Abstract
Due to the global spreading of the COVID-19 virus, countries all over the world are faced with the need to conduct centralized quarantine or home quarantine for "persons who have been in contact with individuals diagnosed with the COVID-19 virus" and "visitors who have travel histories via COVID-19 hot zones". We have presented the community home quarantine service platform design that was utilized in Nanjing, China when the first wave of citizens returns to work after the Chinese New Year holidays on 10th Feb 2020.
The main functions of the home quarantine monitoring system include (1) community grid management,(2) GPS positioning application in home isolation movement management,(3) Bluetooth body temperature patch data transmission integration, (4) health assessment scale (physical and mental health state) and (5) multilingual language options.
Introduction
It is well established at present that the COVID-19 virus is highly contagious1,2,3 and rapidly spreading due to fast moving global traffic via close contact between humans4,5. Regions with either severe community transmission or the presence of strict pandemic prevention measures can focus on the reduction or minimization of human contact to reduce the risk of widespread community transmission in addition to the present procedure of movement tracking of confirmed cases6. The most common method currently being used is either thru quarantine or self-monitoring for fourteen days after returning from affected regions7,8.
Centralized quarantine is the most convenient community transmission prevention management method but it may not be practical in some scenarios. Home quarantine is at present the most common method but the immediacy and reliability of monitoring and management are vulnerable to breaches resulting in loopholes in the prevention of community transmission.
Our main goal of this study is to establish a Real-time Responsible Home Quarantine and Monitoring Management Service which is able to reliably and efficiently manage thousands of quarantined individuals without them being in direct contact with our monitoring management personnel. Taking into consideration of area size and number of quarantined individuals, this monitoring and management system should adopt a hierarchical approach with correspondingly supervisory staff responsible for each level.
The scope of responsibilities for monitoring personnel includes (1) enforcement actions on breaching quarantine restrictions in accordance with local laws9,10; (2) detection of higher than normal body temperatures (although COVID-19 carriers may not always exhibit fever symptoms, it is of the utmost importance to pay special attention to quarantined individuals who might have come down with fever); (3) the mental health of quarantined individuals after a prolonged period of quarantine may have been affected so it is important to monitor their behavior in order to provide timely care and assistance when necessary11,12.
In major cities around the world where human traffic consists of a very diverse and multinational population, it is essential that services are available in multiple languages catering to different nationalities to effectively monitor and manage quarantined individuals to prevent loopholes in the pandemic prevention system.
A cross-platform Mobile Application taking into consideration the above factors could be designed to provide to the public with convenient access to self-monitoring and management via Bluetooth capable smart phones on both the Android or iOS platforms. The smart phone integrated with a personal temperature monitoring patch connected via Bluetooth would then interact with the App to transmit real time data and temperature warnings to supervisors and the establishment of a web management system for local first responders providing for a Real-time Responsible Home Quarantine and Monitoring Management mHealth Platform.
Design
The technology being utilized on this platform includes (1) HTML5 which is currently the most popular cross-platform Web App development technology; (2) Geolocation which utilizes the GPS capabilities of smart phones and online mapping API services for real time location positioning; (3) Bluetooth Low Energy (BLE) transmits measurement information between the body temperature patch and the phone and (4) Node.js is Server site JavaScript technology which is being used to build Web Services for the entire platform.
Grid Management of Hierarchical Administrative Regions
Diverse regions around the world have different levels of local administrative boundaries and different scope coverage of their respective administrative area. Therefore, our design considers a hierarchical management structural approach with multiple administrative affairs systems in the administrative region hierarchy with the specific location as the key factor. Taking for example the coverage of this platform, our first level of administrative management system is the civil administration system. There are six levels of coverage in a city. The second administrative management system is the system of the police force. It has seven levels of coverage in a city. These two different administrative systems (2 Trees) are both able to monitor in real-time the status of individuals under home quarantine and receive warning notifications in this tree structure and provide first response or follow up actions in accordance with their respective unit roles.
In terms of system design, the most basic management unit of the platform is the individual with the home quarantined individual being regarded as the leaf node, which is the bottommost administrative unit connected to the system. The interpretation in abstract is that there is only one Organization Resource (refer to HL7 FHIR Organization Resource13), which can then be flexibly applied to represent a tree-like organization structure regardless of the amount of hierarchical layers.
In the actual application of this platform, the bottommost administrative personnel (referred to locally as either the grid administrator or the community police) will be responsible for front-line operations such as the status monitoring, intervention during detection of abnormalities and basic necessities of quarantined individuals under their jurisdiction. Platform services can ensure that the essential data of quarantined individual can be effectively shared and managed while preventing any face to face contact between our front-line personnel and the quarantine individuals.
The service platform overview features
The platform service is mainly composed of the Client App at the end of the individual under home quarantine and the Monitor Dashboard App on the end of the management personnel. Management personnel of all hierarchical levels log in to the same Monitor Dashboard App but the range of data available to them varies according to their clearance levels. User Interface Exploded view is shown in Figure 1 and detailed system functions are shown in Table 1.
Figure 1.
User interface exploded view.
Table 1.
System function list.
| 1. Home Quarantine Client App (HTML5 cross platform App) |
| 1.1 Status summary, including: A) current body temperature, B) isolation days, C) body status, D) mental status |
| 1.2 Bluetooth body temperature patch using guide |
| 1.3 Bluetooth body temperature patch connection status |
| 1.4 Contact history |
| 1.5 Support needs message |
| 1.6 Health instruction and education |
| 1.7 Medication reminder (on demand) |
| 1.8 Food and drink record (on demand) |
| 1.9 Sport record (on demand) |
| 1.10 Vital sign record |
| 1.11 Physical and mental health questionnaire |
| 1.12 Progress note of quarantine |
| 1.13 Government declarations of epidemic prevention |
| 1.14 GPS trace history |
| 1.15 Home location setting |
| 2. Monitoring and Management Web App |
| 2.1 Quarantined list of hierarchical grid management |
| 2.2 GPS location monitoring of grid manager |
| 2.3 Quarantined list import and export |
| 2.4 Government declarations and health instruction maintenance |
| 2.5 Quarantined individual location alert list |
| 2.6 Support demand message management |
The main functional module blocks of the Client App on the top displays the grassroots management unit to which the monitoring staff belongs to. The right side displays the current status of the Bluetooth body temperature patch device in color while the orange block displays the main aspects of the quarantined individual’s status summary including (1) name, (2) temperature, (3) number of days under quarantine, (4) physical and mental state indicators and (5) location of the quarantined individual.
The main function menus of the Monitor Dashboard App are on the left, from top to bottom accordingly (1) the list of monitoring personnel and their detailed status data, (2) GPS footprint tracking and query, (3) data export procedures, (4) bulletin maintenance management, (5) abnormalities warning notification lists and (6)requests handled during home quarantine.
Geolocation & Period Care Questionnaire
All platform users would have the Client App installed on their smartphones. The individual under quarantine must first set the home GPS location of his home quarantine address upon first login to the Client App. The GPS function on the smartphone would then be used in conjunction with the Web API Service periodically collecting the geographic location data (Geolocation) of the quarantined individual and proceeding to gauge the relative distance from the home location to the quarantined individual’s actual location. If this relative distance exceeds a certain threshold, the Client App would generate a warning event notification to the first responders via SMS text message and management Web App for intervention and follow up. Other units higher up the hierarchical chain of command would also be able to receive real-time event notifications and updates of all home-quarantined individuals in via the management web app in accordance with their area of responsibility and coverage.
During designated intervals, a "Caring Notice" questionnaire will also automatically pop up on the Client App. This designated time interval can be preset according to region preferences. This questionnaire will monitor the basic health status of the quarantined individuals for example whether they are unwell and/or if they are having adequate sleep and meals. At the conclusion of the questionnaire, the quarantined individuals are also required to upload live photos to ensure that the operation of the Client App is being done by the quarantine individual or assisted by an approved family member. In the event the questionnaire is not being responded to within a stipulated period of time, a non-responsive event notification would then be generated to remind the front-line management service personnel to intervene and provide follow up response.
This platform’s Geolocation Web API Service utilizes the Baidu Map JavaScript API which technicality wise provides GPS, WiFi, and base station fusion positioning. Under acceptable GPS signal strengths, the positioning margin of error is under 10 meters or lower. In other parts of the world, there are also other Geolocation Web API Services available and one such example would be Google Map.
Our platform combines these two mechanisms to ensure reliable real-time location pinpointing of individuals under home quarantine and ensuring that front-line management service personnel can effectively respond to both the needs of these individuals and also to any emerging scenarios. User Workflow is shown in Table 2.
Table 2.
User Workflow of Geolocation Monitoring & Care Questionnaire.
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Real-time Body Temperature Monitoring with Smart Thermometer Patch
Individuals deem to require home quarantine is usually people with contact history with diagnosed patients or with prior travel history to affected areas. For individuals who are not currently exhibiting any obvious symptoms, the most clear physiological indication at this stage is body temperature14,15.
The measurement of body temperature via wearable measuring devices has matured as a technology in recent years. Measuring of body temperature can be continuously done via a small (28 mm * 26 mm * 3.5 mm, 3g weight) rechargeable body temperature patch without impacting the user from going about his daily activities. Body temperature data can be collected in real time from the patch to a smartphone through BLE transmission and then synchronized by the Client App to the Web App via the platform management eliminating errors often caused by oral or artificial recordings.
The body temperature patch used on this platform is a CE certified commercially available product with a measurement accuracy threshold of within +/- 0.05 ° C. Additionally, the patch itself is both waterproof and dustproof with coefficient standard of IP 34. The patch is attached to the left armpit of the human body to directly measure the core temperature of the human body.The system design records and stores (Archive) an individual’s body temperature data via a user account and can also support the use of multiple user accounts on a single smartphones (such as for the co-monitoring for parents and their children).
Physical and Mental Health State Assessment
After a prolonged period of isolation while under home quarantine, individuals may experience deterioration in both their physical or psychological states. Based on the principle of minimizing contact with, this platform utilizes a daily questionnaire for the purpose of self-assessment. Due to the fact that quarantined individuals do not have a trained medical professional at their side to assist them, the primary focus on the design of this questionnaire is to be as simple, speedy and straight to the point as possible. We developed two questionnaires Table 3 COVID-19 Symptom Assessment, that includes dyspnea or shortness of breath, coughing, fever, and other systemic symptoms of discomfort. and Table 4 A Mental State Assessment Scale, which includes signs of nervousness, distress or anger, depression, insomnia, and any other signs which might indicate the possible presence of self-harm16,17.
Table 3.
Simple home quarantine body status questionnaire.
| Total score range | Alert Color | Description | ||||||
| 0~1 | Green | Normal | ||||||
| 2~4 | Red | Suspected symptoms | ||||||
| Question 1: Whole Body Condition (Multiple choice) | ||||||||
| 0 | Normal mental, appetite and sleep | 1 | Poor spirit, poor appetite | |||||
| Question 2: Respiration Condition (Multiple choice) | ||||||||
| 0 | No dyspnea or shortness of breath | 1 | Increased frequency, even breathing difficulties | |||||
| Question 3: Cough Condition (Multiple choice) | ||||||||
| 0 | Asymptomatic | 1 | Severe symptoms, mainly dry cough | 1 | Accompanied by sputum, wheezing | |||
| Question 4: Fever Condition (Multiple choice) | ||||||||
| 0 | Asymptomatic | 1 | Fever within 72 hours | 1 | High fever more than 72 hours | |||
Table 4.
Simple home quarantine emotion status questionnaire.
| Total score range | Alert Color | Description | |||||||
| 0~5 | Green | In a good mood. | |||||||
| 6~9 | Yellow | Mild emotional distress, emotional support is recommended. | |||||||
| 10~14 | Orange | Moderate emotional trauma, referral to psychiatric treatment or professional consultation is recommended. | |||||||
| 15~24 | Red | Severe emotional distress, referral to psychiatric treatment or professional consultation. | |||||||
| Question 1: Feeling nervous (Multiple choice) | |||||||||
| 0 | Absolutely not | 1 | Slight | 2 | Moderate | 3 | Severe | 4 | Very serious |
| Question 2: Feeling easily upset or angry (Multiple choice) | |||||||||
| 0 | Absolutely not | 1 | Slight | 2 | Moderate | 3 | Severe | 4 | Very serious |
| Question 3: Feeling depressed (Multiple choice) | |||||||||
| 0 | Absolutely not | 1 | Slight | 2 | Moderate | 3 | Severe | 4 | Very serious |
| Question 4: Feel inferior to others (Multiple choice) | |||||||||
| 0 | Absolutely not | 1 | Slight | 2 | Moderate | 3 | Severe | 4 | Very serious |
| Question 5: Difficulty sleeping, such as difficulty falling asleep, waking up early (Multiple choice) | |||||||||
| 0 | Absolutely not | 1 | Slight | 2 | Moderate | 3 | Severe | 4 | Very serious |
| Question 6: Have suicidal thoughts (Multiple choice) | |||||||||
| 0 | Absolutely not | 1 | Slight | 2 | Moderate | 3 | Severe | 4 | Very serious |
Frontline management service personnel can make use of the Web App to monitor the physical or psychological assessment results and in relation to the assessment scores, highlight warning indicator displays in colors such as green, yellow, orange, and red to provide for easier monitoring and tracking. If a questioner is not filled for a certain day, it would be highlighted in gray. Upon assessment that a quarantined individual may be experiencing signs of physical or mental distress, the frontline management service personnel can then decide to intervene, provide assistance or to refer for consultation with relevant medical professionals.
Multilingual with Internationalization(i18n) Locale
Presently with the worsening status in the global COVID-19 pandemic spreading, regulations are being put in place to home quarantine individuals for a period of 14 days if they have travel history from designated affected areas. Regardless of whether these individuals are exhibiting any possible health symptoms, they must first complete the 14 days quarantine either at home or at a designated quarantine facility before they can resume their daily activities. This situation will inevitably evolve into a universal regulatory norm as the number of confirmed COVID-19 cases continues to rise globally. Ensuring that our Home Quarantine and Management Service Platform’s availability in multiple languages is thus essential in effective epidemic prevention management.
The system design provides the option to switch languages at the Client App’s login screen and upon selection of a particular language, all subsequent related service content is presented in that language including all the options of the daily care notice questionnaire and the physical and mental state assessment scale. On the management end, Web App front-line management service personnel can still monitor and manage quarantined individuals in their own local language setting without being affected by the language preference settings of the latter.
Internationalization is technically set by locale information based on a specific geographic, political or cultural region. Locale information can also be in the form of a language code and an optional country code. The language encoding is defined by ISO-639 (Codes for the representation of names of languages), which is represented by two lowercase letters, such as "ko" for Korean and "zh" for Chinese. Region codes are represented by two capital letters and are defined in ISO-3166 (Codes for the representation of names of countries and their subdivisions), such as IT for Italy and TW for Taiwan. A part of the language comparison table is shown in Table 5.
Table 5.
Partial multilingual (include: English, Chinese, Japanese and Korean) comparison table.
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Result
The basic properties of the platform user
The current online platform has an administrative population of about 260,000. The smallest level of administrative (Grid Node) unit is 267 and the platform is currently being utilized by three groups of users: (1) home quarantine individuals, (2) administrative system managers and (3) police force system managers. This platform has been in use since 9th Feb 2020 and as of 16th March 2020, there were a total of 2,088 users broken down into 779 home quarantined individuals and 1,139 administrative system management personnel of which 983 are frontline management service personnel while the balance 170 are personnel from the police force.
The distribution according to gender and age of the home quarantine individuals is shown in Table 6. 10.91% of the age distribution profile is made up of children and minors under the age of 20, 87.16% consists of adults between 20 and 65 years old and the remaining 1.93% are senior citizens over the age of 65.
Table 6.
Gender and age distribution of home quarantine cases. (n=779)
| Variable | n | % | |||
| Gender | |||||
| Male | 419 | 53.79% | |||
| Female | 360 | 46.21% | |||
| Age | |||||
| 0~10 y | 31 | 3.98% | 41~50 y | 144 | 18.49% |
| 11~20 y | 54 | 6.93% | 51~60 y | 61 | 7.83% |
| 21~30 y | 190 | 24.39% | 61~70 y | 15 | 1.93% |
| 31~40 y | 274 | 35.17% | 71~80 y | 10 | 1.28% |
The amount of daily added home quarantine
The amount of individuals added daily into home quarantine since the platform was launched all the way till the 16th March 2020 is shown in Figure 2.
Figure 2.
The detail of daily added home quarantine cases.
The first wave of a large number of quarantined individuals appeared at the end of January and early February, and the second wave started at 2/10 in the first week to working. Then on 2/18, 2/25, both Tuesday of the week, showing that the people returned to the local area on Monday. Later, they was included in the home quarantine list at the next day. The number of daily added case showed a downward trend until March, and there was a small increase until 3/14.
The amount of location alert
As of the 16th March 2020, the platform has been in operation for a total of 37 days monitoring a total of 779 home quarantine cases. A total of 88 people (11.3% of the total number of home quarantine cases) have breached the preset warning threshold range of leaving their home quarantine locations by exceeding more than 50 meters of the preset location. The total of escaping from home quarantine cases stands at 374 among this 88 people with 71 of them breaching quarantine for 5 times or less, 13 of them from between 6-15 times, and the other 4 for over 15 times.
A further breakdown of the total distance breached (or escapes) at 100 meters or less accounted for 16.87%, 300-500 meters accounted for 69.32% and over 500 meters accounted for 13.81%. The detailed out-of-warning distribution is shown in Table 7.
Table 7.
The detail of location alert events.
| Total alert: 978 events | Total people: 88 | |||
| Distance of escapes | Events | % | Number of escapes | Number of People |
| <100m | 165 | 16.87% | Once | 42 |
| 100~300m | 437 | 44.68% | Twice | 14 |
| 300~500m | 241 | 24.64% | 3~5 times | 15 |
| 500~1000m | 70 | 7.16% | 6~10 times | 6 |
| 1000~2000m | 48 | 4.91% | 10~15 times | 8 |
| 2000~6299m | 17 | 1.74% | >15 times (max to 33) | 4 |
Medical and other results
In the first week of the platform's launch, a total of 324 quarantined individuals (registered before 2/15) from January to early February, 15 of them (4.63%) had triggered a warning of more than 2 points in the daily physical condition questionnaire. Seen as suspected symptoms, referred to hospital for further testing.
During this period, a total of 17 people asked for assistance 34 times, including 29 times for purchasing, parcel collection, and garbage disposal (85.3%), 3 times for physical problems, and 2 times for other problems.
Discussion
The zones which covered by the platform has since been announced by the local government from Monday, 10th Feb 2020 following the end of the Chinese New Year holidays where many would be returning to work and school classes would also begin. This would also mean that individuals who have visited their relatives and have travelled to other countries during this festive season would also be returning around this period. Some of these individuals have visited areas that had been announced as being affected by the COVID-19 virus during this time including the Chinese cities and provinces of Hubei, Zhejiang, and Guangdong provinces and hence needed to be included in the home quarantine management list.
Due to subsequent total traffic closure management measures in some cities in China, the number of returnees from affected provinces and cities in China has gradually decreased but there still remains the requirement for mandatory home quarantine for locals who have had contact with diagnosed patients. With the spread of the pandemic on a global scale, countries like South Korea, Japan, Iran, and Italy have all been listed as affected areas since the end of February. There are also a small number of individuals of various nationalities who have been entered into the mandatory 14 day home quarantine system upon returning to work at the end of February.
Our actual findings of this study are established and managed 779 of home quarantined individuals over a large area. We estimate we can manage thousands of home quarantined individuals using only a smartphone integrated with administrative management system and mHealth service platform.
Quarantine measures often involve both human rights and privacy issues and this study aims to establish and implement an information service procedure that can strike a fine balance between the implementation of home quarantine measures while safeguarding personal rights and privacy in the shortest time possible under the increasingly worsening development of the COVID-19 pandemic. This platform is meant to be both universally inclusive and viable under varying degrees of infrastructure constraints in different regions.
Referring to other previous researches on mHealth application in a wide area and epidemic control18,19,20, this study shows that the use of mHealth technology can effectively and accurately grasp the status of personnel and help us face the challenge of COVID-19 or other infectious diseases in the future.
It is also worthwhile to note that we did encounter problems encountered during the implementation of this system. This include (1) the quarantined individual is either too young or too old to be able to properly operate the basic functions of the Client App and hence we needed to seek the assistance of their family members, neighbors or grid administrators as a workaround, (2) the number of smartphones within a single household is insufficient resulting in the need to perform account switching on a single phone or the reliance on grassroots level administrators to provide an additional smartphone,(3) GPS positioning capabilities may be hampered due to either manual disabling of the phone’s GPS function or in the event of certain smartphone brands’ own automatic firmware updating.
Furthermore when the individuals under mandatory quarantine attempts to intentionally breach their quarantine restrictions, we can only relay the information as fast as possible to first responders and rely on them to get to these individuals as fast as they can in order to address the breach. Temperature measurement patches should also be paired beforehand in scenarios whereby multiple individuals within a single household is quarantined together so that the Client App can detect instances whereby a user is using a wrong patch belonging to another family member.
Lastly, non-local individuals who are being quarantine may not be familiar with local quarantine practices and procedures so it is essential that they be provided with a multiple language user manual to familiarize them with the procedures of home quarantine and what would be expected from them while under quarantine.
The 779 users in this study were all directly assisted by the first-line government service staff of Street Office (the most basic official civil affairs unit in China) in Nanjing City to install this Client App on their personal smartphones. The software service usage agreement description includes: (1) Scope of application (2) Use of information (3) Information disclosure (4) Information storage and exchange (5) Information Security. Each user individually agrees to authorize the use of this Client App to collect, process, and apply data in compliance with local epidemic prevention policies and regulations. Certainly, in different countries/regions, we still need to pay attention to compliance with local personal data and privacy-related regulations.
Conclusion
With the establishment of a real-time responsible home quarantine and monitoring management mHealth platform, we can efficiently and accurately manage future home-based quarantine cases due to global outbreaks of pandemics or highly infectious diseases (such as COVID-19).
Such a service can enable us to instantly access necessary information from quarantined individual while minimizing any possible intrusion into their privacy violation and avoiding face to face contact as much as possible. We can easily replicate and implement this system anywhere in the world with the combination of a variety of proven and popular technologies such as the smartphone, Bluetooth temperature patches, Geolocation, etc.
Acknowledgment
We thank the 9 Rise International Mobile Health Technology (Taipei) Co., Ltd and Kinyoung Smart Health (Nanjing) Co., Ltd for helping this study.
Figures & Table
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