the end of the day. We have some great starting points. You see companies like Apple and Google trying to accelerate contact tracing you look at what the onc is doing and try to put out guidelines and referendums but at the end of the day, we’re only as good as what we have so in a nutshell, that’s what I have to say.

27:29

Thank you so much. Sure and your voice is breaking up to slightly. So I’m going to make sure I heard you correctly you want to know what happens when someone does pest test positive. That’s right. Yep. Okay, no problem. Alright, so today.

27:58

Here at UT Health Austin a couple things one. If a patient does test positive we obviously get let’s assume that they were tested here at UT Health Austin we do get that result immediately an electronic medical record as a critical lab value. We reach out to the nursing triage team to notify the patient of your test result the patient of course can get it near electronic portal as well. We then do contact tracing on the patient to figure out who did Aaron come in contact with within a duration of time around that maybe you’re asymptomatic before your test came back.

28:28

Back, maybe you showed early symptoms and no a week ago. And it took this long to get you a test going. So we try to figure out who have you been around and build a contact list from that contact list. Each of those contacts are given a unique identifiers that we know all the people there and we track them. This is how we’re able to develop, you know, sort of a covert 9 case registry for lack of a better term and understand. Okay, what’s going on here within this cohort of patients and does that have a predisposition to become a cluster a cluster being say a family unit that are all suddenly positive.

28:59

A group of folks that maybe travel in the airplane together those types of things from that. We then share that information with the public health authority and other systems around us to make sure that everybody understands this is what’s going on. This is what we’re tracking from a public health and epidemiology perspective and we’re able to to to work through that whole process on the flip side. If a patient test negative, however, there are eight there symptomatic to some degree. We’re still tracking them. So we create a contact the sort of at that point.

29:28

Point considered a Pui person investigation, you know, what’s going on here. Is there a follow-up appointment to get tested again? Perhaps your tests came back are initially negative. It really should have been positive. We’re seeing a lot of that or early tests were actually false false indicators. So to the degree of it, that’s where home monitoring comes to affect where we’re now asking folks to monitor the temperatures on a periodic basis. We have apps that we’ve deployed here but folks can call it in and other health systems to say. Okay. This is where my temperatures out and suddenly I’m approaching, you know some sort of threshold on different.

29:58

Different metrics there. So at the end of the day like I was saying earlier, it’s about the data. It’s about being timely. It’s about having some sort of decision support in our case. We have a lot of that automated with a rules-based engine sort of baked in there and it’s about engaging with your community. I forget which of my panelists mentioned the total number of contact tracers that may be necessary across the country. But that is a very true number because even with the best of tech even with having phenomenal companies like Apple and Google and Microsoft jump into The Fray, it’s still the human.

30:28

Ament it’s still understanding. Okay, the nuances of Aaron walked into a store, but he didn’t stay there and expose anybody just sort of ran through it. So the chances of exposure are low versus. Oh he hung out in this area for 20 minutes and guess what cost on everybody. It’s there’s a lot of nuance here that it’s very difficult to automate that it does take that Human Condition. So you have to have a good closed-loop process built out.

30:51

You’ve got to understand your population and then in our case here in Austin, we also then had to work with a population of folks that don’t Speak English, they speak Spanish and some folks are very low socioeconomic status. They don’t have smart phone technology. They don’t have ability to get ahold of we call that the disconnected population. We have a send people in to the community to the Salvation Army to the Red Cross to talk to them to understand what’s going on and being able to track and work with them. So it is a very involved process, but that’s what it takes.

31:18

I would maybe somebody positive and when you have someone negative And this is sincere and that was an excellent overview and one additional feature is when you have someone either in isolation or quarantine through the contact tracing that are indispensable. You know Public Health just doesn’t forget about them and just monitor their daily data reporting of their of their situation. I mean, there are some significant demands for wraparound services to really ensure not only compliance but also the most appropriate Health outcome for those individuals.

31:52

The issue of art that you know, do they reside in an environment conducive the proper isolation and quarantine. How are they going to get their medical care? How are they going to get their everyday creature Comfort Care are their education food supply issues security issues.

32:09

So, you know that is that’s basically a public health systems with their with their other partners across state and local government to really ensure that when we when we expect someone to comply with party and isolation that their best interest and their best care is in some way planned for and helped out.

32:30

That’s a really great point and I’m going to I want to get to some of those human human factors in in just a bit and I want to ask a couple questions first just kind of again relating back to that data. And how do we how do we know you Joe earlier today earlier in your remarks had talked about the percent positive read and sort of meeting as a general Benchmark to go from roughly 20% of those tested testing positive down to two.

32:59

10% testing positive. We had a question from the audience about guidelines for testing and at least especially early on guidelines were you know, people really couldn’t get a test until unless it was really really serious severe sometimes even until they were in the hospital talk about the guidelines for the testing and how the stringency or not stringency of those guidelines affect our understanding of just the prevalence of covid in the population.

33:30

Yeah, well, I like the well, you’re calling guidelines and and the situation where we were only testing those serious is really just a function of the fact that we didn’t have very many tasks. So when you don’t have a lot of tests available, then you do have to make decisions on who to test and actually once you’re testing only the most severe it has less and less surveillance and public housing.

33:57

Probably more clinical significance that you know wanting to know whether or not that person is positive in order to move forward on treatment.

34:05

So really what has we start ramping up in our testing we can can change the guidelines and who detest and ideally we really want to be testing anybody that shows any symptoms that are covid like they should be able to get a tap just like we do with influenza and then That point testing becomes much more of a public health surveillance tool and a containment tool because you test them a dispositive you-you-you contact Trace find those that are exposed.

34:41

Ideally the ones that are have high probability of infection because they were the exposure was was much more intimate either being in a household together or work together somewhere where you’ve had a lot of contact with that case that you would want to test them also and there by by doing that kind of testing you can make any kind of containment much more efficient where your contains the people, you know are infectious or quarantine those people that you know, they’re infectious rather than just having to guess or assume that they’re infectious because you they were in contact with somebody so the the the goal with the testing is starting to ramp up and really be the able Cast as wide as we can because the wider the ability that we can test and and the more information we have so I mentioned the test positive the percent test that are positive is an indicator because as that as we move further and further down the epidemic curve, there’s fewer and fewer cases and therefore the tests. We don’t need as many tasks and the contact tracing is much more manageable and some ways that’s what we’re waiting for. Now. We’re doing this.

35:57

This math, you know untargeted social distancing in order to wait both for the testing the ramp up also for the cases the drop-down and there’s going to be a hopefully a sweet spot there where we’re going to have the capacity of testing to be able to test anybody that’s positive and test those contacts that have high probability of exposure.

36:24

Great, that’s a perfect segue into a question. We got from the audience about contact tracing. So I want to stay on you for just just another minute Joe if we cut and then and then kind of expand on the conversation, but we had a question around contact tracing and could you could you kind of spell out a little bit more just really how does the contact tracing work? And what’s the connection with testing? So the the audience member asks us for example, if a person is working.

36:53

Working in a store. They don’t get tested test or maybe they get tested and then their test results don’t come back for a while until they’ve been potentially exposing people for a week or more, you know hundreds of Shoppers that kind of thing talk a little bit about that intersection between the testing and the contact tracing and just like how does it actually work or how the supposed to work in practice?

37:15

Yeah, I know testing is supposed to work in practice where you get results very quickly if you’re not if you’re testing and not getting results for a week, that’s that’s not a very good system and we’re improving on that also, and and and eventually we’ll get these rapid test. It’ll be you know, incredibly quick turn around just like we have with influenza. So the idea is that if there’s anybody that has any covid suspected symptoms.

37:44

Mmm, they should be able to get tested, you know, you know that could be at the clinic but they could also you know many places around the world and now even in this country are having drive through testing with make that more efficient.

37:58

The test result would ideally come back quickly matter of hours even or or last and then the contact tracing is basically interviewing that case that just got Diagnosed with at positive and interviewing them about their contact in the pay, you know past couple of weeks and then those contacts are then contacted. You don’t have sufficient testing for them. You’re giving them advice about isolating for the next few weeks to see whether or not they become symptomatic ideal.

38:40

If you have some you have the availability to testing you can test those Those you know, the priority would be those that add more intimate contact with the person along down the line. So the idea there and that’s why it was mentioned. I think by are and that this is really an A labor intensive activity and we need the public health Workforce to be ramped up to be able to do these kinds of tracings activities bacteria University of Michigan. We are a lot of our mph in turn.

39:14

Are taking on a lot of contact tracing activity. So basically doing those interviews. So any interviews to find out who those contacts are and then calling those contacts and and letting them know that they were potentially exposed and these are the guidelines for them to follow great. Thanks. So so Jim o turn to you about just the role of the state and territorial Health Department’s Public Health departments, and actually carrying out this contact tracing in an idea.

39:44

A fashion and just maybe maybe we can talk a little bit about just the reality of it. You know, when when have you seen it work? Well, when is it, where is it not working? Well, what what’s needed right now to make it work better and then you know once you have certain traits the contacts and talk to them and you know kind of shared that information with them. Like how do you you talked about the wraparound services or one of you dead but just in the sense of like how?

40:14

Is there enforcement are there enforcement mechanisms to require people to help isolate or that more voluntary just talk about the spectrum of some of how it actually worked on the ground. Should I be glad to it’s a great question. So the first point to make is that this is not a new or novel approach for covid-19 the Art and Science and practice of contact tracing has been a staple of Public Health programming or many many years.

40:43

It’s It’s commonly used everyday and sexually transmitted disease investigation. And as Joan mentioned once someone is confirmed with a disease mostly through laboratory analysis. They are interviewed to assess who they are who they are who their direct contacts were and there’s usually parameters and I believe in the case of covid-19 would be you know, who are you been in close contact with, you know household business within that 6 foot 10 foot.

41:14

range for period of time and one and that will and through interviewing recall and sort of the coaching and counseling from a skilled contact Tracer will hopefully yield accurate and complete information sufficient enough because I can go back and interview those people there their risk will be assessed as to whether or not they fall into the definition of a true contact and and if so, they would be be counseling and advised on what to do.

41:47

And as we mentioned before the issue of it, you know, you know staying at home for the 14-day period these are the things you should watch as far as monitoring your own health, you’ll be given guidance as to how they need to check in with the health department either the old-fashioned way or through using modern technology and apps that were briefly mentioned and that will and that will play out until the person remains well, but that 14-day period And if that person becomes ill then that person to would be considered a person under investigation that would go through a covid-19 workup which would definitely require lab testing during that interviewing and and then it’s all about it really is all about interviewing creating that safe space that interaction with these individuals to have them being honest and truthful but also be open to you when you’re going to give them good advice to part of that encounter is also assessing the challenges that they met they do at the face of having to be in a confined space or under those conditions for that period of time. So, what will the public health system is doing is taking Again The Playbook that has that’s being used everyday and health departments for STD’s maybe TB and other diseases and modifying it to the specifics of covid-19. And with this with this new Army that we as a nation have to create quickly.

43:14

You’re clearly is a training element of this because there’s not enough people in state and local Health Department’s to do this job. So those that are doing this every day will become the mentors. The trainers are supervisors who we’re talking about bringing in either new Personnel or reassignment of personnel for many federal agencies to meet this effort. So a training modules are being developed this week. I believe two states already are starting to train at least the first Kadri.

43:44

Of new contact tracers for their communities. So it’s time is of the essence. And again, this is the critical feature to the success of winning the war against covid. All right, I want to ask you a couple of follow-up questions on that because you know, you talked about this new Army earlier, you mentioned an estimate of a minimum of $100,000, which is in the Johns Hopkins paper that’s on up on the alliance website as a resource or will be soon.

44:14

It’s but it sounds like with this human element this trust element me. You need a certain sort of like a special kind of, you know person and earlier Aaron mentioned, you know to going in talking to vulnerable populations. Like what do they need? You know, what’s the sort of cultural aspect of this?

44:29

So talk a little about what kinds of people are needed for this effort and who’s going to hire them as it the public health department is the state like who’s actually in charge of you know hiring It sure so, you know as far as the hiring I mean it would be up to them to the model and the Consortium that have said a state or jurisdiction may may create, you know, some states may have good a good partners with fiscal intermediaries or academic facilities. Some states may say we’re bringing it in on the payroll as a state FTE or temporary higher. So there are multiple models that are you again used every day in Public Health Department’s to do sort of this surge in these special.

45:14

Object activities the type the type of person will clearly cultural sensitivity and awareness is very important and that’s why you know, one of the pipelines are existing community health workers that that sort of know the field the profession they know the community and with a little bit of training who would become competent enough in the areas of covid-19 to be a very skillful.

45:44

the effort student students in undergraduate and graduate public health and biological science programs again, another pipeline looking at retirees, whether individuals from the public health Workforce or even the public safety Workforce, you know, one jurisdiction realizes that you know retired Law Enforcement Officers, they’re skilled interviewers, if they’re good a community policing there’s an assumption that they may really Have they have they have the mindset the the attitude the demeanor to work well in this type of setting so, you know, we’re exploring every option for every reasonable and viable pipeline of individuals that could meet the immediate needs as well as the the long-term need as this will continue certainly for months if not years going forward great. Thanks.

46:41

So I want to ask are Aaron we haven’t heard from you in a little while and I want to ask a little bit a little bit more about the role of tech and apps in facilitating this contact tracing.

46:53

I’m sounds like obviously crust is going to be super critical to these these kinds of contact tracing interviews and then obviously the steps that people need to take our people going to trust an app more than they trust a person or like how can the apps help the contact tracers, you know with their jobs and can you maybe share a little bit if you could have you know have Countries used technology to positive effect. Yeah all great questions. So let’s take this in a couple of pieces. Number one. It’s first and foremost folks got to realize that technology is not going to solve a problem by itself and I implore people to realize that while we have all been empowered by our iPhones and and you know computers and the Dominic personal Computing Age and what we’re doing now is super computers particularly here at UT Austin that doesn’t solve the problem with it’s an augmentation. It’s a way to ability.

47:44

The ability to improve what you’re doing and it’s also the ability to accelerate what you’re doing. So will contact tracing applications and systems and infrastructure help the process along and maybe not take as many contact tracers Absolutely. I’ll give you a real world example a company actually helps us know we’re partnering with in Seattle that was doing some home monitoring and contact tracing on the light way.

48:07

We’re telling me that for one contact Tracer they could they could trace four to five Persons of Interest or Our individuals and our right so we extrapolate that out with a number of people’s need to do. This is manual. This is calling people up on an Excel sheet, you’re documenting it and it’s all old school workflow you think about how slow and mundane it is.

48:26

However, if I could accelerate leveraging smart apps if I could accelerate leveraging some sort of Bluetooth ble technology, which is, you know, kind of what Apple and Google are talking about if you can do those things you now explain entually increase how fast you are able to do contact tracing still make contact tracers, but they’re able To get faster, right? So we’ll apps and and we’re people feel more engaged with an application perhaps but I also have another saying I always say which is don’t be creepy with your technology. It’s very very important that you get consent that you are transparent with what you’re doing that you let people know, you know, if you consent and adding information is application. This is what it’s going to do. Maybe it looks at your contact list on your phone and uploads that to a central repository.

49:11

You tell them hey will destroy it after Days or when the pandemic is over whatever that is, you have to be explicit. So I think that yes, there are apps and there’s technology that will help. Yes that people will have some reservations as they should but if Hospital systems and public health authorities and others are very very upfront and transparent there shouldn’t be too much of a problem getting at least a major attraction to what you get at least 60 70 80 percent of the population. You take care of them now I was saying earlier, you know.

49:44

A good portion of your population does not have a smartphone or if they do own a smartphone. They don’t know how to use it. You’d be amazed at how many people we have tried to contact trace and say hey go download this app. That’s the UT Health Austin app and they’re like, how do I do that? You know and it’s like what do you mean? No Jemma smartphone. Well, yeah. I’ve never downloaded off app store though. Okay. So there’s a there’s a level of Engagement in terms of Education in terms of awareness. There’s other social needs. They need perhaps to live in a food desert and they haven’t eaten for a week here in Texas. We have very long.

50:14

Food lines a lot of people right now are struggling that without eating you think they’re really going to want to go download an app. So these components all play into it. Now the other part of your question, which is has Europe and other places done this. Yes, they have South Korea is a great example. Look what they did there. They were on top of its full scale. You know, you look like a very different kind of society which China they did the same thing there. So technology can be used for good or it can be used for other purposes as well.

50:40

And the key in difference there is being transparent and making sure that you tell the public Look what you’re doing with their data is they’ll be bought in for the common good?

50:49

That’s great. And I’m glad you said you know, don’t be creepy with your technology because we did have a question from the audience about whether the use of technology or whether the surveillance in general threatens people’s privacy. So, I wonder if you could maybe just say a few words about the Privacy implications and then I would certainly invite Jim and Joe to weigh in as well. Yeah, absolutely. So there are of course privacy considerations, you know across the country. We have 50 wonderful states with 50 states of variation.

51:18

Privacy Law and then of course federal law as well. There’s a course GDP are two other components when you go across Waters, you have things like FERPA, which I have to comply with being University. I mean, there’s a Litany of things if you’re a minor then of course, there’s consent rules there. So you have to be mindful of all of that. None of that is put aside during a pandemic. What is put aside though is the ability for you to share information with transparency to the person of hey, may I call your hair salon and asked them who was around you because you don’t remember you just know there’s a lot of people around you getting their hair done.

51:48

Done to right so you have that ability to ask those questions, but you can’t break the glass and go break all the laws because oh, it’s a pandemic. We have to go do this. No, that’s not how this works. Right, but the component of it is that I go back to transparency. If you’re transparent with people most folks out there want to help I have we have not run into one person that we’ve called up and said, hey, you know, we think you may have been exposed to covid-19 in your and your daily passerby. That was somebody that reported that could you please tell me where?

52:18

We’re on this day at this time who is around you there’s been no one that said. Oh my goodness. I don’t want to participate your creepy. Why are you calling me? Everybody wants to help but the key to it is to be transparent and above board and make sure folks don’t understand don’t don’t misunderstand that you’re trying to misuse their data.

52:38

Damn or Joe anything to add to that?

52:42

Well, this is Jim. I mean just to reinforce the point that at that that an app’s a tool and you gotta know its limits and its capabilities and and I think Aaron did an outstanding job of discussing and strengths and weaknesses in the parameters to be used these. The only thing I would add is that you know, you know all well-intentioned that the Public Health Community is being inundated.

53:05

Maybe that’s too strong of a word but they’re certainly being approached by many many entities that Technology Solutions to contact tracing in other aspects of this response and recovery and I think the biggest challenge right now is assessing their capabilities their limitations their vulnerabilities and which ones have great promise in which ones can be used to increase the level of interoperability between the various players that only within it with it with an intrastate, but it with an interstate or national Common operating picture. So I think that is that’s the challenge that the folks in the field of working it is how do you how do you take all of these ideas and prototypes and beta test and try to assess it like you do any other thing you would buy either you’re at home or at work to make sure you’re investing your money well, and it’s going to give you what you need.

54:06

Great. Thank you. Alright, believe it or not. We have only just about five minutes left in the webinar. So we’ve had a few more questions coming from the audience. I’m going to try to weave them in and I’m going to try to make them just a little bit kind of future-focused. So we’re just going to go to each of you and Aaron I’d really like to start with you. So one audience question was can you clarify if States or localities have guidelines or explicit criteria to compile data defined criteria?

54:33

Leah I’m just if you can speak to any kind of existing efforts that you know of and then I’m going to throw you a curveball just ask as as we look to analyzing the data and moving forward. Is there a role for AI in this or isit already being used so he could go ahead of that. Yes. There’s a national CDC form in our case. We have a local local awesome Public Health Forum. There’s also State, Texas State form.

55:04

Data, elements and criteria that we need to we need to capture and gather for the most part. There’s there’s a large degree of overlap on the data sets, which is good. Some of those forms are exactly what you think. They are. They are non discreet field form. So you have to turn them into discrete data to be able to then make it interoperable as it was being said earlier, but to the degree of it those data elements are there.

55:23

So that’ll get you seventy percent of the way there then it’s about understanding your actual population of people that you’re working with right as I told you Austin has some uniqueness to it given that we have a 60% of our Population is Spanish-speaking. The average age of the person is cities under the age of 40. So there’s some Dynamics here that are unique to you that you need to incorporate into that. But the combination of the two and closely partnering with your public health authority. I can’t stress that enough your job is not to be the public health authority but to help them and to augment them and the partner with the city, that’s one and then on your curveball question there really, I mean to the degree of of what we’re trying to accomplish and what we’re trying to do.

56:04

There there is a lot of ability for AI to be there but the data has to be in a way that’s uniform and is trackable and it’s traceable being there’s a you know primary key and secondary key and all those sorts of things. The one thing we lack in this country is a master patient index are unique primary patient identifiers. So it’s hard to be able to track Aaron across state lines, but I do believe with enough data elements that do coalesce together and say that you know, you get Social Security number right? You get it home address right?

56:32

You can create Only a master patient index. So to the degree of it. There is a role for AI there is definitely real for machine learning. We’re doing that now, but it’s take a lot more data and a lot more uniformity of data, which it goes back to my earlier comments around standards.

56:47

Great. Thanks. Alright, so Joe, I want to ask you a couple questions, you know, we haven’t talked a lot about the serological testing and the immunity if you could maybe touch on that ask about, you know, how receipts balancing the need for serological testing with ongoing constraints of appropriate numbers of diagnostic tests. And then we had an audience question around National immunity Registries being used. And is that something that that you can speak to?

57:20

Bye Joe. There you go. Yeah my do you hear me?

57:26

Can you hear me now? Sorry.

57:31

We can hear you Joe. Go ahead. Sorry.

57:36

So yeah, so community and serological testing is a critical test moving forward. It’s not as important in the immediate need of finding the curve but moving forward and understanding how wide spread the infection really is we can only do through serology, you know get it doing test to see if a person has elevated antibodies.

58:06

yesterday were exposed to covid-19 and and therefore it gives us a sense of how many people were exposed and therefore presumably how much protection there is, but the caveat is Is we don’t exactly know how well protection is and antibody response to is not the same as protection. So there may be antibodies that are there that actually say that oh, yes, you were exposed doesn’t necessarily mean it doesn’t tell you how strong that protection is or what protection there is and we don’t actually know a lot about this virus right now. As far as how much protection will give and how long that protection will last week.

58:53

I know a fair amount about other covid coronavirus has that are endemic in the u.s. That gives the common cold. We do only we do know that they’re there is that Comfort immunity but we’d actually don’t know exactly what that means with this virus. We want to be a little careful. You mentioned the National Registry.

59:17

I think that that that that may be a little premature because we’re Then jumping the gun on exactly how protected somebody really is protection can be anything from complete to partial. And so especially somebody that’s a higher risk.

59:34

We don’t want to make that assumption that there’s complete protection before we actually know I think in the long run, it’s just viruses were, you know, operates like all the many other viruses that are similar to it, you know that protection and that heard a minute Unity will build we just don’t know how long I will take it will take repeated infections. And so there’s a lot of uncertainty with this right. Now. The power of the tool is really to tell us how wide spread the infection has been and we’ve got to learn a lot more about the degree that is actually protecting.

1:00:14

Great. Thanks. Alright Jim. I want to ask you the last question is or the last minute that we have left. You know, we have heard so much about the role of Public Health. I think everyone is quickly getting up to speed on key Public Health terms, but we know that it’s usually sort of not in the spotlight as long as things are going. Well. Do you think that that everything is happening right now as far as the the response to covid is going to help to shore up the public health infrastructure for the longer term.

1:00:44

Unfortunately, looking down the road at potential, you know future public health issues just speak a little bit to the public health infrastructure in this country and kind of what we’re learning.

1:00:53

And do you think do you think will be short of for the future as a result of this you both what that’s a great question and certainly want to close and I certainly hope so but I mean, there’s got to be a huge caveat to this, you know, every time you know, and I’ve been in this career this professional long time and every time we have a major event And there are Lessons Learned and we keep on saying we hope this is a wake-up call and what we’re finding is policymakers and funders respond to the emergency the day with emergency funding and over time that just wanes and the core capacity continues to erode. This is an historic event, you know going forward we will learn a lot. We will continue to be stronger for the next one heaven forbid as we’ve done.

1:01:43

Over the last 20 years, but what this is really meaning is all those other public health programs, you know, they’re going to be long-lasting clinical impact on our society and we can’t let that happen. I mean we’re you know, you everyone saw the news.

1:02:00

I mean, there are there are Public Health Department’s state it state government laying off professionals hospitals furloughing nurses at a time when only today but next month Five years from now. We need them more than ever on the job recognizing that the public health Workforce is basically a rodent by 25% you know since 2008 and not quite sure what’s you know, when the dust clears on this one we’re going to be so I’m hoping that basically it’s the biggest of all wake up calls.

1:02:33

There’s a there’s a more clear recognition that public health security is a matter of National Security and that we just can’t you know fight the last fight and be Be better prepared so that we could truly address the everyday everyday emergency the needs of society, but also these major events that are going to commune to come our way more frequently and more severely well. Thank you and will end on that note Jim blumenstock Erin Mary Jo Eisenberg. Thank you for joining us. Thank you to our audience for sticking with us today. You can take a look at all Health policy dot-org for the recording of This webinar.

1:03:13

Later this afternoon and please stay tuned for future announcements of covid-19 related webinars in our series. Thanks everybody. Hope you stay well. Stay safe wash your hands all that good stuff and have a good weekend.