Considerations for sharing information for international contact tracing in the context of COVID-19

1 Considerations for sharing information for international contact tracing in the context of COVID-19 14 June 2021 Summary • International contact tracing should be done through rapid information sharing between National IHR Focal Points (NFP) when cases are identified on conveyances, at points of entry or with a history of international travel while infectious. International contact tracing is particularly important for countries with no cases, imported/sporadic cases or limited cluster transmission. • Data must be protected throughout the process of international contact tracing. Health information and/or personal details of an identifiable individual should be exchanged between countries in a confidential manner by using encrypted and password-protected communication. • A two-step procedure is suggested for sharing information. Initially, the basic information items can be communicated, followed by sharing of additional information upon request from the counterpart NFP for the purpose of case investigation. Background When systematically applied, contact tracing, in combination with effective testing, isolation, care for cases and quarantine of contacts, will break the chains of transmission of an infectious disease and is an essential public health tool for controlling COVID-19 outbreaks (1). Contact tracing involving source investigation may also help to identify an undetected chain of transmission and may trigger early interventions to prevent larger outbreaks. In some instances, cases or contacts may be identified among those who travel across international borders and tracing of cases and contacts may require sharing of information between countries, territories and/or subnational areas.1 International contact tracing refers to efforts to identify cases and trace contacts when the cases travelled internationally while infectious, or when contacts (who were exposed to a confirmed and probable case before departure or during travel) travelled internationally during the incubation period. Article 44 of the International Health Regulations (IHR) (2005) calls for collaboration among States Parties to support detection and assessment of, and response to, public events (2). The Article also requires WHO to facilitate technical cooperation to the extent possible. The temporary recommendations to States Parties issued as a result of the 5th meeting of the IHR (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic on 29 October 2020 included the facilitation of international contact tracing to manage potential risks of cross-border transmission (3). WHO’s interim guidance on “Considerations for implementing a risk-based approach to international travel in the context of COVID-19”(4) also recommends international contact tracing as one of the basic risk mitigation measures that should be conducted in a coordinated and collaborative manner through rapid information sharing via the National IHR Focal Points (IHR NFPs). 1 For ease of reading this guidance document, the term “countries, territories and/or subnational areas” will hereinafter be referred to as “countries” or “country”. 2 In the virtual meeting of IHR NFPs organized in the WHO South-East Asia Region on 26 November 2020, countries of the Region expressed willingness to strengthen timely information exchange for international contact tracing and requested WHO to provide further guidance, including standard operating procedures (SOPs) and information items to be shared for international contact tracing. This document aims to summarize key considerations for countries when sharing personal information for international contact tracing of people who travel across international borders through air and sea as well as via ground-crossings. International contact tracing is particularly important for countries with no cases, imported/sporadic cases or limited cluster transmission. In countries where community transmission is ongoing and surveillance capacities are overwhelmed, international contact tracing may be challenging in the context of an already stretched capacity for contact tracing (4). Nevertheless, countries may consider exposure involving variants of concern or variants of interest as priority for international contact tracing, when there is risk of importation or exportation of those variants. Target audience This document is intended for IHR NFPs, other national and subnational authorities responsible for public health management at points of entry, and case investigation and contact tracing of those who travel internationally through air and sea as well as via ground-crossings. Principles • As per Article 44 of the IHR (2005), countries are encouraged to collaborate with each other in the detection and assessment of, and response to, public health events to the extent possible, including in timely international contact tracing of COVID-19 cases, and for other infectious diseases (2). • For effective international contact tracing, rapid information-sharing among countries is critical. • For sharing information with other concerned countries, the health authority is expected to coordinate and consolidate information from various sources, such as case investigation teams, conveyance operators, civil aviation or maritime authority or authority in charge of point of entry, in the country where a case (cases) was detected. • Relevant consolidated information should be communicated via the IHR NFP to the IHR NFP(s) of the concerned country or countries (i.e. countries of departure, transit and/or destination). • Information of cases or contacts for contact tracing can be shared bilaterally between concerned States Parties, with or without copying IHR Contact Points at concerned WHO regional offices. WHO IHR Contact Points are ready to facilitate or follow-up communication, if they are copied and when required. • In line with Article 45 of the IHR (2005), health information collected or received from another country or from WHO which refers to an identified or identifiable person shall be kept confidential and processed anonymously as required by national law (2). • Article 45 of the IHR (2005) (2) also requires that States Parties may disclose and process personal data where essential for the purposes of assessing and managing a public health risk, but State Parties, in accordance with national law, and WHO must ensure that the personal data are: a) processed fairly and lawfully, and not further processed in a way incompatible with that purpose; b) adequate, relevant and not excessive in relation to that purpose; c) accurate and, where necessary, kept up to date; every reasonable step must be taken to ensure that data which are inaccurate or incomplete are erased or rectified; and d) not kept longer than necessary. 3 • Data protection and data privacy must be considered at all levels of contact tracing activities, while sharing information of individuals (1). When sharing relevant information of an identifiable individual, the file containing confidential information should be protected by a password. This password should be shared in a separate email. • Upon receiving the information from another country, timely acknowledgement of its receipt is encouraged, and the information should be forwarded to the concerned officials at the earliest for taking the necessary measures including possible tracing and quarantining of the contacts in accordance with national guidelines and in consideration of WHO guidance (1, 6). • Any question or request for assistance can be addressed to WHO, either to the respective country office or to the WHO IHR Contact Point at the Regional Offices. The email addresses of WHO IHR Contact Points can be found on the Event Information Site (EIS), which is accessible to all IHR NFPs. Scope of contact tracing WHO released interim guidance on “Considerations in the investigation of cases and clusters of COVID-19” (5) and “Contact tracing in the context of COVID-19” (1). These guidance documents provide steps for conducting case investigation and contact tracing, including definition of contacts. Contact tracing – along with robust testing, isolation and care of cases – is a key strategy for interrupting chains of transmission of SARS-CoV-2 and reducing mortality associated with COVID-19 (1). Contact tracing for COVID-19 requires identification of persons who were exposed to COVID-19 and may be infected, and quarantining them during the incubation period. In this approach, also called forward contact tracing, a contact should have had exposure to a confirmed or probable COVID-19 case during the infectious period defined as follows (1): • Exposure to a symptomatic case: Two days before and 10 days after the onset of symptoms of the case, plus at least 3 additional days without symptoms (including without fever and without respiratory symptoms), for a minimum of 13 days total after the onset of symptoms. • Exposure to an asymptomatic case: Two days before and 10 days after the date on which the sample that led to confirmation was taken. Contacts should be managed in the same way as for a symptomatic case. In addition, some countries, particularly those having no, sporadic or clusters of cases, may also conduct investigation into the source of infection, or so-called backward contact tracing. The investigation into the source of infection should be conducted from up to 14 days before the onset of symptoms in the index case (or diagnosis of an asymptomatic case), focusing particularly on the time period of 2 to 7 days before the onset of symptoms. To identify contacts and potential sources of infection, a detailed case investigation and interview/s with the case or the individual’s caregiver are needed (1). In scenarios where it may not be feasible to identify, monitor and quarantine all contacts, priority for follow up should be given to contacts at a higher risk of infection based on their degree of exposure, and contacts at a higher risk of developing severe COVID-19. Please see WHO interim guidance for more details (1). Scenarios The following four scenarios were identified, based on observed practices of actual information-sharing between NFPs regarding international contact tracing in the context of COVID-19. • The country of departure identifies a case (who is in the infectious period) or contact (who is in the incubation period) among outgoing international travellers after departure (scenario 1, 2) 4 • The country of destination identifies a case (who is in the infectious period) or contact (who had exposure to a confirmed or probable case within the past 14 days) among arriving international travellers after departure (scenario 1 and 2) • The country of departure identifies a case (who is in the infectious period) or contact (who had exposure to a confirmed or probable case within the past 14 days) among arriving international travellers upon arrival or within 14 days of arrival (scenario 3a, 3b and 4). These four scenarios have a distinct information flow and purposes, all of which are summarized in Table 1. Suggested steps (SOPs) for sharing information for international contact tracing in the four scenarios are proposed in Annex 1, and the procedure for creating password-protected files is given in Annex 2. Table 1. Different scenarios for international contact tracing A country which identifies a case or contact A country with which information is to be shared Scenarios Purpose of contact tracing Country of departure Country of destination Scenario 1. A country identifies a case among outgoing international travellers who are in the infectious period.* • Isolation and management of the case upon arrival • Forward tracing, including identification and quarantine of contacts Scenario 2. A country identifies a contact among outgoing travellers who had exposure to a case within last 14 days • Monitoring and quarantine of the contact Country of destination Country of departure Scenario 3a. A country identifies a case among travellers recently arriving from another country, whose infectious period had started before leaving the country of departure – the symptom onset (symptomatic case) or the specimen collection for a positive result (asymptomatic case) was within 2 days after the departure. • Forward tracing, including identification and quarantine of contact • Backward tracing for source investigation Scenario 3b. A country identifies a case among travellers recently arriving from another country, whose infectious period had started after leaving the country of departure – the symptom onset (symptomatic case) or specimen collection for a positive result (asymptomatic case) was more than 2 days but within 14 days after the departure. • Backward tracing for source investigation 5 This scenario usually does not require information sharing between countries.# Scenario 4. A country identifies a contact among travellers arriving from another country, who had exposure (in the country of departure or during the travel) with a case within the last 14 days. • Monitoring and quarantine of the contact Note: • In the scenarios 1 and 2, the “country of destination” includes all the countries where the traveller had planned to be present during the infectious period (including the country/countries where transit was planned). In scenarios 3a and 3b, the “country of departure” includes all the countries where the traveller was present (including the country/countries where the traveller had transited). • * Infectious period is defined as follows (1): o Exposure to a symptomatic case: Two days before and 10 days after the onset of symptoms of the case, plus at least 3 additional days without symptoms (including without fever and without respiratory symptoms), for a minimum of 13 days total after the onset of symptoms. o Exposure to an asymptomatic case: Two days before and 10 days after the date on which the sample that led to confirmation was taken. Contacts should be managed in the same way as for a symptomatic case. • # The scenario 4 usually does not require information-sharing between countries. However, if the contact is diagnosed as COVID-19 within 14 days after the departure from the country of departure, then the situation should be considered as scenario 3a or 3b, and information sharing for the international contact tracing is warranted. Information items to be shared for international contact tracing Basic information on a case (scenarios 1, 3a and 3b) or a contact (scenario 2) Category Information items Case identification Information as appears in the passport • Full name • Nationality • Date of birth • Age • Sex • Number of passport or other relevant travel document Other information • Case (unique) ID • Address/addresses in the country of departure (2 weeks before travel) Laboratory and clinical information • Laboratory test (PCR, antigen test, other [specify]) • Date of specimen collection for a positive result • Date of symptom(s) onset • Clinical signs and symptoms, or asymptomatic 6 Travel history and conveyances • Departure from the country of departure o Date of departure o Point of departure (airport, port or border crossing) • Country or area where the person had transited, or stopped en route o Date of arrival and departure o Airport, port or station • Entry to the country of destination o Date of arrival o Point of entry (airport, port or border crossing) • Conveyances o Flight number/ship number (name)/train number/vehicle identification o Seat/cabin number Additional information that may be used for forward contact tracing Category Information items Contact history in the country of departure • Vaccination status • History for the 2 days before symptom onset (or from the date of specimen collection for a positive result if asymptomatic) in the country of departure or at the place of transit, including: o Close contacts (see WHO guidance for the definition of close contacts (1)) – Name, address, phone number (or other contact information) Additional information that may be used for backward contact tracing Category Information items Contact history in the country of departure • Contact with known COVID-19 cases o Yes, no or unknown o If yes, name, address and phone number of the case • History from 2 days to 14 days (with particular focus on 2 to 7 days) prior to symptom onset (or from the date of specimen collection for a positive result if asymptomatic) in the country of departure and at the place(s) of transit, including: o Close contacts (see WHO guidance for the definition of close contacts (1)) – Name, address, phone number (or other contact information) o Places visited, meetings and gathering attended ▪ Venues considered to be high risk (e.g. health-care facilities, enclosed space with poor ventilation crowded with many people) ▪ Meetings or gatherings attended (particularly those with more than 10 people) ▪ Accommodation(s) and place(s) of work 7 Digital contact-tracing tools and international contact tracing Digital tools, such as mobile phones and apps for location tracking or proximity tracing, can support and complement surveillance and contact tracing efforts, both for national and international travellers. However, such technology cannot replace the public health contact-tracing workforce required to carry out the critical function of finding, communicating with and supporting people throughout the process of contact tracing. Furthermore, the effectiveness of digital tools, such as apps, depends on whether a large proportion of the general population downloads the applications and allows their use (4). For international travellers, issues of compatibility of information management systems and data sharing between countries need to be considered, if international contact tracing is warranted. Legal and ethical aspects related to individual privacy and personal data protection should be considered in line with WHO guidance (7). 8 References 1. Contact tracing in the context of COVID-19: interim guidance, 1 February 2021. Geneva: World Health Organization; 2021 (https://www.who.int/publications/i/item/contact-tracing-in-the-context-of-covid-19, accessed 7 May 2021). 2. International Health Regulations (2005) third edition. Geneva: World Health Organization; 2016 (https://www.who.int/publications/i/item/9789241580496, accessed 7 May 2021). 3. Statement on the fifth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic, 30 October 2020. Geneva: World Health Organization; 2020 (https://www.who.int/news/item/30-10-2020-statement-on-the-fifth-meeting-of-the- international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid- 19)-pandemic, accessed 7 May 2021). 4. Considerations for implementing a risk-based approach to international travel in the context of COVID-19: interim guidance, 16 December 2020. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-Risk-based-international-travel-2020.1, accessed 8 May 2021). 5. Considerations in the investigation of cases and clusters of COVID-19: interim guidance, 2 April 2020. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/handle/10665/331668?search- result=true&query=Cases+and+clusters&scope=&rpp=10&sort_by=score&order=desc, accessed 9 May 2021). 6. Considerations for quarantine of contacts of COVID-19 cases: interim guidance, 19 August 2020. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/333901/WHO-2019- nCoV-IHR_Quarantine-2020.3-eng.pdf?sequence=1&isAllowed=y, accessed 8 May 2021). 7. Ethical considerations to guide the use of digital proximity tracking technologies for COVID-19 contact tracing: interim guidance, 28 May 2020. Geneva: World Health Organization; 2020. (https://apps.who.int/iris/handle/10665/332200?search- result=true&query=ethical+considerations&scope=&rpp=10&sort_by=score&order=desc, accessed 8 May 2021). 9 Annex 1. Suggested steps (standard operating procedures, SOPs) for sharing information for international contact tracing SOPs for sharing information for international contact tracing are proposed for each scenario described in the main text. Countries are encouraged to adapt these procedures based on existing national legislation, systems and SOPs. To ensure effective and timely contact tracing, it is desirable to complete all steps within 48 hours from the identification of the case (scenarios 1, 3a and 3b) or contact (scenario 2). Scenario 1 Responsible authority or entity Procedure 1 Country of departure – public health unit or conveyance operator Upon identification of a confirmed or probable case who departed for another country by subnational public health unit, or by conveyance operator, report the case information to the national public health authority (go to step 2) or IHR NFP (go to step 3) following the national reporting protocol. 2 Country of departure – national public health authority Upon receiving information on a confirmed or probable case who departed for another country or area, validate the information if needed, and prepare the basic case information to be shared with the country of destination. Pass on the case information to the IHR NFP. 3 Country of departure – IHR NFP Prepare the basic information of the identified case, following the national protocol for sharing case information internationally to another country or area. This process may require internal approval depending on country’s requirement. Create an email message and a password-protected file containing basic case information (see Annex 2 for the procedure for password protection). 4 Country of departure – IHR NFP Send the email message attaching the password-protected file containing basic case information to the IHR NFP(s) of the concerned country or countries. The password should be sent via a separate email. This communication can be done with or without copying the IHR Contact Points at WHO regional offices. 5 Country of destination – IHR NFP Acknowledge the email received from the IHR NFP of the country of departure and share the information with the relevant public health unit in charge of case investigation and contact tracing (following the national protocol). 6 Country of destination – public health unit Conduct investigation of the reported case, and trace and manage his or her close contacts, following the national protocol. If additional information is required from the country of departure, ask the IHR NFP to request it (clarify what specific information is needed). Otherwise, the process of international information sharing is complete. 7 Country of destination – IHR NFP Communicate with the IHR NFP of the country of departure to request additional information required for investigation of the case. 8 Country of departure – IHR NFP To the extent possible, provide information requested by the country of destination to support case investigation and contract tracing. Use a password- protected file for sharing information of the case. 10 9 Country of destination – IHR NFP Acknowledge the information received from the IHR NFP of the country of departure and share the information with the public health unit that requested the additional information. 10 Country of destination – public health unit Use the additional information to conduct or optimize case investigation. Repeat steps 7 to 9 if needed. Otherwise, the process of international information sharing is complete. Scenario 2 Responsible authority or entity Procedure 1 Country of departure – public health unit or conveyance operator Upon identification of contacts (of a confirmed or probable case) who departed for another country by a subnational public health unit, or by conveyance operator (e.g. among crew member), report the information of the contact(s) to the national public health authority (go to step 2) or the IHR NFP (go to step 3) following the national reporting protocol. 2 Country of departure – national public health authority Upon receiving information of contacts who departed for another country, validate the information if needed, and prepare the basic information of the identified contact to be shared with the country of destination. Pass on the information to the IHR NFP. 3 Country of departure – IHR NFP Follow the national procedures for sharing personal information internationally with another country. This process may require internal approval depending on the country’s requirement. Create an email message and a password-protected file containing basic case information (see Annex 2 for the procedure for password protection). 4 Country of departure – IHR NFP Send the email message attaching the password-protected file containing basic information of the identified contact to the IHR NFP(s) of the concerned country or countries. The password should be sent via a separate email. This communication can be done with or without copying the IHR Contact Points at WHO regional offices. 5 Country of destination – IHR NFP Acknowledge the email received from the IHR NFP of the country of departure and share the information with the relevant public health unit in charge of contact tracing (following the national protocol). 6 Country of destination – public health unit Identify and initiate management of contacts, including quarantine, following the national protocol. If additional information is required from the country of departure, ask the IHR NFP to request necessary information (clarify what specific information is needed). Otherwise, the process of international information sharing is complete. 7 Country of destination – IHR NFP Communicate with the IHR NFP of the country of departure to request additional information required for tracing and managing the contact. 11 8 Country of departure – IHR NFP To the extent possible, provide information requested by the country of destination to support contract tracing. Use a password-protected file for sharing information of the case. 9 Country of destination – IHR NFP Acknowledge the information received from the IHR NFP of the country of departure and share the information with the public health unit that requested the additional information. 10 Country of destination – public health unit Use the additional information to conduct or optimize contact tracing. Repeat steps 7 to 9 if needed. Otherwise, the process of international information sharing is complete. Scenarios 3a and 3b Responsible authority or entity Procedure 1 Country of destination – public health unit Upon identification of a confirmed or probable case who arrived from another country, whose symptom onset (symptomatic case) or specimen collection for a positive result (asymptomatic case) occurred during the travel or within 2 days after arrival (or within 14 days for backward contract tracing), report information of the case to the national public health authority (go to step 2) or the IHR NFP (go to step 3) following the national reporting protocol. 2 Country of destination – national public health authority Upon receiving information on a confirmed or probable case, validate the information if needed, and prepare the basic case information to be shared with the country of departure. Pass on the case information to the IHR NFP. 3 Country of destination – IHR NFP Prepare the basic information of the identified case following the national protocol for sharing case information internationally with another country. This process may require internal approval depending on the country’s protocol. Create an email message and a password-protected file containing basic case information (see Annex 2 for the procedure for password protection). 4 Country of destination – IHR NFP Send the email message attaching the password-protected file containing basic case information to the IHR NFP(s) of the concerned country or countries. The password should be sent via a separate email. This communication can be done with or without copying the IHR Contact Point(s) at relevant WHO regional office(s). 5 Country of departure – IHR NFP Acknowledge the email received from the IHR NFP of the country of destination and share the information with the relevant public health unit in charge of case investigation and contact tracing (following the national protocol). 6 Country of departure – public health unit Assess the information received. If there is adequate information, initiate contact tracing and manage the identified contacts following the national protocol. If additional information is required from the country of destination, ask the IHR NFP to request necessary information (clarify what specific information is needed). Otherwise, the process of international information sharing is complete. 12 7 Country of departure – IHR NFP Communicate with the IHR NFP of the country of destination to request additional information required for contact tracing. 8 Country of destination – IHR NFP To the extent possible, provide the information requested by the country of departure to support contract tracing. Use a password-protected file for sharing personal information. 9 Country of departure – IHR NFP Acknowledge the information received from the IHR NFP of the country of destination and share the information with the public health unit that requested the additional information. 10 Country of departure – public health unit Use the additional information to conduct or optimize contact tracing. Repeat steps 7 to 9 if needed. Otherwise, the process of international information sharing is complete. Scenarios 4 This scenario usually does not require information sharing between countries for international contact tracing. However, the identified contact should be followed and supported for quarantine by the local public health authority in accordance with the national protocol. If the exposure occurred in an international conveyance, it is important to coordinate with the conveyance operator to assess the risk of exposure, and identify all the passengers who are considered as having close contact with the case. In case any passenger who is identified as a close contact is allowed for onward travel, then such information should be shared with the country of destination of the passenger. In case the contact is diagnosed as COVID-19 within 14 days after the departure from the country of departure, then the person should be considered as a case and follow the procedures for the scenario 3a or 3b to initiate information sharing for international contract tracing. 13 Annex 2. Procedure for creating password-protected files Passwords are case-sensitive and can be a maximum of 15 characters long. Microsoft Word® file (Word for Microsoft 365, Word 2019, Word 2016, Word 2013 and Word 2010) 1. Open the Word document. 2. Click on File. 3. Click on Info. 4. On the right side, click the Protect document menu. 5. Select the Encrypt with Password option. 6. Type a password to protect the document. 7. Click the OK button. 8. Retype the password. 9. Click the OK button. 10. Once you complete these steps, every time you open the document, you will be prompted to enter the password to decrypt its contents. Microsoft Excel® file (Excel for Microsoft 365, Excel 2019, Excel 2016, Excel 2013, Excel 2010 and Excel 2007) 1. Open the Excel sheet document. 2. Click on File. 3. Click on Info. 4. On the right side, click the Protect Workbook menu. 5. Select the Encrypt with Password option. 6. Type a password to protect the document. 7. Click the OK button. 8. Retype the password. 9. Click the OK button. 10. Once you complete these steps, every time you open the document, you will be prompted to enter the password to decrypt its contents.