CommCare interface for contact tracing
CommCare is one of two leading systems that could help health officials monitor COVID-19 patients and people who may have been exposed to the disease.
Illustration: Dimagi
  • Public health officials are rushing to set up contact tracing to monitor everyone who may have been infected.
  • Health workers will need to monitor the health of thousands, or millions, of patients as part of that task.
  • Sara Alert and CommCare, two software systems, could help by automatically collecting data on symptoms. 

Your phone buzzes with a notification: Do you have a fever or a cough? Is it hard to breathe?

Some people who have signed up for pilot programs in San Francisco; Danbury, Conn.; and throughout Arkansas have recently started getting automated messages like these every day, and more of us may soon join them. The questions—which can appear in a text message, an email, or an automated phone call—are designed to help public health officials monitor people known to be at risk of contracting COVID-19 and those who already have it.

They’re coming from state and local health departments that are testing two new messaging systems in a race to collect the data they need to slow the spread of the pandemic.

Last week, San Francisco began using CommCare, a system developed by Boston-area software company Dimagi, to automatically ask patients about their symptoms. And on Monday, Arkansas deployed a similar system called Sara Alert, from Mitre, a research nonprofit funded by the federal government.

These trials may provide a glimpse at the coming new normal in the U.S., as the country tries to rein in the pandemic and restart the economy without causing massive new waves of infection.

Sara Alert interface for contact tracing
Sara Alert is being evaluated by health departments in Arkansas and elsewhere. To work, contact tracing systems require widespread testing for the coronavirus.
Illustration: Sara Alert

Several states are already allowing some businesses to reopen, and others will eventually follow. But once we all start to mix and mingle again, public health experts say people will need to be monitored at extraordinary levels for a long while—possibly years—to keep the coronavirus in check.

To do that effectively, experts say the country needs a massive commitment to contact tracing—a vital, longstanding tool for keeping pandemics in check.

Here’s how contact tracing typically works: Investigators ask anyone who tests positive for COVID-19 about the places they’ve gone and the people they’ve seen in the previous two weeks, when they were likely to be contagious. Then, the investigators try to get in touch with every person the patient may have come into contact with, advising those people to self-isolate and monitor themselves for disease symptoms.

More on COVID-19 and Technology

It’s messy and slow, with lots of phone calls and manual data entry. This means it requires a lot of people—but the U.S. is far short of the investigators it needs. 

The country will need to bring on about 100,000 more contact tracers (PDF) to keep up with the virus, according to a recent report from the Johns Hopkins Center for Health Security.

Just this week, New York Gov. Andrew Cuomo said his state needs to stand up a “tracing army” before people start going shopping or returning to work in droves, and he announced a joint plan with neighboring New Jersey and Connecticut to hire thousands of investigators. (Max Reiss, a spokesperson for Connecticut Gov. Ned Lamont, tells CR the three states have not settled on a contact-tracing technology.) Nearby, Massachusetts is planning to deploy at least 1,000 contact tracers.

As all these new contact tracers interview people who are sick or may have been exposed to the coronavirus, they will create a mountain of information—and every new patient can mean dozens of additional contacts to follow up with.

That’s where the new software platforms come in.

The idea is to automate a time-consuming part of contact tracing—case management, which requires regular check-ins with people who have tested positive for COVID-19, along with those who may have been exposed to it but haven’t been tested.

Arkansas has one of the largest health departments currently testing this type of software. When the state’s contact tracers—many of them public health students at the University of Arkansas—notify someone they’re at risk because they came near an infected person, the investigators offer to sign them up for Sara Alert.

If they agree, they begin getting the automated daily symptom checks. They can choose to get an email with a web link that takes them to an online form—or, if they’re in the 10 percent of Americans who don’t use the internet, they can respond to a text message or an automated phone call.

If a participant reports potential COVID symptoms, his file is automatically flagged for public health employees, who can follow up and suggest next steps.

Meanwhile, aggregated data about people’s symptoms and health status can be compiled into reports for public health agencies, helping them to make critical decisions about school or workplace closures and where to route disease testing resources.

Arkansas recently grew its contact-tracing team from about five to more than 150, says Jennifer Dillaha, the state epidemiologist—but it’s still short-staffed. She hopes Sara Alert will relieve some of the pressure. “If our people working on following new cases or following people on quarantine are not personally needing to contact everyone every day, it increases our capacity to contact additional new cases,” Dillaha tells CR.

“This is really very important to keeping our economy and our communities open,” she says. “As we work to revisit the limitations we have placed on businesses and activities in Arkansas, we need to make sure that if there is a resulting increase in spread that it’s quickly identified and brought under control.”

In addition to Arkansas, Sara Alert is being tested in Danbury, Conn., and the Northern Mariana Islands, a U.S. territory in the Pacific Ocean. Several other health departments—including in New York, Washington State, Florida, Massachusetts, and Pennsylvania—have asked Mitre for demonstrations of the system. 

Outside San Francisco, Dimagi’s CommCare is being used in Silicon Valley’s Santa Clara County, and the company is in discussions with Alaska, St. Joseph County in Indiana, and several other public health departments, according to CEO Jonathan Jackson.

If these systems are widely adopted, they could be a boon to the public health response to COVID-19. Taiwan, for example, was “able to mount a robust and effective response in part because of a nationalized health and data system that made it much easier to track travel and health symptoms,” says Jonathan Chen, a professor at Stanford University Medical Center who studies the use of data analysis in healthcare. “In the U.S., we’re totally fragmented, which makes it very hard to get integrated data for population-level decisions.” Centralizing some information could provide important data about large groups of people for policymakers.

Dimagi and Mitre are providing their software to interested health departments free of charge. (Dimagi’s CommCare, which has been used overseas with other diseases for years, can cost thousands of dollars per month; the company is asking public health departments to pay if they can afford it.) And when the COVID-19 crisis passes in the U.S., the systems can be repurposed for the next pandemic, the companies say. 

Contact tracing, after all, has been a bedrock of public health for decades, and will continue to be relevant once the coronavirus is no longer a crisis.

Putting the Pieces Together

Case management is just one of the two halves of contact tracing (PDF). The other is proximity tracking.

Proximity tracking can be conducted through traditional interviews or with technology like the program recently announced by Apple and Google. That system, which is supposed to start rolling out in May, would let you have your smartphone keep a temporary record of every other phone you linger near for a certain period of time.

If you eventually test positive for COVID-19, you can choose to hit a button that automatically notifies every other participant who came near you in the previous two weeks. And you’d get notified if you’d been near someone else who told the system about their own diagnosis.

This is where case management tools such as Sara Alert and CommCare can jump in to monitor people who may be infected.

The two kinds of contact tracing technology could talk to each other. Mitre and Dimagi are in discussions with Apple and Google about what it would take to integrate their software with the tech giants’ proximity tracing. In that scenario, people who are notified via the Apple-Google system that they may have been exposed to the virus would be given the option to sign up for Sara Alert or CommCare.

“If we relax social distancing, we’re going to have a rebound,” says Paul Jarris, Mitre’s chief medical advisor for health transformation and a former Vermont health commissioner. “We’ll need to quickly identify that [rebound], isolate people with symptoms, take their contacts and actively manage them on a daily basis. If there’s going to be a second wave, like the CDC says, we need to have a tool in place.”

CDC Director Robert Redfield told the Washington Post on Tuesday that a potential second spike of COVID-19 cases this winter could coincide with flu season, making it even more deadly than the current crisis.

Other Challenges Remain

Even as contact-tracing technology gains momentum across the country, several hurdles need to be overcome. The most fundamental problem is that COVID-19 testing is still extremely limited in the U.S. Without enough tests, contact tracing is far less powerful because it’s difficult to know who’s infected.

A second challenge is that any system would need to be widely adopted to be useful. Convincing the public to participate could require answering some difficult questions, like where sensitive health data is stored and how it might be reused later.

When it comes to privacy, how long agencies retain records and who can access them are critical questions, says Matthew Guariglia, a policy analyst at the Electronic Frontier Foundation. His organization is devoted to bolstering privacy protections for consumers, and is often skeptical of new kinds of data collection. But, Guariglia says, “of all the COVID-related scenarios I’ve seen this one is the least likely to make me lose sleep.”

Mitre and Dimagi say their systems emphasize consumer privacy and data security: Mitre sends people’s health status updates to a centralized database maintained by the Association of Public Health Laboratories, which already runs sensitive systems for labs across the country. Dimagi manages health data in its own database, and both companies say they don’t make money by using the data for marketing or any other purpose. In both cases, the information that public health departments upload remains the departments’ property. 

Public health agencies have long been custodians of private health information, and they have a good track record of protecting it and using it appropriately, says Dena Mendelsohn, director of health policy and data governance at Elektra Labs, a health technology startup, and a former CR senior policy counsel. “I don’t think we should have any more concern now than we did when public health agencies engaged in contact tracing in the past,” using old-fashioned tools, Mendelsohn tells CR.

The public health departments of San Francisco and Arkansas did not respond to questions about whether the data they are gathering for contact tracing could be reused for other purposes, such as research or law enforcement.

A final, near-term hitch is that public health departments are stretched so thin trying to contain the virus that they might not have the time, money, or staffing to evaluate and set up new systems, says Lori Freeman, CEO of the National Association of County and City Health Officials. “Introducing anything new to them at this point is really a crapshoot because they don’t have a lot of resources.”

Here, Sara Alert may have a head start. Since January, Mitre has been getting constant feedback from health departments about how they would use the system, and taking steps to make it easier and more useful. Arkansas, for example, asked for the system to be able to monitor current COVID-19 patients in addition to people who may have been infected—and Mitre promptly added that capability, Dillaha says.

CommCare isn’t being rolled out as broadly in the U.S. yet, but the company is well established in global health, and Dimagi says it has seen a lot of interest from public health officials.

Sara Alert and CommCare appear to be front-runners in the race to help health officials ramp up contact tracing with technology. Soon enough, you may be asked to enroll in one of them if it turns out you had a brush with a person infected with COVID-19—or if you test positive. In the coming months or years, the two contact tracing systems could become household names.

“For the foreseeable future, this is the new normal,” says Mitre’s Jarris. “This is part of our new experience.”


Correction: A previous version of this article misstated Paul Jarris's title. He is Mitre's chief medical advisor for health transformation, not its chief medical officer. It was originally published on April 23, 2020.