Immuni, the contact tracing application desired by the government, has so far contributed little to attempts to contain the second wave of coronavirus that has affected Italy. If you look at the numbers published on the official website of the app, updated as of 25 October, you can see that despite the 9.3 million downloads, Immuni sent only 36,200 notifications of exposure at risk with a positive. Furthermore, only 1,530 coronavirus positive people have used the app to alert their close contacts, thus generating the aforementioned 36,200 notifications. The numbers are on the rise: in the last week, the notifications sent were about 14 thousand. But given that the new positives in Italy are now more than 20,000 per day, and that the contacts of each positive are on average at least 10 (but often many more), the final result is insufficient.
Taking it out on Immuni is in a certain sense ungenerous, because few of the measures to contain the second wave have worked as expected, and this applies to both Italy and Europe. But Immuni's success or failure is particularly important because contact tracing in Italy is failing, and having technological tools to help Tracers in trouble would be key.
– Read also: Contact tracing no longer works
We have put together a few of the things that don't work, and a few of the things that might work better, to understand if Immuni will be able to lend a hand during the second wave or if, as now, it will have a small and insignificant part in the containment policies of the epidemic.
Technical problems
Does Immune work? Those who download the app for the first time might wonder. After installation, in fact, Immuni no longer makes itself heard: it is as if it did not exist. On iPhones and some Android models, but not all, it sends a periodic notification to those who have not had risk exposures to remind them that everything is fine. On many smartphones, however, it remains completely inert. The idea is that the app acts in the background, without disturbing, and that it sends the notification of a risk exposure only at the right time.
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In reality there have been problems that in some cases have slowed down the notification work of the exhibitions: in September Repubblica reported a malfunction that made the app on android phones, and that has been fixed. More recently, however, many iPhone users have noticed when opening the app that Immuni had detected a contact at risk, but had not sent them the notification. This problem appears to be due to Apple's latest operating system, iOS 14, and has not been fixed for now, although there are ways around it. While the Android version of the app explicitly says “Open Immuni once a day to check its status”, this advice is not present on iOS. Yet it is better to do it: Immuni may have detected your contact with a positive but not have notified you. You have to enter the app and see if there is a warning or not.
This does not mean that Immuni is a technically bad app, quite the contrary. The code of Immuni is open source, so it is freely available, and several people expert in technology and development of smartphone applications have confirmed that Immuni is written excellently: Bending Spoons, the company that took care of it, is very efficient. in its field.
– Read also: Immuni, well explained
But Immuni is an app that has a harder life than others, not only because it must work well on all smartphones in Italy on which it can be installed, but also because it must integrate with the Apple and Google exhibition notification protocols: this often means that problems do not depend on its code, but on protocols or on the integration between code and protocols. In general, when there is a problem on Android you have to go to Google and when there is a problem on the iPhone you have to go to Apple. Public administrators who have been involved in the implementation of the Immuni project have said that Google is usually more responsive than Apple in solving problems.
The confusion over the notification
What to do when I get a notification from Immuni? In theory it's simple, says the app: you have to contact your general practitioner and follow his instructions. The doctor will then contact the competent ASL. The fact is that what the doctor decides can vary enormously, and no one really knows what awaits him when, after receiving a notification from Immuni, he decides to report it.
The main problem is that Immuni identifies a “contact at risk”, but the technological system on which it is based allows for very little information on this contact: the date it occurred, as well as the certainty that the smartphones of the two people were less than two meters away on the other hand for at least 15 minutes. Some people may remember that they were in a restaurant that day, and imagine that the contact at risk was a diner or a neighbor, but for others it may be impossible to reconstruct how the contact took place, and this means that doctors find themselves taking difficult decisions with very little information available.
On the subject, the health authorities are very ambiguous. The circular of the Ministry of Health of 29 May, which defines the parameters for contact tracing and for Immuni, says that those detected by Immuni are “close contacts”: but at the same time it says that doctors and pediatricians of free choice are entitled to a “Assessment of the subject's actual risk exposure”. The definition of “close contact” is important: if you are asymptomatic close contact of a positive, the guidelines of the ministry leave no room for discretion to doctors, and impose a quarantine of 10 to 14 days, depending on whether or not to do a swab. Being recognized as a “close contact” also means being taken over by the regional ASL, having the right to a certificate of illness and having a swab. In short: close contacts are a central category in the whole tracking system, and unfortunately it is not yet clear what role Immuni plays.
The Post asked the Ministry of Health directly how a notification from Immuni, and the response was that the notification is a close contact, and “we need to quarantine.”
– Read also: What to do if you have had close contact with a positive coronavirus
This, at least in theory, counts as a last word, because the decisions on the quarantine protocols are up to the ministry. In reality, everyone continues to interpret the value of the notification in their own way. The Post also spoke with representatives of the Minister of Innovation, who has no competence on quarantines but managed the development of the Immuni app and its operating criteria, and the interpretation changes: the one detected by Immuni is indeed a “close contact », But then the decision on whether or not to impose the quarantine rests with the doctor.
Also the regional ASL interpret the value of the notification in various ways: in Lombardy the ATS has communicated to doctors that anyone receives the notification must do a quarantine period of 14 days, from which you can exit – so say the guidelines sent to the doctors – only with a negative swab. Veneto interpreted the ministerial provisions in a restrictive manner, but rebelled: the public reason why the Region did not use Immuni until a few days ago was that the local government did not agree in considering the notifications as close contacts ( we go back). In Emilia-Romagna, on the other hand, the interpretation is much looser: the AUSL of Bologna, with a web page published only a few days ago, provides those who have received a notification from Immuni the possibility of taking a swab by booking it autonomously and, in awaiting the outcome of the test, advises to “avoid contact with other people as much as possible”, without talking about quarantine.
And then there are the general practitioners, who with little information to their disposition make enormously varied decisions. There are no exhaustive data, but on an anecdotal level it can be said that sometimes doctors impose quarantine on patients, sometimes they book a tampon for them, in the Regions where they can do it, sometimes they find middle measures, such as advising to stay at home only a few days, and sometimes they tell the patient to ignore the Immuni notification. Part of this strong variability also depends on the poor support that doctors have received: some of them have said that, from the launch of the app to today, they have never been contacted by their ASL or by any other health authority about Immuni. : they have not been provided with material, guidelines or communications of any kind.
Loading the codes
Since the Prime Minister's Decree of 18 October, the government has imposed on all ASL operators the obligation to enter the codes of positive citizens who use the app in the Immuni central system. It means that when a citizen tests positive for a swab, the health worker who communicates the positivity to him is also obliged to ask him if he has installed Immuni and, if necessary, to upload his anonymous codes to the central system, so that contacts can receive notification of exposure to risk. This very recent government imposition also indicates that, before 18 October, not all regional ASLs loaded the codes.
– Read also: The Veneto Region is not using Immuni
The best known case is that of Veneto, which only integrated Immuni into its system in mid-October, but there are other regions that have explicitly boycotted Immuni, in many areas app support has often been overlooked. Again on an anecdotal level, it happens that positive people say that the health professionals who communicated the positive test to them did not then mention Immuni during the conversation.
There are problems with integration and delays
From what has been said so far, it seems that one of the main problems of Immuni is its poor integration with the national and regional health system: the protocols are not clear , some general practitioners do not know what to do with it, the ASLs boycott or neglect it, and so on. There are a few ways to explain this lack of integration, which is greatly complicating the coronavirus tracking attempts.
Possibility 1: External infrastructure is lacking
It is the most common and accredited hypothesis: Immuni finds it difficult to track infections because all the infrastructure that is around it, and which does not depend on the app, is lacking. This would be the reason why notifications of exposure to risk often arrive very late, even 10 days after contact with a positive, when their usefulness is now very limited: for a notification to arrive, the contact must develop. symptoms, do the swab, receive the result, come into contact with the ASL and that the health worker who communicates the positivity uploads the Immune codes on the central system. This operation was rapid until a few weeks ago, when the Italian “trace and test” system was still reactive, but now that it is overwhelmed by new cases, and that in many areas of Italy making an appointment for a swab takes time and results arrive many days late, Immuni slows down along with everything else.
The infrastructure theory is supported among others by Luca Ferrari, the co-founder of Bending Spoons, who at Repubblica a few days ago he said that “the most urgent problems to solve are outside the app.” According to Ferrari, a national call center would be needed to manage the positives and upload their codes. Furthermore, it would be necessary to ensure that those who receive a notification will be able to take a swab in the shortest possible time. Other experts are of the same opinion. The Professor Andrea Crisanti said a few days ago to Adnkronos: «We must have Immuni, a tracking system, an enhancement of the buffers. In a similar context, even Immuni would work. “
Possibility 2: political will is lacking (but maybe we solve this)
Other commentators have argued that if certainly Immuni has an external infrastructure problem, on the other hand the efficiency of the app does not depend only on that of the pads. In recent months, other measures could have been taken to make Immuni more useful and responsive, but the government has only recently been adopting them, once the crisis has already begun.
In the “refreshment decree” approved by the government, October 27, for example, the establishment at the Ministry of Health of a “national telephone answering service for health surveillance”, practically the call center mentioned by Ferrari, whose operators will have, among other things, “the task to carry out contact tracing and health surveillance activities “. Above all, operators will have access “to Immuni's central system to upload the key code in the presence of a positive case”. There is already a call center dedicated to Immuni only, but it only provides information. The establishment of this call center is a welcome change, but it is a step that should have been taken months ago (and which will probably take additional time to implement). Immuni in this is not an isolated case, but many circumstances suggest that in these months of preparation for the second wave the app has been neglected by the government.
Some people heard by the Post and who have collaborated in the implementation of the Immuni project, in particular, said that for the Ministry of Health the app was a rather low priority. Another element of neglect is the fact that the promotion campaign of the Ministry of Innovation to persuade Italians to download Immuni only started in September, when it would have been better to get close to the second wave with as many downloads as possible.
Possibility 3: Immune is an inadequate tool
This is the most extreme hypothesis, but it deserves to be taken into consideration because it is supported in Italy by the same experts who, between March and April , had promoted the creation of a contact tracing app. The idea is that “Immune works but does the bare minimum”, says Carlo Alberto Carnevale Maffè, professor at Bocconi University and member of the task force appointed last April by the Ministry of Innovation to evaluate contact tracing applications: therefore one of the people who materially chose Immuni (even though there was controversy about this: the members of the task force said that the ministry had disregarded some of their indications).
Carnevale Maffè and other professors who have been part of that task force – or who have studied digital contact tracing – today say that Immuni is incomplete, because the data it provides on contact with a positive is not sufficient for the needs of tracing. According to them, a geolocation of the contacts would be needed (ie knowing where the contact took place) and the possibility of reconstructing a “social graph”, that is, to anonymously compare the results of the notifications in order to reconstruct the second or third level contacts. The use of geolocation in tracking apps has been banned by the government and is not compatible with the Apple and Google protocols used by Immuni, by the will of the two companies.
Some things are improving, others not
The increase in notifications sent by Immuni in the last few days and the indications in the “refreshment decree” for the creation of an operational call center, that contributes to the tracing activity, are both elements that suggest that the government has decided to fully support Immuni. The same applies to the obligation imposed on the ASLs to upload the positive codes.
In general, it is possible that the lack of integration between Immuni and the health system, which has not yet been due to neglect, it will start now, partly thanks to last-minute measures and partly because doctors, ASLs and health professionals are starting to really deal with Immuni, which was launched in May, when by now the first infection curve had been largely lowered.
This is an element that Immuni shares with other European contact tracing apps, which are quite similar to each other because all – except the French one, but it's not a case of success – they use Apple and Google protocols. Immuni is less downloaded than Corona-Warn-App, the German application that has 19 million downloads, and NHS Covid-19, the English app that has 18 million, but is more widespread than the respective apps in France and Spain. From the point of view of effectiveness, the role of all European apps in tracking activities has so far been reduced, and largely still to be tested.
One of the further problems of Immuni, which influenced downloads, it was its politicization: being a government initiative, in the spring and summer the app was heavily criticized by opposition figures (and in some cases even by some politicians closer to the government) , who advised their constituents not to dump it. Attitudes may change as the health crisis deepens. Matteo Salvini, leader of the League, criticized Immuni just a few days ago.
