Prepared for the DELVE Initiative by Genevie Fernandes, Devi Sridhar, Diva Fanian, Mariana Soto Pacheco

Citation

Genevie Fernandes, Devi Sridhar, Diva Fanian, Mariana Soto Pacheco (2020), A Review of International Approaches to Test, Trace, Isolate. DELVE Addendum TTI-TD4. Published 27 May 2020. Available from https://rs-delve.github.io/addenda/2020/05/27/a-review-of-international-approaches-to-tti.html.

BibTeX
@Misc{addenda/2020/05/27/a-review-of-international-approaches-to-tti, title = {A Review of International Approaches to Test, Trace, Isolate}, author = {Fernandes, Genevie and Sridhar, Devi and Fanian, Diva and Soto Pacheco, Mariana}, year = {2020}, publisher = {The Royal Society}, url = {https://rs-delve.github.io/addenda/2020/05/27/a-review-of-international-approaches-to-tti.html} }
Endnote
%0 Generic %T A Review of International Approaches to Test, Trace, Isolate %A Genevie Fernandes %A Devi Sridhar %A Diva Fanian %A Mariana Soto Pacheco %D 2020 %F addenda/2020/05/27/a-review-of-international-approaches-to-tti %I The Royal Society %U https://rs-delve.github.io/addenda/2020/05/27/a-review-of-international-approaches-to-tti.html
RIS
TY - GEN TI - A Review of International Approaches to Test, Trace, Isolate AU - Genevie Fernandes AU - Devi Sridhar AU - Diva Fanian AU - Mariana Soto Pacheco DA - 2020/05/27 ID - addenda/2020/05/27/a-review-of-international-approaches-to-tti PB - The Royal Society UR - https://rs-delve.github.io/addenda/2020/05/27/a-review-of-international-approaches-to-tti.html ER -
APA
Fernandes, G., Sridhar, D., Fanian, D. & Soto Pacheco, M.. (2020). A Review of International Approaches to Test, Trace, Isolate. Available from https://rs-delve.github.io/addenda/2020/05/27/a-review-of-international-approaches-to-tti.html.

TTI strategies have been developed by countries across the world, including Germany, South Korea, Taiwan, Singapore, New Zealand and Iceland, as part of their efforts to lower the number of COVID-19 cases and minimise related deaths. A review of these international approaches around this strategy offers insights for the UK.

  1. Each of these countries initiated this strategy as soon as the first COVID-19 cases were reported and have been consistently implementing it, with the three components of testing, contact tracing and isolation being implemented in tandem.

  2. Each of these countries have an expanded testing criteria in place. All countries use polymerase chain reaction (PCR) tests for symptomatic cases, high risk individuals, and health workers. South Korea, New Zealand and Iceland have gone a step further by introducing mass testing for individuals at the community level regardless of symptoms. Germany and Iceland have also started conducting antibody testing. One area that needs to be further investigated is the consideration of repeat testing, especially for health workers as they have repeated risk of exposure.

  3. Random community testing and antibody tests are being used to inform countries’ future steps such as plans to exit from lockdowns.

  4. All these countries offer testing across traditional healthcare settings (clinics and hospitals) as well as novel locations (drive through centres, walk-through centres, mobile sites outside supermarkets).

  5. These countries have managed contact tracing through a combination of physical teams (consisting of multisectoral public staff), big data analytics and mobile-based applications. Four countries (South Korea, Singapore, New Zealand and Iceland) initiate contact tracing after a confirmed positive test results; whereas in Taiwan, this process begins even within a suspected case. South Korea, for instance, leverages technology to aid its contact tracing efforts. The government has an ICT system that automatically integrates GPS data, credit card information and CCTV footage to create a moving history (transmission route) for the confirmed case in a span of 10 minutes. This data is verified by patient interviews, contacts are then identified and sent automated text messages on the same day. The transmission route of the confirmed patients (anonymised) is also uploaded on government websites, so that citizens can avoid these places to reduce the risk of transmission.

  6. The total time for TTI (i.e. from testing, tracing and tracking contacts to instructing contacts to isolate) is around 2 to 3 days in South Korea, Singapore, Taiwan, and New Zealand. Test results in these four countries are available in 4 to 5 hours.

  7. While digital applications can aid contact tracing teams, they can also raise privacy concerns, for example relating to the risk of personal data being repurposed for causes other than outbreak control, and concerns about location and duration of storage of personal data. Iceland has tried to address these privacy concerns before launching their contact tracing application, by gaining certification by an independent reviewer, making it voluntary for users to download the application and agree to share GPS information, and storing anonymised data on the user’s device.

  8. In all the six countries, close contacts, once identified, must self-isolate for 14 days and seek testing on displaying any symptoms. Approaches to ensure isolation and quarantine measures vary across countries. While Germany, New Zealand and Iceland have recommended isolation for certain individuals, South Korea, Taiwan and Singapore have made quarantine mandatory and enforce it through the use of smartphone applications and fines.

  9. Countries made use of existing national capabilities in implementing this strategy. Germany and South Korea used their robust biotechnology industry and laboratory networks and Iceland employed a public-private partnership to ramp up testing. Singapore and Taiwan used big data and multisectoral response teams.

  10. A range of challenges implementing TTI have already been reported, including staff fatigue (especially frontline and laboratory staff), logistical hurdles of sourcing testing materials, privacy concerns over smart phone applications, and public adherence to social distancing and isolation guidance.

The tables that follow give an overview of approaches to TTI in Germany, South Korea, Taiwan, Singapore, New Zealand and Iceland.

Germany

Total population 82.79 million
Date of first reported case of COVID-191 25 February 2020

Epidemiological situation2

Confirmed 174,478
Deaths 7,884
Recovered 150,000

Testing3 4 5 6 7 8

Who gets tested?

Initially, those with symptoms, travel history and close contact with confirmed cases were tested. Since 25 March 2020, the testing criteria has been relaxed to include anyone who has symptoms including healthcare workers.

What kind of tests are being used?

Real-time PCR assay is being used. Germany developed its first rapid PCR test on 16 January. Since February, a nationwide network set up between doctors’ practices, normally used to monitor the flu, is being used for testing for COVID-19. Labs are also using pooled testing procedures that produce reliable results in short times, thereby increasing the overall testing capacity. Antibody testing is also being conducted, drawing from blood donation services, samples from regions with large outbreaks and representative samples from the broader population.

Where are tests conducted?

  • Healthcare facilities
  • Drive-through testing centres

What is the daily testing capacity?

As of May 11, a total of 3,147,771 tests have been conducted. Daily testing capacity as of 21 April was reported at 1,20,000 tests a day. Tests per million: 37,857.

Contact tracing 9 10 11

Under Germany’s contact tracing policy, implemented as soon as first cases were recorded, every person who has come into contact with an infected patient in the last two weeks is tracked and tested. Public contact tracing teams use phone calls to trace and monitor close contacts. Contact tracing teams will soon be assisted with Germany’s home-grown smartphone app, developed for the Robert Koch Institute, to trace infections. Further, mobile carriers in Germany have started to share cell phone location data with health officials in an aggregated, anonymized format. On 21 March, the German health ministry also drafted changes to the Infection Protection Act to allow, among other things, the tracking of people who were in contact with those infected with the coronavirus.

North-Rhine Westphalia, the country’s largest state and one of the worst affected by the coronavirus outbreak, currently has 3,385 people employed in contact tracing. The federal government announced that each state was expected to have at least one team of 5 contact tracers for every 20,000 people, and 11 of 16 states have met this target. The federal government has recruited 362 containment scouts (plus 130 are being trained) to operate alongside contact tracers in about 400 local health authorities spread across the country.

Isolation12 13

Since late February, self-isolation for 14 days on becoming symptomatic or having close contacts with confirmed or suspected cases is a recommended measure. Visits and events in nursing homes are cancelled in an effort to isolate and shield the over 800,000 seniors who live in around 11,700 facilities across the country.

Facilitators14 15

Early response, strong biotechnology industry and laboratory testing capacity, decentralised diagnostic system have been the major facilitators for Germany’s test, trace and isolate strategy for COVID-19.

Challenges16 17

Regional bodies have reported bottlenecks such as the struggle to recruit additional staff to deal with increased workload and backlog as well as coordinating with the limited number of global suppliers for testing materials. Privacy concerns have been raised around mobile-based applications, particularly on the location of the data storage viz. government hosted central servers versus decentralised on user phones, with the latter being recommended by privacy experts.

South Korea

Total population18 51.47 million
Date of first reported case of COVID-1919 20 January 2020

Epidemiological situation20

Confirmed 11,018
Deaths 260

Testing21

Who gets tested?

Mass testing began in February regardless of symptoms or travel history. Test results are delivered between 24 to 72 hours, via text messages or phone calls along with corresponding advice. Around 20% of all those who tested positive were found to be asymptomatic.

What kind of tests are being used?

Real-time PCR assay is being used. As of 15 April 2020, five diagnostic reagent companies (Companies KogeneBiotech, Seegene, Solgent, SD Biosensor, and Biosewoom) have obtained emergency use approval from the Korean Center for Disease Control and are producing RT-PCR reagents in the country.

Where are tests conducted?

  • Primary health clinics and hospitals

  • Public health and environment research institutes

  • Private healthcare providers

  • Drive-through testing centres

  • Walk-through testing centres

What is the daily testing capacity?

As of 15 May 2020, 726,747 tests have been conducted, leading to nearly 11,000 tests per million.22 Daily testing capacity increased from 200 in January to 20,000 in March. Tests per million: 14,05523 24

Contact tracing25

Korean public health authorities, national police agency, financial services commission, and local governments collaborated for contact tracing through interviews, analysis of closed-circuit television, credit card and smartphone GPS data, and publicizing the moving histories of anonymised COVID-19 patients on the Ministry of Health website (all measures are legally sanctioned by the government).The effective contact tracing system, known as the COVID-19 Smart Management System, is run by the Korean Centers for Disease Control and Prevention and can analyse a person’s movements in just 10 minutes. This moving history (i.e. transmission route) of the confirmed case is verified with the patient interview and then contacts are identified and notified through automated text messages.

Isolation 26 27 28 29

South Korea uses a combination of local teams, mobile-based applications and fines to ensure mandatory 14-day quarantine for asymptomatic cases, those with minimal symptoms, close contacts of confirmed cases, as well as those who have tested negative.

The primary case is classified based on the severity (mild, moderate, severe and extremely severe). Mild cases are isolated at local specialised clinics called ‘living and treatment support centres. Moderate, severe and extremely severe are hospitalised at national infectious disease hospitals and hospitals that were designated specifically for this at each location.

The government-endorsed Corona 100m (Co100) application, launched on February 11, using government data, alerts users when they come within 100 metres of a location visited by a confirmed case. Another government GPS-based application named ‘self-quarantine safety protection’ launched on March 7, enforces self-quarantine measures. South Koreans are encouraged to download this application after getting tested. If they are advised to self-quarantine based on test results, then they have to input their symptoms into the mobile application twice a day for the period of the quarantine, and the application will monitor their locations and set off an alarm if they leave their designated quarantine location. For those who do not use the application, a local monitoring team calls twice daily to make sure the quarantined stay put and check for symptoms. Citizens and international visitors are also encouraged to use a government-based self-diagnosis mobile application, launched on February 12, allows users to monitor health conditions and access readily available information on follow-up actions such as physical check-ups, using helplines and finding clinics.

Quarantine violators face up to 3 million won ($2500) fines. If a recent bill becomes law, the fine will go up to 10 million won and as much as a year in jail.

Facilitators30

Preparedness, early response, government leadership and transparent communication, and innovations have been the key facilitators for ensuring that the test, trace and isolate strategy works. Following the 2015 MERS outbreak, the government invested in its research and development for PCR testing kits, creating financial incentive for competition among private biomedical companies to develop rapid diagnostic tools. In the last week of January 2020, South Korean health officials convened a meeting with representatives from more than 20 medical companies on developing rapid testing kits, and by early February, two companies received approval for PCR tests. Transparent government communication has been demonstrated by daily press briefings and emergency texts to all citizens. Innovations including drive-through and walk-in test centres have speeded up the testing and have been adopted around the world.

Challenges31 32 33

Challenges have included privacy concerns owing to publicising people’s movements, health worker fatigue, unintended negative economic consequences on businesses as people avoid places that have been visited by confirmed or suspected cases, and hardships for vulnerable groups due to mandatory quarantine.

Taiwan

Total population 23.78 million
Date of first reported case of COVID-1934 21 January 2020

Epidemiological situation35

Confirmed 440
Deaths 7
Recovered 383

Testing36 37 38 39 40

Who gets tested?

Targeted testing for symptomatic individuals with travel history, close contact with suspected or confirmed cases, and vulnerable individuals including patients with severe respiratory symptoms and healthcare workers with pneumonia. Most recently, any patients who report a loss of the sense of smell or taste are mandated to be tested.

What kind of tests are being used?

PCR tests began in January. In early March, Taiwanese genome researchers developed a rapid COVID-19 diagnostic test, which reduces time to test from the current 4 hours to 15 minutes. With funding from Taiwan, in early April, Taiwan and Denmark jointly developed ViroTrack, a diagnostic test that can produce a result within 12 minutes, indicating whether the person is carrying the virus or has recovered from a COVID-19 infection.

Where are tests conducted?

  • Taiwan Centers for Disease Control
  • Designated hospitals

What is the daily testing capacity?

As of May 15,2020, 68,659 tests have been conducted. Daily testing capacity for COVID-19 is approximately 1,300 samples. Tests per million: 2909.

Contact tracing41 42

Taiwan’s contact tracing teams are heavily aided by big data analytics. The country leveraged its digital national health insurance database and integrated it with its immigration and customs database to generate real-time alerts during a clinical visit based on travel history and clinical symptoms to aid case identification. The government also creates real-time digital updates alerting citizens to avoid locations where infections had been detected. Once confirmed cases are identified, close contacts are traced, and then digital fencing is utilised to ensure mandatory quarantines. The example of case 19 indicates that from the active tracing of this person [a sweep of cases that showed influenza symptoms but tested negative for influenza] to tracing and testing their close contacts (mostly family members) 48-72 hours transpired.

Isolation43

The government enforces a mandatory 14-day home quarantine through a mobile-based location-tracking application that essentially geofences those at high risk (travellers from high risk areas, close contacts of suspected or confirmed cases). Home quarantines are monitored by the police and flouting these rules can result in heavy fines.

Facilitators44 45

Taiwan effectively delayed and contained community transmission as a result of its preparedness owing to the SARS outbreak (including outbreak simulations), early and multisectoral response, transparent communication, big data analytics, and digital tracking. Public acceptance of its protective policies has been influenced by the SARS experience.

Challenges

Taiwan will have to expand its testing criteria as community transmission spreads. Concerns have been raised regarding the digital tracking of those under quarantine as well as the heavy fines imposed. Finally, it is unclear if the current intensive nature of Taiwan’s response can be maintained until the end of the epidemic.

Singapore

Total population 5.6 million
Date of first reported case of COVID-1946 23 January 2020

Epidemiological situation

Confirmed 26,098
Deaths 21
Recovered 5973

Testing47 48 49

Who gets tested?

Any individual (citizens, migrants, visitors) who are symptomatic, or have been in contact with a confirmed case, or are at high-risk including healthcare workers and those with pneumonia regardless of symptoms.

What kind of tests are being used?

PCR test. Singapore developed its first rapid diagnostic test in early February and since March, ten companies have received provisional government authorisation for COVID-19 tests that can be supplied to healthcare institutions, private hospitals, medical clinics and clinical laboratories.

Where are tests conducted?

  • Public hospitals
  • Public Health Preparedness Clinics (GPs)

What is the daily testing capacity?

As of May 10, Singapore has tested 224,262 individuals, which accounts to 39,319 tests per million.

Contact tracing50 51

Public health staff have been working in partnership with police and detectives from the Criminal Investigation Department, in teams of 10, for 7 days a week, to trace, test and isolate contacts of patients with COVID-19. These teams have been using interviews, CCTV analysis, and the recently launched government mobile application ‘Trace Together’ for contact tracing. The government encourages the public to download this application on their mobile phones, which then uses Bluetooth technology to track and identify close contacts of a patient with COVID-19, including timestamps. Individual patients can choose to allow the Ministry of Health to access the data in the application to identify close contacts.

Isolation52 53

Since 27 January, people returning to Singapore from hot zones (countries with widespread community transmission) were given a ‘leave of absence’, where they don’t go to work but can leave their homes for meals and necessities. From 28 January, suspected carriers are being given a ‘quarantine order’ (QO) and have to be isolated at home or a government facility. On 18 February, the government announced the ‘stay at home notice’ (SHN), wherein all Singaporeans have to stay at home for 14 days and can leave their residence to purchase daily necessities and attend to important personal matters. Those who flout SHN or the QO may face penalties and can be prosecuted under Section 21A of the Infectious Disease Act. Singaporeans can also calculate the number of days of social distancing based on their arrival in the country, using a government-based website.

Facilitators

Multisectoral task force, early response, targeted testing and rigorous contact tracing, and timely and transparent communication have served as facilitators.

Challenges54 55

It appears that Singapore was slow to test in the crowded dormitories leading to a large cluster of cases among migrant populations. Government enforced social distancing is difficult to follow in such crowded settings. More than half of the 43 registered dormitories have reported active viral clusters. The government has now responded by placing medical teams within the dormitories and enforcing quarantines.

New Zealand

Total population 4.88 million
Date of first reported case of COVID-19 28 February 2020

Epidemiological situation56

Confirmed 1498
Deaths 21
Recovered 1421

Testing57 58

Who gets tested?

Any individual with symptoms can be tested, including health workers and those at high risk. Random community testing started in April.

What kind of tests are being used?

PCR tests.

Where are tests conducted?

  • Public health facilities
  • Mobile clinics (set up for community testing in settings such as supermarkets and car parks)

What is the daily testing capacity?

As of 13 May 2020, there have been 209,613 tests completed in total. Tests per million: 42,061

Contact tracing59 60

New Zealand has 12 public health units (PHU) that manage health services for clusters of its districts. Contact tracing is conducted by each PHU, which is supported by the centralised ‘National close contact service’ (NCCS) hub that sits within the Ministry of Health and has been operational since 24 March. PHUs continue to receive notifications of new confirmed or probable cases from laboratories and clinicians. PHUs experiencing heavy workloads can choose to divert parts of the workflow to the NCCS. PHUs inform the case of their result, arrange their home-isolation and identify close contacts.

Close contacts who live with the index case are managed by the PHU. Other contacts can be transferred to the NCCS for tracing. These lists of close contacts, which take various forms, are forwarded to the NCCS either via entry into REDCap (an existing web-based database used by some Public Health Units), secure file transfer, or email. The NCCS has developed a ‘finding service’ that seeks contact information from various health and other government datasets. NCCS staff call close contacts and advise they are contacts of a COVID-19 case and obtain the contacts’ agreement to quarantine (commonly called self-isolation). As of April, contact tracing application is in the process of being developed.

Isolation61

Apart from self-isolation for close contacts of suspected or confirmed cases, on March 23, New Zealand imposed a lockdown requiring all citizens except essential workers to stay home at all times, unless they are accessing vital services or walking for exercise.

Facilitators62

Strong government leadership, early and coordinated government response, transparent and empathetic communication have been the major facilitators for ensuring New Zealand’s test-trace-isolate strategy.

Challenges63

Logistical hurdles of sourcing kits and testing materials, challenges in contact tracing (to be offset by increased funding and staffing) and public breaches of lockdown measures have been reported as issues.

Iceland

Total population 364,164
Date of first reported case of COVID-1964 28 February 2020

Epidemiological situation

Confirmed 1802
Deaths 10
Recovered 1780

Testing65 66 67 68

Who gets tested?

Targeted testing of persons living in Iceland who are at high risk for infection (mainly those who are symptomatic, with travel history to risk areas, or had contact with infected persons) began on 31 January. This targeted approach is supplemented with mass population screening (initiated on 13 March) using two strategies: issuing an open invitation to 10,797 persons and sending random invitations to 2283 persons. Nearly 50% of positive cases are asymptomatic.

What kind of tests are being used?

PCR tests. Screening for antibodies started on 8 April 2020.

Where are tests conducted?

  • Symptomatic and those at high risk are tested at the national public hospital
  • Mass screening conducted in clinics by biopharma company deCODE genetics

What is the daily testing capacity?

As of May 13, 55,075 people have been tested. The daily testing capacity is 2600. Tests per million: 151,197.

Contact tracing69 70

Iceland’s contact tracing team is about 160 members strong and operates from part of a hotel in the capital. This team includes public health staff, police and experts in counter-terrorism and organised crime. All individuals who tested positive for COVID-19 are contacted by telephone by a team designated by the public health authorities to track their infection and contacts. All registered contacts are interviewed by telephone, asked about their symptoms, and requested to go into 2 weeks of quarantine. Those with symptoms and those in whom symptoms developed in quarantine are tested for COVID-19. Contact tracing teams are also aided by a government-backed mobile application that was launched on 1 April.

Isolation71

All individuals who test positive for COVID-19 are required to self-isolate until 10 days after fever had subsided or until they tested negative, and all contacts of these individuals are required to self-quarantine for 2 weeks. To protect the elderly and other groups who are at increased risk for serious illness, health authorities promoted self-isolation and banned visits to nursing homes and hospitals. Icelanders returning to the country must also go into quarantine.

Facilitators

Early response, public-private partnership for wide scale testing and transparent government communication have been the key facilitators for Iceland’s success in containing COVID-19.

Challenges72

Logistical issues such as a shortage of tests at certain points have acted as barriers for Iceland’s control and tracing efforts.

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