Virginia’s contact tracing app could be a vital tool in fighting COVID-19 — if people would use it

Jess Reingold, a web project manager who lives in Alexandria, has lots of ideas for Virginia’s COVIDWISE app, which was the first software system in the nation to alert users if they’ve had a close contact with someone who tested positive for coronavirus.

“There isn’t much to see or do in it unless you’ve tested positive,” she wrote in an email last week. Some of her ideas include a statewide heatmap of cases, a search portal for nearby testing sites, and other dashboards to make the app more interactive, like a tab with vaccine development updates and the latest announcements from Gov. Ralph Northam.

What Reingold isn’t so sure about is how many other people use the app. Like many of the Virginians who discussed their experiences with COVIDWISE for this story, she’s never gotten an alert warning her of a potential exposure, even though she lives in Northern Virginia and “there are a lot of people around in this area,” she wrote.

“While people do appear to have it on their phone, it also doesn’t seem like the vast majority of the Virginia population does,” Reingold added. Sarah Sams, who lives in Mechanicsville, said that at least 90 percent of her friends, family and neighbors said they haven’t downloaded the app. 

Sometimes, there’s a clear reason, like a few friends who have told Sams they’re worried about potential privacy violations (though COVIDWISE uses anonymized Bluetooth technology to share location data, making it less invasive than most other apps). But among her close friend group, she said it’s more common to hear that people just aren’t interested.

“It’s apathy, pretty much,” Sams added. “They’re skeptical that enough people are going to download it to make it work.”

That lack of engagement is one of the biggest challenges for Virginia health officials as they struggle to contain a growing swell of COVID-19 cases. While transmission is far more restrained across most of the state than it is in national hotspots such as North Dakota and Minnesota, Virginia’s seven-day average of daily new cases topped 2,400 on Tuesday — higher than it’s been at any point during the pandemic. The state’s percentage of positive test results rose from 5 percent to 7.4 percent in a matter of weeks, and hospitalizations are approaching previous peak levels in May, according to data from the Virginia Hospital and Healthcare Association.

Amid a growing surge of cases, COVIDWISE should be one of the most easily accessible ways for Virginians to learn if they’ve been exposed to the virus and avoid infecting others. But nearly four months after the app’s launch, participation is still decidedly mixed. As of Thursday, a total of 808,774 people had downloaded the app — roughly 10 percent of the state’s population, according to Jeff Stover, the executive advisor to Virginia Health Commissioner Dr. Norman Oliver.

“We’ve done better than most any other state in the country with the percentage of our population that’s downloaded the app,” he added (Maryland, which launched its own app on Nov. 10, has roughly 1,075,000 subscribers, but its state Department of Health said it’s still too early to provide additional analytics).

By VDH calculations, the department has also reached 19 percent of its target population — defined as the roughly 80 percent of Virginians aged 18 to 65 that can be reasonably assumed to have cell phones, according to Stover. But for COVIDWISE to really be effective, downloads aren’t the only metric. Virginians also have to update the app if they’ve received a positive test result — a critical part of the process that allows the software to alert contacts who spent 15 minutes or more within six feet of the infected person over the last 14 days.

Submitting a positive test requires some interaction with local case investigators, who provide users with a six-digit personal identification number once the health department has validated the result (a step that prevents the app from being flooded with false positives). As of Thursday, Stover said 553 people had submitted their PINs and positive results to the app, which has led to a little more than 8,600 likely exposure notifications going out. Not every notification equates to one Virginians — Stover said the same person can get multiple alerts over a 14-day period. As of Tuesday, Virginia has recorded 223,582 COVID-19 cases since the start of the pandemic — and nearly 100,000 since COVIDWISE launched in early August.

In total, though, the department has sent out 874 PINs, which means there’s more than 300 Virginians who received a number but never uploaded their results to the app. Others have tried, but the result hasn’t always been seamless. Seth Hochman, an Arlington resident, said he tried to submit a positive result but never heard back from his local health department after he got a PCR test at a nearby pharmacy.

“No one has contacted me — no text, no call, no email,” added Hochman, who said he was asymptomatic and caught off-guard when his test from Preston’s Pharmacy came back positive. COVIDWISE warns that it could take health officials between one and three days to contact users, depending on when their lab results are submitted to the agency, but Hochman said he hadn’t heard back more than a week after the pharmacy notified him that he tested positive.

“I ended up just doing my own contact tracing,” he added. While he had been careful for most of November, Hochman said he went into Washington, D.C. earlier this month after President-elect Joe Biden was officially declared the winner of the 2020 election. Hochman suspects that he caught the virus in the city and carried it back to Virginia, where he met with friends for a couple of small gatherings later that week, before he received his results.

“It seems to me like a massive waste, really,” Hochman said. “What’s the point if you can’t even notify people?”

In an interview after Northam’s news conference last week, Oliver said only a small minority of Virginians aren’t contacted by a case investigator who can provide a PIN or help someone download the app. But the contact tracing process also becomes more difficult as cases continue to rise. 

Dr. Molly O’Dell, the communicable disease director for the Roanoke City and Alleghany Health Districts, told the Roanoke Times last week that infections in the region sometimes spiked by hundreds a day, forcing investigators to pick which cases to prioritize. VDH reports that it’s currently reaching an average of 72.5 percent of new COVID-19 cases within 24 hours — a slight decline from late July, when it was reaching 74.3 percent.

“Our case investigators are working tirelessly, calling as many people as they can every single day, but when cases are surging and the numbers are climbing, it’s just not humanly possible to get to as many people as we would like to,” said Elena Diskin, an epidemiologist and COVID-19 containment expert with VDH. She and Seth Levine, the epidemiology program manager, said the agency is in the process of finalizing recommendations for local health departments on how to prioritize cases, based on modeling that projects which infections — and demographics — are most at risk of furthering transmission. 

“As the surge continues, it gets really difficult to maintain the expectation that they interview every single contact,” Levine added. In a presentation to state lawmakers last week, Oliver said the department has hired more than 1,700 public health workers to track and contain the virus since the pandemic began. But for the second time this year, VDH is in the process of putting together a “surge team” of 60 workers — roughly 12 per region — who can serve as case investigators or contact tracers in areas seeing the biggest growth in cases.

More than eight months into the pandemic, Diskin said the contact tracing process is still uniquely susceptible to bottlenecks, including delays in test results or case growth that exceeds the capabilities of a state’s contact tracing workforce. It’s why health officials like Stover are urging Virginians over and over to download COVIDWISE, which is most effective when most of the population is using it.

“Modeling’s been done to show that obviously, the greater percent adoption, the greater the likelihood of decreased infections and decreased hospitalizations,” he said. In other words, the more Virginians who download the app — and upload their results if they come back positive — the easier it will be for the software to make matches and send out notifications to likely contacts.

What counts as a likely exposure is also a frequent point of confusion. Many Virginians told the Mercury that they felt the app wasn’t working because they’ve never received an alert, despite living in densely populated areas or working in public-facing jobs. But Stover pointed out that the COVIDWISE software — which identifies potential matches, or contacts, using anonymized Bluetooth signals from other users’ phones — uses the definition of “close contact” from the U.S. Centers for Disease Control and Prevention.

Until recently, the agency defined it as anyone who spent 15 minutes or longer within six feet of someone who was infected. But in the next few weeks, Stover said VDH would amend the state definition to match new recommendations from the CDC, which recently changed its definition to include anyone who spent a cumulative 15 minutes within six feet of an infected person over a 24-hour period — even through multiple meetings. Those changes are based on new findings that the virus can spread even through brief interactions.

“So, if you do not meet those criteria, that is a match that did not result in someone being notified of a likely exposure,” he said. Since COVIDWISE launched in early August, a little more than 17,000 Virginians have matched with someone who’s positive for COVID-19, but haven’t qualified for a likely exposure notification.

Stover said the state is still in the process of improving the app and marketing it to more Virginians. At the end of October, the COVIDWISE campaign had spent $966,350 on advertising efforts including billboards, bus wraps and social media ads. The first six weeks were focused primarily on digital ads, but Stover said VDH has added more broadcast television promotions in the last month, including a “Students for COVIDWISE” campaign.

VDH is also in the process of transitioning the app to a national server that’s used by most of the other 15 states or territories with their own notification systems. Stover said that server — hosted by the Association of Public Health Laboratories — has the advantage of receiving anonymized cell phone data from every other participating state. That means a Virginian who had a long lunch indoors with a Maryland resident would be notified if that person later submitted a positive result to their own state’s contact tracing app.

“We’re out there on our own for the moment,” Stover said. “It’s a remnant of being first. But trying to make that transition now is going to be very important.”