Author: Jennifer Gilbertson – Norwegian Red Cross
Do we really know the true scope and spread of COVID-19? Even the highest resourced settings are struggling to track the virus as it spreads and understand the implications on different communities. In the complex settings where the Red Cross Red Crescent Movement works, this challenge is further compounded by ongoing migration, rural communities disconnected from national reporting, and vulnerable groups who do not have access to testing and care.
In order to make meaningful decisions concerning resource allocation during COVID-19, public health tools which allow us to measure, understand, and plan around transmission can be a valuable input.
In rural communities, or where there is a lack of digital infrastructure, traditional surveillance systems are often ineffective in timely detection of outbreaks.
Community-based surveillance (CBS) is the systematic detection and reporting of events of public health significance within a community by community members, and an approach the RCRC movement has been exploring for several years.
In February 2020, the Norwegian Red Cross launched a new platform for CBS for epidemics/outbreaks called Nyss. Nyss (short video introduction) is the result of multiple volunteer codeathons, where over 250 volunteers from several countries contributed to the realization of the platform. Currently being used in Senegal and Somaliland, Nyss allows for real-time detection, reporting, aggregation, and analysis of community health risks. With the rapid spreading of COVID-19, the Nyss users quickly identified the potential value added of using CBS and Nyss to also detect potential cases of COVID-19 in the communities.
After COVID-19 began spreading outside of China, volunteers were quickly trained in the signs and symptoms of COVID-19 and how to report any potential cases to Nyss. Following this, Nyss was used to detect one of the first two cases in Somaliland (full story). Somaliland RCS shares more about this work on a recent IFRC talk.
Some of the features that enabled this success were:
- Strong support network between RC community health volunteers collecting data and their supervisors.
- System for monthly refresher trainings already in place.
- Simple technological infrastructure – volunteers report to Nyss by sending a simple, coded SMS from their feature phones, decreasing the barrier to usage.
- Collaboration between the health authorities and the National Society, which allowed alerts to feed into a fast response system.
- Volunteer literacy not needed to report data to Nyss.
What is next for this new platform? Nyss is intended to be the core CBS-tool within the Movement, and there is also increasing interest from outside actors.
Additional CBS resources can be found on RCRC Movement websites:
- Health Help Desk FAQ (CBS pages 8 – 11)
- CBS for COVID-19 Guide
- IFRC Community-based surveillance Assessment tool (12/2019)
- IFRC CBS Protocol Template (12/2019)
A sufficient supply of COVID-19 tests is still limited in most, if not all, countries. New ways of tracking the spread of the virus can help supplement testing efforts and answer open questions linked to COVID.
While self-reported symptoms are hardly a reliable indicator of actual COVID-19 spread, they can be a signal which can support researchers and public health professionals to understand unanswered questions. This includes how the disease clusters, high-risks areas, high-spread areas, symptoms in different populations, and the effect of different public health interventions.
The need for tracking and reporting on COVID has been identified by many companies and groups, which increases the risk of spreading data over multiple platforms and diluting its accuracy and impact. It also brings up important questions around data security. In the review of existing platforms and apps there are several tools which stand out.
COVID-19 Symptom Tracker app has been developed by King’s College London and health science company ZOE, and it is endorsed by the Welsh Government, NHS Wales, the Scottish Government and NHS Scotland. At the time of reporting, more than 2.5 million participants have downloaded the app and are using it to regularly report on their health. The app developers have updated the app to reach more elderly users by allowing multiple user profiles, so that family, friends or caregivers can log daily health reports on behalf of anyone who wishes to take part in the study but does not have access to a smartphone. The app is now being used in the USA in addition to the UK. All research findings coming out of the data are available on an open blog.
A similar app, How We Feel, is supported by the Bill & Melinda Gates Foundation among others. Something innovative and interesting about this app is that every time the app is downloaded, they will donate a meal through Feeding America. What makes this app stand out is the usability – It’s free, simple to set up, and requires very minimal data input. The design is meant to encourage daily interactions.
A slightly different model is being tested by the Danish Ministry of Health, where Danish citizens who sign up to C19.DK receive a daily text message which includes a simple health status survey. At the time of this article, only 32,531 citizens had signed up, as COVID-19 infections are currently on the decrease in Denmark. The software is open source (hosted on GitHub) and the developers are interested in spreading this technology to other interested countries.
A non-smartphone related platform, the ‘Covid Near You’ map, was developed by Boston Children’s Hospital and Harvard Medical School. On this website, community members can self-register whether they have had symptoms correlated with Covid-19 and whether they’ve had testing. The platform, which originally started in the US, has already expanded to Canada and Mexico.
For National Societies considering using or developing self-reporting apps in their community engagement, it is important to investigate whether local governments have already endorsed or created an app for this purpose. Many governments, such as Norway, India (who’s app is available for download in 11 languages), and Ghana, have already launched apps, and others, such as Australia and New Zealand, have repurposed previously existing platforms (FluTracking – an influenza monitoring app). The Ghanian app, developed by RedBird Health Tech, is planning to roll out to Nigeria, Kenya and South Africa.
Social distancing has been extremely difficult to maintain, sustain, and reinforce in many settings. We also have seen that many people are shedding viruses before they show symptoms and unintentionally infect those they encounter.
Since COVID-19 can be transmitted through contact with affected individuals, public health officials have identified contact tracing as a valuable tool to help contain its spread. The hope is that those who have come into contact with someone who has corona can self-isolate before infecting others. Compared to the self-reporting of symptoms, tools for contact tracing look at interactions and movement of people.
One of the first National Societies to actively incorporate contact tracing into their national response was the Austrian Red Cross. In collaboration with Accenture and the Austrian Government Crises Management Team, the team rapidly developed an launched an application called Stopp Corona (German; English). The Stopp Corona app contains a contact diary, where personal encounters are saved anonymously. If someone tests positive to COVID-19, or begins to show symptoms, all contacts from the past 54 hours will be notified (watch this video to see a 1-minute explanation of how the app works).
Since the launch of the app, several National Societies, from Germany to Australia and Namibia, have been in dialogue with the Austrian RCS in order to explore expanding the platform to their setting. The app has been downloaded over 250,000 times in Austria (population of 8 million) and they expect that number to increase significantly as the economy reopens. The app is available open source through GitHub.
Several things that make this solution stand out:
- It was developed and scaled within three weeks.
- It collects no personal data, other than a phone number.
- It has been audited to safeguard the security of users.
- If you report symptoms, you can schedule a RC volunteer to come to you house and conduct a COVID-19 test.
- The Austrian RCS has developed an information package for other NSs to scale this app.
Several National Societies in Europe have been in dialogue with Apple and Google to explore using their joint COVID-19 tracing tool. The Netherlands RC has also been looking to develop principles to help guide National Societies to decide if and how to engage responsibly in contact tracing for COVID-19.
The first phase of the project is an API (interface which allows software to communicate) that public health agencies can integrate into their own apps. The next phase is a system-level contact tracing system that will work across iOS and Android devices. The system will use Bluetooth to identify contacts over the past 14 days with whom you have spent a specific threshold of time and proximity with. If that data matches with someone who has self-reported a positive COVID test, you will be alerted to self-quarantine. One of the benefits of this project is having both Apple and Google onboard – Traditionally iOS and Android systems do not work well together, and fragmentation would decrease the effectiveness the of data. In this second phase, the user wouldn’t need to download in app – They could opt-in to their device being directly traced. More specifications can be found here.
While the solution being developed by Apple and Google has a large focus on data security, apps for contact tracing and apps containing health data need to have rigorous data protection. Countries outside of Europe, who are not protected by GDPR rules, should particularly review the risk-benefit analysis.
Many governments are looking to their local National Society to support on contact tracing efforts. One example of this is in Trinidad and Tobago. In early March, when the reports of COVID-19 spreading outside of China was starting to increase significantly, the Ministry of Health asked the Trinidad and Tobago RCS for support from their volunteers. Volunteers were deployed to follow up citizens who had recently returned from overseas travels and perform a manual contact tracing. After an interview with these quarantined individuals, volunteers would call all people who had had significant contact with the individual and share with them signs and symptoms of COVID. If any of these people had symptoms, the volunteers coordinate a referral for testing, schedule a surveillance nurse to visit them at their homes, and if needed schedule an ambulance to bring them to a hospital. A similar partnership was formed between the National Society and Ministry of Health in the Seychelles.
Mobility & Risk Reporting
In many of the countries where we work, complete country lockdown is impractical and often impossible. Understanding how certain populations are moving, whether that is within urban slums or rural IDP camps, can help us understand exposure in many of the settings we work. It can also help Movement actors see the impact of different public health and community engagement interventions. Many of us also see the risk of COVID-19 placing already vulnerable communities at a further risk, and being able to conduct risk scenario planning can help us better allocate resources.
Contact tracing focuses on the who, not the where. Mobility data is the opposite.
One of the easiest ways to track mobility is through platforms where people are already sharing their mobility, i.e. virtual maps. Tech giants, who have been collecting data of hundreds of millions of users for years, have been sharing that data as part of the COVID response.
Apple has been producing mobility trends (accessible for cities, countries, and regions) through using aggregated data collected from Apple Maps. Their new website currently offers mobility trends for 63 countries. Apple Maps generates the data by counting requests for directions. The data sets are then compared to reflect a change in volume of people driving, walking or taking public transit around the world. It is important to note that data availability in a particular city, country, or region is influenced by a number of factors (such as people using other navigation services). Google has produced a very similar website with mobility reports, except that their data is linked to users who have Location History enabled. Both providers offer free download of the data.
Facebook has been collaborating with the COVID-19 Mobility Data Network to contribute aggregated mobility data (the Facebook dashboard is currently displaying data for the United States only). They do offer additional tools specifically for nonprofits, including a Disease Prevention Map which shows population density, movement, and cellular connectivity. This tool can be used to look at trends on staying near home and general mobility patterns, including using the data to model different mobility scenarios and model to visualize overlapping risks, such as flood risk incidence.
A similar project within the Movement is being led by the Netherland’s 510 team. The team has created a COVID vulnerability index, where they have been feeding in data from multiple sources to compare COVID outbreak to overlapping vulnerability, such as a risk of a secondary natural disaster or higher incidence of non-communicable diseases. This data has been used nationally to predict distribution of resources and map out future COVID-19 scenarios. 510 is now looking to expand the work to additional National Societies in other parts of the world.