Retrospective Contact Tracing: How States Can Investigate Covid-19 Clusters

Margaret Ellis Bourdeaux M.D.: Welcome everyone. Margaret Ellis Bourdeaux M.D.: I am thrilled to go ahead and start. So welcome, everyone. This is our to the seminar on retrospective contact tracing Margaret Ellis Bourdeaux M.D.: Co hosted by the Berkman climb center on the internet and society Harvard Medical Schools Program and global public policy, the National Governors Association and Partners in Health Margaret Ellis Bourdeaux M.D.: I’m Dr. Margaret Bordeaux, and the research director of the program and global public policy at Harvard Medical School. Margaret Ellis Bourdeaux M.D.: And I co chair the Brooklyn Klein center digital pandemic response I am thrilled to welcome all of you to our first seminar and what I hope will be a series that focuses on practitioners and implementation of the code response. Margaret Ellis Bourdeaux M.D.: Okay. I’d like to welcome with today Dr Hitoshi should tiny who’s a member of Japan’s novel kind of virus disease control subcommittee. Margaret Ellis Bourdeaux M.D.

his pioneering work has helped to develop the retrospective tracing methodology, he will present today on this methodology, how it was developed and how it is being implemented him in Japan. I think that before I turn it over to him. I should note that we are really Margaret Ellis Bourdeaux M.D.: Happy to have him here because, as I think many listeners know we are in a very difficult position here in the United States when it comes to the code epidemic. We yesterday had more cases reported in the country. Margaret Ellis Bourdeaux M.D.: I think overall, if not at least since its first peak in in April and we are at a moment where we really need to think about Margaret Ellis Bourdeaux M.D.

What we’re going to do over the next couple of months. So I’ve always maintained and and i know Berkman climb center and Harvard Medical School has always maintained that we are not helpless before Margaret Ellis Bourdeaux M.D.: This this epidemic that there are things that we can do and public health strategies that we can develop and implement and that will leave us in a much, much better place. Margaret Ellis Bourdeaux M.D.: And so many of you have heard me talk about sort of the three legged stool approach to the public health response. Margaret Ellis Bourdeaux M.D.: With one leg being these environmental modifications that we can make ventilation air filtration in our buildings to make transmission less likely Margaret Ellis Bourdeaux M.D.

The public and the other leg being the public health population based strategies of asking people to adopt behaviors that will protect them like mask wearing are wearing P P and appropriate contexts. And then the third leg of contact tracing, which is where you try to interrupt. Margaret Ellis Bourdeaux M.D.: Individual chains of transmission to decrease Margaret Ellis Bourdeaux M.D.: For a transmission. But the thing we haven’t talked about so much is the seat of that stool of that three legged stool, which is really health intelligence and how you understand Margaret Ellis Bourdeaux M.D.: The epidemic, where it is spreading how it is spreading so that you can refine each of those three legs of the stool. Margaret Ellis Bourdeaux M.D.

And in some sense retrospective contact tracing is one approach to helping build more robust health intelligence in the during the epidemic and not only helping you with your basic contact tracing approach as well. So without further ado, I’ll turn it over to Dr. O’Shea, Tommy. Dr. Hitoshi Oshitani: Thank you, Margaret for kind interest deduction. It’s my great pleasure to be at this seminar to share our experience in Japan. I’m going to share the mice ride. Dr. Hitoshi Oshitani: I hope you can see the mice, right. So I’m going to talk about the the cluster based approach in Japan. The with the focusing on Dr. Hitoshi Oshitani: Retrospective contract tracing Dr. Hitoshi Oshitani: So the these are the findings of in Japan. Dr. Hitoshi Oshitani: Among cross contact the we had a very low. The positive rate 1.1 point 3% you know already cases, the RD. The cross contact and similar finding the world obtained in China and also the, the, the, the chain of transmission patterns were analyzing the Dr. Hitoshi Oshitani: berry berry the cluster. The in February in Japan. The which showed that the one the individual infected many others, and the many other infected individual did not pass the virus to anybody else.

That was the these are the are you finding and 05:22 - Dr. Hitoshi Oshitani: Also, the doctor Nishimura Hiroshi Nishimura the had some preliminary data which suggested that Dr. Hitoshi Oshitani: The majority of the infected the individual. The did not pass the virus to anybody else. And the small proportion of the infected the person, the infected many others. And this over dispersion characteristics of Dr. Hitoshi Oshitani: Was also the shown in other countries. The other places like Hong Kong and Dr. Hitoshi Oshitani: So that was a basis of our cluster based approach. And if there is no the the the cluster was super spreading event. Dr. Hitoshi Oshitani: The, the, no, there is no sustained outbreak, but the only fine the chain of cluster is established. That’s the time that the situation where the we can we have sustained outbreak of Dr.

Hitoshi Oshitani: And the prospect of contact tracing are the the need done like this and if you do find confirmed cases that you identify the contact and among contact the 06:52 - Dr. Hitoshi Oshitani: You are trying to identify the cases capital 19 positive cases but doesn’t mention the positive rate is quite role. Dr. Hitoshi Oshitani: And probably the one over to contact the maybe the identified by the prospect contact tracing, but the know the cluster that can be found the by identifying that 10 or so the confirmed cases, you need to find many more. The confirmed cases to identify the clusters and Dr. Hitoshi Oshitani: The also the another the tricky part of this virus. The Clinton is the invisible. Invisible nature of this virus.

The four stars, the majority of infected individual developed 07:52 - Dr. Hitoshi Oshitani: very severe than pneumonia viral pneumonia. That’s why we could identify the almost all chains of transmissions and we managed to interrupt the old chains of transmission and Dr. Hitoshi Oshitani: But before cubby to 19. There are many mild cases or even a symptomatic cases and which makes this virus, the more difficult to identify. Dr. Hitoshi Oshitani: And this invisible nature is another challenge for Corrigan 19 and also there is a significant difference Dr.

Hitoshi Oshitani: Between Colby can 19 and the sauce in terms of infectivity for sauce. Only the, the, the, when the patient, they were up very severe symptoms. That’s when the they had infectivity but for Dr. Hitoshi Oshitani: The peak of infectivity is believed to be the before the onset of the illness. So this also makes this virus more difficult to control. Dr. Hitoshi Oshitani: And the in net respective contact tracing if when we find the one confirmed cases, the we try to identify the source of infection. Dr. Hitoshi Oshitani: The as I mentioned there. If there is no crust or super spreading event that they’re using is no sustained the the Dr. Hitoshi Oshitani: chain of transmission. So there must be the cluster somewhere they around the that each case. So we try to identify the source of infection. Dr. Hitoshi Oshitani: The breach. Some day in many cases the which is a cluster or the associated with cluster. So this is a literal speaker contract Tracy Dr. Hitoshi Oshitani: So in Japan.

Now we also doing a prospect contract racing, but we are more focusing on metal SPECT contact racing which identify the common source of infection there. Dr. Hitoshi Oshitani: And the contact racing in Japan. The is mainly done by the public helps NASA’s there are the over the 460 public health centers all over Japan. Dr. Hitoshi Oshitani: And there are more than 28,000 the officers stationed in these public health centers equaling the more than eight songs and publishers NASA’s Dr. Hitoshi Oshitani: And these publications NASA’s mainly in charge of the contract racing and the retrospective contact racing has been done the ads their routine work. Dr. Hitoshi Oshitani: For investigation of the, particularly the tuberculosis cases, as you probably know, we are still having many Dr. Hitoshi Oshitani: Cases in Japan. What TV.

The identifying the source of infection is very important. So that’s why they are used to the these the literal literal respective contact racing. Dr. Hitoshi Oshitani: And actually the from the beginning they being the political analysis, there have been doing the these retrospect to contract pressing them. Dr. Hitoshi Oshitani: And then this is a the diagram for the our contract to Tracy, the in addition to the Dr. Hitoshi Oshitani: The to identify the secondary cases from the confirmed cases that we try to identify the source of infection by asking their activities in the past 14 days. Dr.

Hitoshi Oshitani: And probably 14 days is too long and in most cases that we identify the source. The within the the five or seven days before the onset, but in some cases the the Dr. Hitoshi Oshitani: That we identify the source the nine or 11 days before the onset and metaphor. Many cases that we identified the source. The, the three to five days that before the onset. Dr. Hitoshi Oshitani: And then by doing this approach, the, the, the one the who’s active of this approach there is to interrupt the chain of chain of clusters. Dr. Hitoshi Oshitani: And now it is a usually the point we identify the super speaking event.

The there there there are some the secondary transmission from the cluster, but 12:47 - Dr. Hitoshi Oshitani: We still can the interrupt the chain of transmission. The from the cluster. Dr. Hitoshi Oshitani: And we also that try to identify common characteristics of clusters. The we have identified the many clusters in Japan. And so these are the most important common characteristics, all of the clusters. The cross space crowded places and the cross contact settings. And so these Dr.

Hitoshi Oshitani: Now known as a son meeting Japanese and the Wall Street is in English and they even the primary school kids that know about this concept and the public was they asked to avoid the these the risky, the environment that to reduce the number of the clusters. Dr. Hitoshi Oshitani: And the father honest McMasters the identify the some additional risk factors such as the exercises talking in now the boys, the singing and also the night Dr settings and Dr. Hitoshi Oshitani: Also the the day we identify the who were right carried through directly to transmit the virus to the others. So these are the Dr. Hitoshi Oshitani: Characteristics of the primary cases of the cluster. The primary cases that tend to be young in 20s and 30s and the although the, the, the average, the age of the other case total cases, the war much the older so they are probably the a Dr. Hitoshi Oshitani: The more infectious.

The because they are more active and the majority of primary cases and more than 40% of the primary cases there were that pre-symptomatic faces. Dr. Hitoshi Oshitani: And the we analyzing the more cases in Japan. Dr. Hitoshi Oshitani: And over the seven teen Southern cases have been the unauthorized and the pattern is to exactly the same. The, the more than the three quarter of the cases the Dr. Hitoshi Oshitani: Did not pass the virus to anybody else. And, but the small proportion of the infected the individual that infected many others. The day sometimes more than 10 people and Dr. Hitoshi Oshitani: So the secondary cases, the, the is generated the by the later to be the older people and the from the children. The percent of the cases are generating the secondary transmission was the quite role. Dr. Hitoshi Oshitani: And this is the epidemic of Japan as of November 10 and we had a fast outbreak.

The first wave about Baker from the February to May. Dr. Hitoshi Oshitani: And the second one started the at the beginning of the June and this way, we still continuing. And now we sing the song increasing trend. And so we are analyzing the clusters and many clusters have been analyzed and the setting for the cluster are occurring there is changing and Dr. Hitoshi Oshitani: So it is important to the monitor the the clusters and so that we can implement the specific measures for the specific setting. Dr. Hitoshi Oshitani: And especially in June and July the we had the many the clusters in the garage nightlife entertainment district in the major cities there, especially in Tokyo. Dr.

Hitoshi Oshitani: And from there, the we had many community transmission, including household schools lesson parties and then the at the end, the virus. The reach to the the nursing homes and hospitals. Dr. Hitoshi Oshitani: And for the majority of severe cases. So, current send these important to transfer to interrupt the transmission somewhere. The before the virus reach to the hospital and nursing homes. Dr. Hitoshi Oshitani: And then, and these are the transmission patterns in the community. And even there is a medium to large sized clusters. The we may see there are some household Dr. Hitoshi Oshitani: Household the clusters and the cross does in the workplaces and they eventually in the hospital. But even there is only small cluster that there might be some household cluster, but there is no further the transmission and many of the transmission chain is interrupted in the community. Dr. Hitoshi Oshitani: So now we are discussing the privatization of cross to investigations, including the retrospective contact racing then because the party because Dr.

Hitoshi Oshitani: We are seeing the increasing trend of the cases and the public as nurses and the public or centers are overwhelmed and now and 18:41 - Dr. Hitoshi Oshitani: They in such settings. The high priority should be given to the hospital and long term care facilities, including in a nursing homes. Dr. Hitoshi Oshitani: And the nightlife entertainment. The is also the the nice key setting the because Dr. Hitoshi Oshitani: The from these settings. So the community transmission. They can be the starting and also the largest social gathering like a parties and the theater live music a band and saw and but the schools University courageous and walk races. These are the setting to where the Dr. Hitoshi Oshitani: The from where the the community transmission is less likely to occur. Dr. Hitoshi Oshitani: There, unlike in us.

We haven’t seen the very large clusters in universities. Dr. Hitoshi Oshitani: And so the forefather information that we set up our website and you can see the some of the information Dr. Hitoshi Oshitani: About our approach, including the, the English the guidance for the the the optimal scanning based solution, including the little speck contact tracing. And so this site was actually the day established by our colleagues. Dr. Hitoshi Oshitani: Including Dr. Jean de and the miracle Kikuchi and so I appreciate appreciate their effort to set up this the website and thank you very much for your attention. Margaret Ellis Bourdeaux M.D.

Fantastic, thank you so much for going through that with us. I you know I think we can all start to see how Margaret Ellis Bourdeaux M.D.: You know how this approach can really change how we think about, you know, super spreading events being not necessarily about an individual, but where that individual goes and and how they’re relating to others and which environments. Margaret Ellis Bourdeaux M.D.: I want to. So just to say I’m going to turn it over to Dr. Sung and then afterwards, I see some questions coming in. We’ll have plenty of time for for questions after Dr songs or marks so keep them coming. Margaret Ellis Bourdeaux M.D.

So to introduce my colleague Dr KJ seven is a total honor. He is the chief of strategy and policy at Margaret Ellis Bourdeaux M.D.: Partners in Health in Massachusetts coven 19 response. He’s also an associate physician at the division of global health equity at Brigham and Women’s Hospital. Margaret Ellis Bourdeaux M.D.: And assistant professor at the Department of global health and social medicine at Harvard Medical School and he’s going to focus on sort of, okay, yes, this is a cool amazing technique, but how do you do it, how do you, how do you execute on it so KJ, I’ll go ahead and turn it over to you.

21:45 - Kwonjune Justin Seung: Morning everybody Kwonjune Justin Seung: I think for a lot of you, it’s the first time I’ve heard Professor Hsu Tani Kwonjune Justin Seung: For us it was actually, I think it was back in July, when we heard Kwonjune Justin Seung: You know, Professor, I was shining was very gracious to get on a quick zoom call with our project and Kwonjune Justin Seung: It was a it was really a different way of doing things. And so we want to explain exactly how we restructured our project to you into incorporate a lot of these techniques. Kwonjune Justin Seung: And just a little background on our project here in Massachusetts. This is a state 7 billion people. Kwonjune Justin Seung: The project. This is the community tracing collaborative and you can see up there on the left there are Kwonjune Justin Seung: There are 351 local boards of health in in the state in the Commonwealth of Massachusetts. So each one of those has jurisdiction over its town has its own public health department, the Kwonjune Justin Seung: And so the collaborative is really Kwonjune Justin Seung: Is really meant to incorporate all of these.

So it’s really the those local health departments that are doing a lot of the content tracing and there is another surge workforce of contact tracers that is meant to backstop those in case those 23:17 - Kwonjune Justin Seung: Those public health nurses really who are very closely aligned with what’s happening in the field start to get Kwonjune Justin Seung: Overly Kwonjune Justin Seung: High case loads and so Kwonjune Justin Seung: A lot of these concepts and strategies we have incorporated into this surge workforce, which tends to, you know, which can really float across the state and is not Kwonjune Justin Seung: Restricted to work in any one jurisdiction. So it’s really set up as a large call center and a lot of other states have done this as well. And it’s a unified force. It’s a, it’s got a single database. There might be a few things in message you should set are different from other states. Kwonjune Justin Seung: For us, the CTC content tracing units have have case investigators in contact tracers the case investigators do the initial case investigation. Kwonjune Justin Seung: The contact tracers are then making calls to close contacts in reality, those two roles are very, very similar. And in fact, those people really do both things.

24:26 - Kwonjune Justin Seung: Depending on the need. We also have a third Qadri called the care resource coordinators and we know that Kwonjune Justin Seung: People need support they need the traditional support they need medicines they need transportation any and all of these things to stay in isolation and quarantine so Kwonjune Justin Seung: So there’s a third Congress smaller code, right, that is also floating throughout the the content tracing units in for those cases and contacts that are flagged the the CRC will will be able to provide that support. Kwonjune Justin Seung: So the first problem. You know, I think as you listen to Dr Joshi Tani and Kwonjune Justin Seung: Probably had the same reaction I did, which was that what he is really explaining with respect to retrospective contact tracing is different. It is not actually what we are doing. It is not part of the way Joe protocols or CDC protocols.

25:24 - Kwonjune Justin Seung: There is, you know, our, our protocols are meant to do perspective content tracing and that means Kwonjune Justin Seung: From 48 hours prior to symptom onset, that is anybody, you’re really looking for the people who that case could have infected. Is it but to go back retrospectively is, you know, there are in all of these protocols, there is some Kwonjune Justin Seung: There are some data collection about about possible exposures, but really I think if you listen to the professor. You can you can you can see that it’s actually much more involved. And so what we have done is, if you really think about as level one and level two instead of Kwonjune Justin Seung: In instead of really pushing out that level to which is a retrospective component into the entire content tracing workforce of over 1000 1000 people we chose it to develop a smaller unit. So really a unit within the overall content tracing team.

26:28 - Kwonjune Justin Seung: And we called it the epidemic intelligence unit, the EU and it’s really less than 20 people at this point. Kwonjune Justin Seung: But Kwonjune Justin Seung: You can see here, though, that that if you’re going to take this approach. Kwonjune Justin Seung: The, the larger context racing workforce. So, level one clearly has to involve some aspects of level two. So in some sense, level one is the first Kwonjune Justin Seung: The first contact the first communication with the case that initial first call. And so if the person, the comp.

The case investigator is not really sensitized not really thinking about 27:07 - Kwonjune Justin Seung: Where the case was was infected, then that hint, or that tip about a possible cluster at a workplace at at a restaurant at a yoga studio Kwonjune Justin Seung: Or hockey team that cannot be given to the US then Level two can’t start so level one definitely here. I think it’s, it’s, you know, I think it shows the different roles and the differences between the level one and level two, but Kwonjune Justin Seung: Really that level one, even if you do have an ECU a smaller unit that can really handle the retrospective component. You can’t completely. You know, there’s still a lot of training that has to be done to your larger content tracing work for. So really over in our cases it’s over 1000 people Kwonjune Justin Seung: So that’s one issue here is that is that have you expand your protocols and Kwonjune Justin Seung: And how do you expand your, your workflows to get around the first problem, which is that it’s not really what Professor is describing is not contained in current contact tracing protocols for coded so the other problem is, is this one. It’s just that. Kwonjune Justin Seung: The you know the the cluster.

And I think that in the previous presentation there was some discussion of this is that 28:34 - Kwonjune Justin Seung: clusters are not obvious. They are the cluster analysis and investigation is is fragmented and so you Kwonjune Justin Seung: Really, you know, I know that Professor of study has talked a lot about the danger of the isolated case. So when you’re seeing a lot of isolated cases so cases to say, you know, Kwonjune Justin Seung: I don’t know where I got infected. I have no i don’t i don’t know i know who I could have infected because I’m living maybe with my household. I don’t know where I got infected. That’s an isolated case it’s not connected to a cluster that’s dangerous.

29:09 - Kwonjune Justin Seung: And you know the other thing I would I would expand on that is that it’s really the isolated household right so we know Kwonjune Justin Seung: The easiest part of this is, is, is the household transmission. I’m not saying that it’s easy to prevent but it’s certainly easy Kwonjune Justin Seung: To to find everybody is living with with people, they’re close contacts are there are high risk for infection. So you what you see Kwonjune Justin Seung: Is isolated households, you have high households. There are household clusters are all over the place, but they don’t seem to be connected to any Kwonjune Justin Seung: Any cluster. So when you start to do this retrospective analysis.

What you find is that, you know, each household and 29:50 - Kwonjune Justin Seung: You know, in Massachusetts is that we consolidate those household key contacts and those cases into one contact Tracer. So really, Kwonjune Justin Seung: Those follow up calls can be made in a much more efficient manner, but you know as your retrospective contact tracing continues, you may find that this household is actually connected to a larger cluster. So suppose actually three households. Kwonjune Justin Seung: ACTUALLY WENT TO A PLAY DATE FOR for Kwonjune Justin Seung: One of the one of that addresses. So now you know. Now these aren’t actually isolated houses. This is a small cluster, but Kwonjune Justin Seung: The way that you have set up your concentrate with the way that we set up our content racing program is that Kwonjune Justin Seung: There is one contact Tracer. So there are actually three contact racers who are following this relatively small cluster, because there are three households that are involved.

30:45 - Kwonjune Justin Seung: If you continue to direct retrospective contact tracing and hypothetically, you find actually, this is part of a larger Kwonjune Justin Seung: Not a gigantic cluster, but still a larger cluster, because one of the children went to a pool party where there were some teenagers involved if we had actually gone to Kwonjune Justin Seung: a Halloween party. Kwonjune Justin Seung: Well, again, this is a this is really not a gigantic cluster, but you can see here that there are seven different contact racers involved because there are seven different households. So it’s very difficult. In fact, to see for each of these contacts racers. Kwonjune Justin Seung: They may part of the training in that phase is that Phase one is you at least get a hint. Kwonjune Justin Seung: Is to really ask further than the 48 hour so they get an idea of how where the exposure happened, whether their plate. Those are playdates or Halloween parties but Kwonjune Justin Seung: Really it’s impossible for for all of them.

And it’s not it’s not efficient for them to try to figure out the extent of this cluster and and to trace back even for this relatively small size size cluster to to the to the Halloween party. Kwonjune Justin Seung: So the he really has to be a it’s really a problem of communication. So, you have fragmentation, because the, you know, people aren’t getting tested, you cannot test 100% of the people in the community. Kwonjune Justin Seung: Every day you may only pick up certain cases in the cluster, but then those cases are followed by different people and Kwonjune Justin Seung: You really have to have a central a central unit and we for us. That’s the EU and there has to be just free communication with the entire contact racing workforce.

So, you know, this cannot be done with a database, you know, there’s no way to do this. Kwonjune Justin Seung: There’s, there’s no way to do this from from from the outside the, the EU has to be able to communicate. Kwonjune Justin Seung: With the people who are directly interviewing the cases and context, because what you find. Kwonjune Justin Seung: And, you know, this is one of my pet peeves is that when people are talking about why content tracing is not being effective. Kwonjune Justin Seung: And when people are not listening or people are not are not are not complying with kind of tracing what I usually say, and I tell them is that is because in fact you’re not you’re not listening to what they’re saying.

And in fact, in our experience, for example, retrospect to conduct tracing 33:27 - Kwonjune Justin Seung: Cases are extremely interested in how they got infected, they want to talk about it for hours they Kwonjune Justin Seung: In and what we’ve in fact trained our contact traces to do is to ignore that information that that the cases want to tell them. So it’s really a systems failure, rather than an individual failure. Failure of Kwonjune Justin Seung: The community to comply quote unquote would contact tracing Kwonjune Justin Seung: So, Kwonjune Justin Seung: Just the last slide here, you know, because there’s this other question that’s and that’s the third problem is that is really what one of my colleagues calls the so what problem. What are you going to do with this information. So we have here a case we have a case investigator, we have Kwonjune Justin Seung: You know, the, the follow up the support, there is a resource coordination. So this case can stay in isolation but Kwonjune Justin Seung: Actually this case, let’s say, is connected to a cluster.

This is not an isolated cases is perhaps it’s a yoga instructor that was. It was a Yoga Retreat that was held at a Kwonjune Justin Seung: A weekend retreat that was held at a hotel or it’s a it’s a hockey team with a coach, that’s part of a league or it’s a business, a large Kwonjune Justin Seung: It’s a large Kwonjune Justin Seung: meat processing plant with a manager and multiple shifts. So there is a larger social background. Kwonjune Justin Seung: Behind this cluster that this cases in you know the the case investigator, you know, that’s phase one can get it can get a tip and can provide a tip to the EU, but it’s really the EU that’s responsible for looking at and really delineating Kwonjune Justin Seung: The, the boundaries. The size of, of, of where this this cluster to places particular cluster to place there. We have a lot of tools for that. Kwonjune Justin Seung: You know that I’ve shown in previous slides for example those cluster maps, but the end the end of the question is really Kwonjune Justin Seung: Is so what.

So how does this actually 35:40 - Kwonjune Justin Seung: Prevent Kwonjune Justin Seung: Future clusters. And that’s really with, you know, in our case, with our local health departments. Right, so that they have really jurisdiction. They have responsibility. Kwonjune Justin Seung: They can those public health nurses are able to to talk to coaches to talk to leagues to talk to hotels to talk to businesses. Kwonjune Justin Seung: And to have very much more in depth discussions about how they’re trying to defend against covet to prevent outbreaks in their, in their settings and can even, you know, as a blunt instrument implement more other sorts of Kwonjune Justin Seung: Of of restrictions on ours or operations that will cross out you know that will Kwonjune Justin Seung: encompass an entire sector. So the EU here is, you know, the idea is that it’s supposed to provide actionable intelligence, so Kwonjune Justin Seung: You’re, you’re, you’re collecting information from all of these cases investigating these thousands of conduct tracers you’re trying to put them into a Kwonjune Justin Seung: A a format that’s useful, not, not a bunch of names and numbers and dates but to put them into a cluster map.

36:54 - Kwonjune Justin Seung: And we’ve developed some of those tools that I showed you previously, but those can be taken by local health departments can be used to understand, you know, very specific small or large clusters can be used to discuss with business owners with places of worship. Kwonjune Justin Seung: With with restaurant owners and even you know with with with mayor’s with Kwonjune Justin Seung: With city councils can can be used to to change policy. Kwonjune Justin Seung: Surrounding covert in in those jurisdictions. Kwonjune Justin Seung: Um, thank you very much. If you know the US pH is public health, a company unit is available to help states and, you know, I hope that we’ll be able to talk more in the future. Margaret Ellis Bourdeaux M.D.: Fantastic. Margaret Ellis Bourdeaux M.D.: Right.

So a lot of a lot of learning has happened here at the contact chasing program in Massachusetts. And thanks to Dr Usha Tani for for coaching us us through it. Margaret Ellis Bourdeaux M.D.: I want to quickly give the first, the right of first question to Dr. Becky, who is a techno sociologist who has written about Margaret Ellis Bourdeaux M.D.: Specifically retrospective contact tracing and the nature of coven is something that spreads in these clusters. And so I know that ever since your article in The Atlantic, you’ve also been getting lots of questions. Margaret Ellis Bourdeaux M.D.: Dr. Becky about about this. So I’ll turn first to you and then we’ll go to our Q AMP. A in the q&a panel. Zeynep Tufekci: Thank you. I do want to start by thanking especially Dr. OSHA Tony, both for the presentation and how willing. He has been throughout the process to share Zeynep Tufekci: From Japan all these important key points and as you’ve noted, I have written about some aspects of dependent, including potential for airborne transmission and its relationship to ship two clusters and the backward cluster tracing that Zeynep Tufekci: From as we learned from Dr Usha Tony’s example. So the first question I have is Zeynep Tufekci: What percent of the cases you’re finding are coming from this retrospective cluster busting or or are you not doing like the traditional perspective tracing because as we heard from Zeynep Tufekci: From the United States, that is not at all in our protocol.

We just sort of mostly in most places to forward tracing 39:47 - Zeynep Tufekci: And one question I got a lot since writing this has been well if we do do this backward tracing. What do we expect. Do we have some numbers. Some Zeynep Tufekci: I mean, the theory is easy to explain. And a lot of people are convinced, but it’s kind of hard to get the practical side moving. And so people would like to hear Zeynep Tufekci: What’s the payoff. Do you have some percentages. Do you know like how what percent of your cases are found, you know, maybe first backward then forward or Zeynep Tufekci: If you could enlighten us a little bit more. That would be very interesting.

I think too many states that are considering these protocols. Dr. Hitoshi Oshitani: Okay. Dr. Hitoshi Oshitani: Can I answer this question. Margaret Ellis Bourdeaux M.D.: See The Dr. Hitoshi Oshitani: Day. I don’t have exact numbers, but the it also depends on the situation, when we define the cluster by doing the retrospective contact racing. Dr. Hitoshi Oshitani: We usually can find the number of cases, sometimes. So the cluster is more than 50 or even more than 100 so the by identifying the many clusters, we can find more cases and the Dr. Hitoshi Oshitani: Day. I don’t have an exact number, but the probably the nearly half of our cases were found the by identifying the clusters and also the.

We also the identify many unlinked cases, the cases with without any epidemiological readings and but there are many of these cases. Dr. Hitoshi Oshitani: That many of these isolated cases, the poverty. The do not generate any secondary cases or the very few secondary cases. Dr. Hitoshi Oshitani: It’s more important to identify the cluster then identifying the many isolated cases. And that’s our concept. And that’s why there we are putting more effort to identifying to identify the clusters. Margaret Ellis Bourdeaux M.D.: Fantastic.

Katie, do you want to follow up on that, how and maybe you can include a little bit of so okay so you think that 42:34 - Margaret Ellis Bourdeaux M.D.: The cluster was at a yoga class or a Halloween party then then what do you do, do you go and test everybody that was at the Halloween party or at the at the yoga class or how does that practically work. Kwonjune Justin Seung: Yeah, I think that we’re really getting to that that question. It is which is the so what. So what are you going to do Kwonjune Justin Seung: What will you do with this information and it really depends on the type of cluster. So I think that what we’re seeing now in messages. Anyway, are we’re not seeing. Well, I can’t really say. Kwonjune Justin Seung: That we’re not seeing any very large clusters. Certainly, we do see some of them.

But what we’re what we see more of are lots of little clusters. Kwonjune Justin Seung: And whether this is happening in the in the workplace, which is relatively controlled or schools or or Kwonjune Justin Seung: Or social gatherings, which, you know, I don’t think we’re having the same sorts of large social gatherings that we did in the spring when we were really taken aware but these are these are harder to do. And I think that certainly, in certain cases, you can Kwonjune Justin Seung: You can you can increase, you can target your testing. So if you have an idea that there’s an outbreak at a church or workplace is quite common in fact for business owners to say Kwonjune Justin Seung: Well, now I’m going to test the entire I’m going to test the entire workforce, so that Kwonjune Justin Seung: You know, at that point, you’re not trying to characterize the cluster, you’re actually trying to stop transmission their social clusters, you know, this is the Kwonjune Justin Seung: Very, very difficult. These are not huge gatherings. These are gatherings of 15 people maybe four households, maybe six people but with the tax rates of 60 70%, you know, pretty much everybody with it at an indoor gathering at an indoor dinner party getting infected.

44:28 - Kwonjune Justin Seung: And there are, you know, it’s really about you can you can certainly inform your, your community education but Kwonjune Justin Seung: Also just community advisories and restrictions of the size of social gatherings. You can inform those those things as well. So I don’t think that it is, I think, really, for every type of cluster there is, there are certain Kwonjune Justin Seung: actions that can be taken on on a on a local level and I you know I would also agree with the professor that that it is a clustering disease. So when you find these if you know we certainly are not able to find Kwonjune Justin Seung: 100% of the clusters. We may not be able to connect 100% or even 80% of all cases two clusters. I don’t think that’s necessary. Kwonjune Justin Seung: You know, this is if you have characterized well and it certainly when you’re having a huge caseload. It’s really impractical.

You cannot, you cannot do retrospective contact tracing 45:34 - Kwonjune Justin Seung: Every single person. I don’t think that’s the point. The idea is to get a sense of where the transmission is taking place, what sorts of social gatherings. Kwonjune Justin Seung: You know, is it happening in colleges and universities isn’t happening in churches. We know overall there’s quite good evidence of of Kwonjune Justin Seung: Outbreaks at all of those places, but this will give you on a local level, where it’s tending to happen in in your area. Kwonjune Justin Seung: And it doesn’t say you don’t need to to find 100% of the clusters.

You just have to get a sense of where they are happening by essentially doing a sampling and and then you can take action. Margaret Ellis Bourdeaux M.D.: Fantastic. Yeah, so I just to underscore those points retrospective contact tracing helps you both identify cases so that you can do perspective. Margaret Ellis Bourdeaux M.D.: Well perspective contact racing and help ice isolate our stop onwards transmission, but maybe more importantly is you sort of learn about the environment in which transmission is happening so that you can modify that environment and so that the transmission doesn’t occur there anymore. Margaret Ellis Bourdeaux M.D.: I so the just Humor. Humor you with a little bit of an example of this at KJ has watched as my family, which is a very strong hockey playing family. I have four daughters. They all play hockey. My husband coaches for hockey teams and hockey, was it was discovered that it was Margaret Ellis Bourdeaux M.D.

had led to a couple of clusters, maybe more than a couple in Massachusetts. And much to the heartbreak of my whole family. Margaret Ellis Bourdeaux M.D.: Hockey in Massachusetts was stopped youth hockey was stopped. But really what what was able to happen was they started looking at, well, why was that happening at hockey games. Margaret Ellis Bourdeaux M.D.: You know, why were they finding this and they were able to at least try to modify the practices of the youth hockey teams, such that Margaret Ellis Bourdeaux M.D.: Such that they could re restart youth hockey and you know that’s the kind of battle rhythm that we all need to need to get into here.

If we’re going to figure out how to 47:51 - Margaret Ellis Bourdeaux M.D.: Both drive down the transmission and get ahold of the epidemic. But also, you know, keep living keep living life. And so I think there’s a number of questions around that in the Q AMP. A really about the issues around Margaret Ellis Bourdeaux M.D.: The well I’ll pick a few Margaret Ellis Bourdeaux M.D.: Why our universities in Japan and schools less.

Why are you having fewer clusters there than in the United States, do you think, is it something about how you’ve changed your school, something about the age of the students or something about 48:32 - Margaret Ellis Bourdeaux M.D.: The nature of the epidemic there. Dr. Hitoshi Oshitani: Thank you for the question that actually we are also seeing the some clusters in university but the most loved the clusters in university are have been occurring in dormitory setting and or the outside of the the lecture that drinking party after the lecture and some other the Dr. Hitoshi Oshitani: The, the activities and particularly the we do not have the many dormitories in Japan and the compared to the, the university in us. And so the dormitory is the probably Dr. Hitoshi Oshitani: The most important the setting the end, they, they, for the sports crafts, they are living in the in a dormitory and we’ve been seeing the many clusters of large clusters in such things that the usual student and not remaining most of the usual students and not staying in the dormitory. Dr. Hitoshi Oshitani: That make and also that we are still doing online that online lectures. Dr.

Hitoshi Oshitani: In the most of the universities and but the property, the dormitory is the most important factor. With you. Interesting. Margaret Ellis Bourdeaux M.D.: Um, so, so that’s interesting in terms of how you sort of think about about clusters, I think that, you know, another sort of bulk of a cluster of questions in our, in our Q AMP a has to do with really the US context. Margaret Ellis Bourdeaux M.D.: And you know, we, we’ve been struggling with testing and having very sort of big limitations on our testing capability and also we are, you know, seeing the surgeon cases. Margaret Ellis Bourdeaux M.D.: So some questions. I am back to song. Maybe you can answer does this work, Ma, and I low we have low testing capability. And you know what about in with rising case loads. Is it kind of worth it worth the effort. Kwonjune Justin Seung: I do think it’s worth it.

I think that is, you know, with the rising case codes, you know, you cannot, you cannot contact your trace contact trace yourself out of an epidemic. Kwonjune Justin Seung: Not a covert epidemic, but the the retrospective caught that tracing and the Kwonjune Justin Seung: Prospect of contact racing is not going to catch every case and catch every cluster. It’s not, but I think that for retrospective contents racing. That’s not the goal. The goal is not to is not defined everything. The goal is to understand better Kwonjune Justin Seung: Where the transmission is happening and also to guide your efforts so so targeted testing targeted outbreak. Response Kwonjune Justin Seung: And but just going back to the first one, you know, there’s another question there about really this rigid Kwonjune Justin Seung: Definition of a close contact, and I think this is really a great example of how it changes, you know, doing retrospective content tracing changes your understanding.

This is really 52:10 - Kwonjune Justin Seung: A you know the definition of close contact that’s meant to facilitate content tracing, but it has been so driven into the minds of the community that they think that is actually protective Kwonjune Justin Seung: And, you know, we’ve seen many, many, you know, as you do as you talk to the churches as you talk to businesses. Kwonjune Justin Seung: We can see, you know, it’s obvious, right, if you have eight, you know, if you have 12% of your workforce in a large warehouse that is infected with coven documented infection. Kwonjune Justin Seung: You know, these and none of them actually fit the definition of close contact. Okay, so what do you realize is that in certain situations in the three C’s, for instance. Kwonjune Justin Seung: You know there is infection that can happen actually quite easily.

Even for non close contacts and no it’s not difficult to figure out that there is an outbreak going on that all these are linked. Kwonjune Justin Seung: You know if 12% of your workforce is infected with covert is PCR positive and is symptomatic OBVIOUSLY THEY ARE LINKED IN SOME WAYS, THESE ARE NOT. These are not independent infections. So this is, you know, even on the, on the, you know, even on the very basic Kwonjune Justin Seung: Understanding of how coven is transmitted within a place that fits the three C’s and for broadening your perspective and and and and giving you Kwonjune Justin Seung: The impetus to go a little bit beyond these very, very rigid protocols that were using I think retrospective contact tracing is is extremely valuable. Margaret Ellis Bourdeaux M.D.: And as well. Um, you mentioned sort of Margaret Ellis Bourdeaux M.D.: The idea of six feet being kind of drilled, you know, just like the mantra now is like this protective work invisible work shield.

As long as you’re staying six feet away from someone and we you know we just know 54:05 - Margaret Ellis Bourdeaux M.D.: That that is just not the case in in tight spaces with with bad ventilation and you’re there for a period of time, you’re going to get it. Whether you’re six feet apart from other people or not. Margaret Ellis Bourdeaux M.D.: And Natalie Dean so nice question here about how do we communicate the need for retrospective contact tracing with the public. How do we handle Margaret Ellis Bourdeaux M.D.

Some of the sensitivities that might come up, you know, I know you said people like to talk a lot about where they got infected, which is definitely chimes with my experience of patients as well late, you know, 54:43 - Margaret Ellis Bourdeaux M.D.: So for some that’s not going to be an issue. But for others, you know, they’re not going to want to reveal. You know that it was their hair styling business. Margaret Ellis Bourdeaux M.D.: You know, or, you know, there’s a lot of a lot of difficulties there. So how do we explain this to the public. And how do we address some of the sensitivities around doing this kind of investigation. Kwonjune Justin Seung: Well I you know I will say that I think that in the United States we Kwonjune Justin Seung: We are really behind in this aspect I think that Kwonjune Justin Seung: People you know i and i and I’ll say what I again I’ll repeat that.

I don’t think the problem is with with the community and people are quite happy to talk about these things. They are not worried about Kwonjune Justin Seung: Talking about this, they you know and like I said, you know, obviously. Kwonjune Justin Seung: These are some reluctance sometimes to give up names and phone numbers, of course. Kwonjune Justin Seung: But, you know, in some sense, in, in, in, in, in retrospect, the concentration. That’s not even necessary right because you can certainly, you know, if somebody says, I went to a Halloween party if they’re if they’re if Halloween parties are Kwonjune Justin Seung: Are coming up again and again and again 10 days after Halloween.

56:02 - Kwonjune Justin Seung: You don’t have to know exactly who went there. You don’t have to know exact guest list of every single one of those parties to know that this is a major, major problem going along. Kwonjune Justin Seung: Popping up and that in Thanksgiving and Christmas is going to happen again. So I think that Kwonjune Justin Seung: You know, we do have information here that we can gather, we have to be. We have to figure out how to convey that to the public in terms of community education. Um, but, you know, even more broadly.

Like, I think that because we haven’t figured out how to how to explain 56:40 - Kwonjune Justin Seung: Covert outbreaks to the American public. There is a lot of of both stigma and discrimination, which I think is ridiculous for for what is relatively Kwonjune Justin Seung: You know, which really by now you know well into the epidemic should be routine, there should not be any shame, there should not be any discrimination about being exposing Kwonjune Justin Seung: Your church or your business while you, you know, while you were not symptomatic which which is really the most common situation. Kwonjune Justin Seung: And people shouldn’t be scared about getting email saying you’ve been exposed, you need to go get tested. Kwonjune Justin Seung: Out of quote unquote in abundance of caution, we have not been able to, you know, we haven’t done very good communication on this we have, we have a lot of media that jumps on Kwonjune Justin Seung: On clusters and likes to make a huge a media event out of it. And I think it perpetuates the problem but I definitely would like to hear from professors you Tony how Japan has dealt with this problem. Dr. Hitoshi Oshitani: So thank you yeah in Japan. Dr.

Hitoshi Oshitani: We also have some issues regarding a discrimination and song. And sometimes people do not want to talk the Dr. Hitoshi Oshitani: Especially that we have this problem. The with the cluster been the horse craft or hostess graphs that kind of the nighttime nightlife in entertainment settings and the people do not want to talk to where they were the and Dr. Hitoshi Oshitani: The both customers and the people working in a deed settings.

And that was the one with the reason why the probably the main reason why the these clusters what difficult to control the in June, July, and we also seeing the some increasing 58:49 - Dr. Hitoshi Oshitani: Of the clusters. The in the foreigners community. And so, so the communication is quite difficult. The people do not usually the go to the clinics for testing. Dr. Hitoshi Oshitani: So the we are now trying to find a better way to communicate with them and but usually the people that are willing to cooperate with a local authorities there, particularly with the public consciousness is that in certain setting, it’s more difficult to investigate. Margaret Ellis Bourdeaux M.D.: All around the world. People are people. Margaret Ellis Bourdeaux M.D.: And certain things. They like to keep private Dr. Becky, do you want to wrap up with any other any other question and then we’ll and then we’ll have to continue our conversation and the offline and the in the coming days. Zeynep Tufekci: I would love for DR otani to address the close contact question a little more because I think that’s the part of the puzzle that’s not very well understood in the United States, we just kind of talked about it.

00:08 - Zeynep Tufekci: But there was a lot of debate to try to get airborne transmission, you know, aerosol transmission accepted as a method of transmission Zeynep Tufekci: And CDC has acknowledged it but there’s some question on like how prominent is this method of transmission, and how does this connect with contact racing. So if he could address Zeynep Tufekci: How like what Japan’s epidemiologist see as the primary mode of transmission or secondary motive transmission. If you have any data on how much or which one you’re seeing and how that links to Zeynep Tufekci: How you define close contact, what role ventilation plays and how that links to the kind of cluster busting you do. I think that would be very illuminating for our audience. Dr. Hitoshi Oshitani: Thank you very much for the question.

And we still do not know the exact the proportion of the different model transmissions, but 01:12 - Dr. Hitoshi Oshitani: there from the beginning we were considering the possibility of the as or transmission day, especially the short distance. He has a transmission Dr. Hitoshi Oshitani: Because the problem early findings. The we saw many clusters. The, the, from the pre-symptomatic the individual and Dr. Hitoshi Oshitani: So they did not, of course, the have any cough or sneezing, but still the transmission. The occurred in these clusters.

And so, and also the, the, we had the many the cluster seen cross contact setting just the having the conversation there between the people 02:10 - Dr. Hitoshi Oshitani: In these settings. Many the transmission. The while occurring. And so the, I think the the the at least the short distance as or transmission Dr. Hitoshi Oshitani: Is probably the, the, one of the important mode of transmission. But there was still do not know how the the is a proportion of such transmission and that Dr. Hitoshi Oshitani: That we are considering their to they implement some control measures the we are considering this possibility and we are using the super computer Dr.

Hitoshi Oshitani: To simulate the different the settings and Decker, the theater. The, the live music price and so on. And we they in these simulation, we are considering the the at least the short distance as a transmission Dr. Hitoshi Oshitani: And then we also the highly recommend that good ventilation, because the mini clusters. The most of clusters are occurring in the closed. They environment. So the integration is probably important. And that also suggested the, the importance of the ears or transmissions. That is settings. Like you Margaret Ellis Bourdeaux M.D.: Said fantastic I you know I feel badly.

We have to wrap up, I feel like we could go on for another couple of hours on 04:05 - Margaret Ellis Bourdeaux M.D.: You know, on the issues. Everything from how do you set up your, your data, you know, and Margaret Ellis Bourdeaux M.D.: Are there any tools that we can use to help of investigators put information together in a way that is more effective or faster. Margaret Ellis Bourdeaux M.D.: All the way to the to the issues around building trust with communities and thinking about privacy and protections. Once you’re doing this type of really deep dives into how people interact with one another. Margaret Ellis Bourdeaux M.D.

So they had lots of my mind dissolves and full of ideas for follow up seminars, but we’ll stop here and just a huge thank you to all of the folks that spoke today and to the folks that tuned in. .