Saturday, October 24, 2020

What went wrong with Covid-19 Contact Tracing Apps - PART III

The Ups and Downs of Immuni

A Brief History of the Italian Contact Tracing App

Italy was the first nation in Europe to be heavily hit by the COVID-19 wave. In mid February, the virus was silently circulating in the northern regions, and the superspreading event of the Atalanta-Valencia Champions League football match, now known as “Game Zero”, accelerated its diffusion in the nation and later in the rest of the continent. 

Since the early days of the pandemic, researchers, technicians, journalists, and common people started flooding the media with discussions on the possibility of an app to support contact tracing and contain the virus. The solution, called Immuni, was announced on April 16, and was released on June 15, without any financial cost for the Italian government. In mid October, it has been downloaded more than 9 million times (24% percent of Italian smartphones). In almost 5 months from its release, about 1.000 positive users shared their status, out of almost 500.000 positive cases identified. It is not clear how many new cases have been discovered through Immuni at today---the number of notifications is increasing rapidly---but at the beginning of September the total number of people who discovered to be positive thanks to the app was only 7 and one month later increased to 13.

A free, privacy-preserving, transparent app

Immuni only uses public infrastructures located within the national borders, and it is managed by a public company, Sogei S.p.A. The source code has been developed by a private company, Bending Spoons S.p.A. without any financial cost for the government, it is released under a GNU Affero General Public License version 3, and can be downloaded from GitHub

It was  developed to fulfill utility, accessibility, accuracy, privacy, scalability and transparency principles, as stated in its documentation. On October 22, it had 4.1 stars in the App Store, and 3.5 in the Play Store, with highly polarised reviews. One of the most common titles of its negative reviews is “inutile”, which means useless. But let’s start from the beginning. 

Immuni in the Play Store has highly polarized ratings.

How does it work? Immuni uses the distributed DP-3T protocol, and the Google and Apple Exposure Notification framework, which is also adopted by the German Corona Warn-App. The app stores the identifiers of the smartphones of other Immuni users who come into close contact with you for more than 15 minutes, by exchanging information through Bluetooth Low Energy. The identifier of each user is generated locally, and changes frequently. If you are tested positive, a healthcare operator asks you if you want to report your case by sharing your recent list of generated identifiers. If you decide to share, the healthcare operator enables your app to load your list of identifiers on a central server. Each day, Immuni downloads the lists of identifiers of positive cases from the server, and looks for a match in the list of recently met people. This way, the users who came into contact with a positive case can be warned by their app and can go get tested. 

Debated Incubation Italy started its nationwide lockdown on March 9, and less than ten days after, the contact tracing app was announced as “already developed”. The app was expected to use the GPS to track movements, and also to identify crowds and dangerous behaviours. This was of course regarded as a privacy threat by the population and a long debate followed in the news and social media. On 16 April 2020 the solution from Bending Spoon S.p.A. was selected, but many aspects of the working principles of the app (e.g., centralised vs decentralised model), were still unknown, and on April 20 an open letter was issued by Italian researchers encouraging the government to go for a transparent solution and a decentralised model. The public debate led to abandoning the initial option of the GPS, and led to an open-source, privacy preserving, and decentralised app based on Bluetooth. Somehow, the public opinion acted as a (self-involved) user that ended up changing the system specification. 

Late-spring birth After a pilot study in four specific regions that led to the discovery of three cases, Immuni was released on June 16. Italians saluted with excitement, with half a million downloads in the first 24 hours, and two millions in the first week.

Summer hibernation  The initial buzz ended quite early, and the final number of downloads stagnated between 4 and 5 millions for the whole summer, with around 100-200.000 downloads per week. The virus felt less dangerous as the cases were decreasing, and people almost forgot that an app existed for contact tracing. Although the key idea of a contact tracing app is to identify cases of casual contacts, as the family contacts can be traced more easily, the app was not used in the period in which casual contacts were more frequent: summer time, which in Iitaly means seaside crowds, discos, and loud aperitivos in small roads. In Sardinia---a typical holiday region, almost untouched by the virus until June---the number of local outbreaks passed from 3 to 80 during summer.

Autumn awakening With the increasing number of cases that followed the summer (2.000 at the beginning of October and 15.000 today) people started downloading Immuni more and more, with one million downloads per week, somehow looking at it as a vaccine, as also its name suggests. More users means also that more problems are emerging, especially concerning the integration of the app with the regional healthcare system, and, also to avoid the refusal of the app by some of the regions, the Government Decree of October 18 obliges the healthcare operators to enable the loading of the codes for the users who are tested positive. 

Problems and Users’ Opinions

  • I need it! When will they release it? During the incubation of Immuni, from March to June 2020, news and social media were filled with discussions about the imminent release of the digital medicine for COVID-19. Both enthusiasts and skeptics seemed to think that people are as fast in developing apps as the computers are quick in running them, and thought that a novel, privacy-aware software with national impact, and (nice-to-have) able to interact with apps from other nations, could be developed in a weekend of mad programming. This was of course a false hope, but it is true that when the app came out it was almost summer, the pandemic appeared less dangerous (around 100 daily cases in mid-July), and you don’t carry your phone when you’re playing volleyball on the shore. Therefore, Immuni was released too late to be considered useful as initially planned.

  • Wait, is it working? The majority of the app reviews state that the Immuni is useless and they wonder if it’s working. Similarly to the australian app, Immuni was conceived to be as discreet and privacy-preserving as possible, but this implies that it does not clearly report the contacts, and their duration, so that you can have an idea if it is correctly doing what it’s supposed to do. The only moment in which you know that Immuni is working is when you get notified that you had a contact with a positive case. For some users, the possibility of this notification is too scary to keep the app installed. In conclusion, although the app was developed around the pillar of transparency, with open source code, it should also be somewhat transparent at runtime, with clear information about what it has been doing

  • Shall I buy a new phone? The app was designed to be accessible, so that everyone could use it. However, some older versions of Android and iPhone could not run it. Furthermore, with some iPhone versions users complained of having problems when moving to certain provinces, as the app notifies them that their area is not covered. This is also a weird notification, as the app should not be aware of the position of the user.  

  • Oh, I am COVID-19 positive, what to do now? One of the problems noticed by some users is the lack of information on what to do when you are tested positive and you are an Immuni user. You receive the test results at home, and the healthcare operators should provide you information, but this did not happen and a special Government Decree was needed in October to oblige the healthcare operators to take Immuni into account. Still, some users complain that after receiving the results, they did not get any call from the healthcare operators, did not know what to do, and their casual contacts remained unaware of the possibility of being positive. 

  • Oh, I had a contact with a COVID-19 positive, what to do now? Users complained that, after receiving the scary notification that they had a contact with a positive case, they did not know what to do. Were they supposed to self-isolate? Go for a test at their own cost? Many healthcare operators who were called in these cases did not have an answer for that. 

Overall, Immuni in itself appears to do its job, but it is still not well connected with the socio-technical ecosystem for contact tracing, and the healthcare practitioners involved in the contact tracing loop are not sufficiently trained on their role in the usage of the app. 

All is lost?

No, and we do not have to thank only the doctors this time, but also the software practitioners. I will report a personal fact. In my gym there was a positive case. As soon as my coach knew that, he notified us athletes through our Whatsapp group, and told us that we would be called by the healthcare operator to fix a test. The coach also sent the phone number of all the people present during the last training to the healthcare operator. How could he know who was present? Everytime we go, we register through a specific app, so we can be traced. The day after I received a call, I fixed the test, and I received an official email stating that I should self-isolate. After the test, I could check if I was positive from a very simple web portal, set-up just to release COVID-19 analysis (I was negative). This whole loop did not involve Immuni, but was supported by apps and software, that, together with the platforms entertaining me during the self-isolation, made me clear how much software practitioners have done to set-up the infrastructure to fight the pandemic, even before knowing there would be one. 


Previous Articles on Contact Tracing Apps