Positioning digital contact tracing applications in COVID-19 pandemic management (Preprint)

BACKGROUND To face the first wave of Covid19 pandemic, many European countries have instituted a strict lockdown coupled with PCR testing, which relevant decline in fatality [1]. Meanwhile, countries have developed a public health strategy with digital contact tracing (DCT) applications improving timely tracking and contact tracing [2,3]. Despite these measures, a second epidemic wave occurred in autumn, more rapid and higher than expected, leading to a second lockdown in many countries. France did not achieve its goal of less than 5000 infections a day by December 15th. In addition, its most vulnerable population has been subjected to greater virus exposure, stronger lockdown impact and less access to prevention and health care services. OBJECTIVE The France’s independent COVID-19 Control and Society Connection Council (CCL) has been established by law in May 2020 to issue advises and recommendations on the national epidemic digital systems. It is composed by 13 members, including representatives from Parliament and civil society, jurists and academics (Appendix). The CCL has considered that national “Teste, Trace and Isolate” strategy needed consistency: testing without effective tracing and efficient isolation of positive cases does not make sense. METHODS Mobile phone applications (apps) for contact tracing and information on public health policy has been developed in Europe (Table 1). These apps should respond to scientifically valid and time-bound ethical guidelines. Insufficient privacy protection could erode trust in the government and public-health services [4,5]. Unfortunately, adoption of these apps is below expectations [6]; real adoption is high in Finland (45%) and limited elsewhere (24% in Ireland, 21% in Switzerland, 19% in Germany and 13% in Italy [7]). French DCT app “StopCovid” was notably based on the Bluetooth exposure notification. Conceived as silent app, it has then been replaced by a conversational one renamed “TousAntiCovid” on Oct 22, 2020. Among 66 million inhabitants, only 1.5 million (2.3%) had downloaded “StopCovid” and, on January 19th, 2021, 12.5 million (19%) “TousAntiCovid” app. Moreover, positive declarations are weak (99 967) such as notifications of a contact (54 366). The poor result of “StopCovid” stemmed from lack of attractiveness and prevention information, from a fear of insufficient privacy protection, from Bluetooth bugs and from the incompatibility of the apps with older smartphones. RESULTS To solve these issues, the CCL had recommended to introduce in “TousAntiCovid” app increased communication about the tool’s individual and collective objectives. The CCL has also recommended the introduction of clear, simple, accessible, incentivising, non-coercive information inside the tool. Indeed, messages aimed at emphasizing risk are less effective than those encouraging self and collective efficacy [8]. Moreover, to stimulate the uptake of DCT apps should enhance perceived benefits [9]. In addition, the CCL recommended improving public health policies to address the needs of socially disfavoured [10]. It bears mentioning that apps are effective only if users are comfortable with digital tool; yet technical problems are among the main reasons for failure to download [11]. On the other hand, Covid-19 accelerated digital health uptake: 49% of French people used their first health digital tool during the first lockdown, yet 14 million French people (28% of French population) have remained exterior to the digital universe, and among them, 16% never connect to internet [12]. In Europe and France, apps progress to incorporate isolation module. Their development should be aimed at measuring isolation prescription and adherence. Apps could help families to stay connected, and to maintain link to resources that support their physical and mental well-being [13]. Despite contrasted strategies of lockdown – either strict and/or coupled with testing capacity in Germany, Italy and Spain or incomplete, and not coupled with an extensive diagnostic PCR testing in Sweden, France and UK – no dramatic difference in the second epidemic wave magnitude is observed among these countries (Table 1). For people with positive test results, the strategy includes 7-day-isolation in most countries [14]. Among European policies of isolation, either strict and instituted by national regulations with severe fines or based on incentives, the CCL recommends an intermediate position with national guidelines accompanied with strong incentive supports, to ensure good adhesion from the population and avoid weaken the facets “testing and contact tracing” of the national strategy. However, apps will not resolve by themselves the problem of isolation non-adherence, particularly among persons who are outside the healthcare system. The CCL recommends adaptations of the informational process for these persons. As regards those for whom pragmatic isolation is difficult, because of home overcrowding, family composition or work needs, the CCL recommends a prosocial approach with community officers to ensure that sufficient supplies (essentials such as food, medication and children care) are provided [15]. CONCLUSIONS To conclude, the CCL calls for developing population empowerment with digital tools, public health culture for decision-makers dealing with health determinants, emphasis placed on social considerations into account, and incorporation of community participation [16].