JMIR Preprints Ekong et al

COVID-19 mobile positioning surveillance and contact

tracing, and patient privacy

Iniobong Ekong, Emeka Chukwu, Martha Chukwu

Submitted to: JMIR mHealth and uHealth

on: April 05, 2020

Disclaimer: © The authors. All rights reserved. This is a privileged document currently under peer-review/community
review. Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for
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Table of Contents

Original Manuscript....................................................................................................................................................................... 4

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COVID-19 mobile positioning surveillance and contact tracing, and patient

privacy

Iniobong EkongMD, ; Emeka Chukwu; Martha Chukwu

Corresponding Author:
Emeka Chukwu
Phone: +35699330888
Email: nnaemeka_ec@hotmail.com

Abstract

Background: The coronavirus disease pandemic is the biggest global economic and health challenge of the century. Its effect
and impact are still evolving with deaths estimated to reach 40 million if not checked. One effective and complementary strategy
to slow the spread and reduce the impact is to trace primary and secondary contacts using technology.
Objective: The objective of this paper is to survey strategies for digital contact tracing for COVID-19 pandemic and to present
how using mobile positioning data conforms with Nigeria’s data privacy regulations.
Methods: We conducted an exploratory review of current measures for COVID-19 contact tracing globally. We then analyzed
how countries are using mobile positioning data technology in handling the COVID 19 pandemic spread. We made
recommendations for how Nigeria can adopt this approach in context of Nigeria’s Data protection Regulation (NDPR).
Results: Despite the potentials, digital contact tracing always comes in conflict with patient data privacy regulations. We found
that Nigeria’s response complies with the NDPR, and that it is possible to leverage telecommunications call detail registry
(CDR) to complement current strategies within the NDPR regulation.
Conclusions: Our study show that mobile position data contact tracing is important for epidemic control as long as it conforms
to relevant data privacy regulation. Implementation guideline will limit data misuse.
(JMIR Preprints 05/04/2020:19139)
DOI: https://doi.org/10.2196/preprints.19139

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Original Manuscript

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JMIR Preprints Ekong et al

Does COVID-19 mobile positioning data contact tracing

conform with patient privacy regulation?

Iniobong Ekong1, Emeka Chukwu2 Martha Chukwu3

1
Department of Health Planning, Research and Statistics, FCT Health and Human Services Secretariat, Nigeria
2
Department of Computer Information Systems Faculty of ICT, University of Malta, Msida, Malta
3
Ragnar Nurkse Department of Innovation and Governance, School of Business and Governance, Tallinn University of
Technology, Tallinn Estonia.

Abstract
Background:
The coronavirus disease pandemic is the biggest global economic and health challenge of the
century. Its effect and impact are still evolving with deaths estimated to reach 40 million if not
checked. One effective and complementary strategy to slow the spread and reduce the impact is to
trace primary and secondary contacts using technology.
Objective:
The objective of this paper is to survey strategies for digital contact tracing for COVID-19 pandemic
and to present how using mobile positioning data conforms with Nigeria’s data privacy regulations.
Methods:
We conducted an exploratory review of current measures for COVID-19 contact tracing globally. We
then analyzed how countries are using mobile positioning data technology in handling the COVID 19
pandemic spread. We made recommendations for how Nigeria can adopt this approach in context of
Nigeria’s Data protection Regulation (NDPR).
Results:
Despite the potentials, digital contact tracing always comes in conflict with patient data privacy
regulations. We found that Nigeria’s response complies with the NDPR, and that it is possible to
leverage telecommunications call detail registry (CDR) to complement current strategies within the
NDPR regulation.
Conclusions:
Our study show that mobile position data contact tracing is important for epidemic control as long as
it conforms to relevant data privacy regulation. Implementation guideline will limit data misuse.

Keywords: COVID-19; Contact tracing; NDPR; GDPR; HIPPA; Coronavirus; Surveillance;

mHealth; eHealth; digital health

Introduction
The coronavirus disease 2019 code-named COVID-19 is caused by severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) [1]. This infectious respiratory disease was first detected in
Wuhan City, China, in December 2019. It was declared a global pandemic by WHO on March 11th,
2020, and has currently infected over two million people globally, killing over 150,000 people.
Globally, responses have been swift and in full influenza pandemic control mode [2]. Travel and
movement restrictions to curtail spread both within and across cities are in force. Many cities around
the world are in lockdown or lock-in mode. Some have issued dusk-to-dawn curfews. In other
scenarios, large gatherings have either been banned, or discouraged. Estimates suggest that this
pandemic can claim the lives of as many as 40 million people globally [3]. The Spanish flu that

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lasted between 1918 and 1920 in some places has been estimated to have cost the lives of between
21million and 50 million people globally [4]. Evidence suggests that influenzas can mainly be spread
through large clusters [5]. The WHO Global Influenza preparedness plan are guidelines for influenza
and other disease management and control [6]. Nigeria, one of the countries that adopts WHO
guidelines have over 493 cases diagnosed as of 17th April 2020, with seventeen mortalities. This is
an increase from an index case first reported on February 27th. To better manage the spread, the
Nigeria’s Federal Government has declared a lockdown in key affected states of Lagos, Ogun, and
the Federal Capital Territory. The lockdown was in addition to several mitigating actions by State
governments, ranging from a ban on social gatherings to dusk-to-dawn curfews. During the
lockdown, schools, markets, churches, mosques, banks, offices, parks, motor parks, and airports
remain closed often for 14 days.

The Nigeria Centre for Disease Control (NCDC) reported it is currently conducting contact tracing of
over 9000 contacts of confirmed cases in an attempt to effectively contain the spread of the disease,
in line with recommended measures for response in a pandemic [7, 8]. These measures include
antiviral, vaccine, and non-pharmaceutical measures such as case isolation, household quarantine,
school or workplace closure, and travel restrictions. Given the scale of the COVID 19 pandemic,
non-pharmaceutical actions appear to be the only practical and logical option in the absence of any
known antiviral drug or vaccine. Resources are stretched even in advanced health systems, as seen in
Italy, United Kingdom, China, and the United States [9] [10].

NCDC's approach, has been commended for its compliance with WHO guidelines for large scale
containment and contact tracing, there remain options that may yet be explored [11]. Given the
inadequacy of testing kits, critics believe the figures of confirmed cases may be far lower than the
actual numbers in Nigeria and most African countries. This is fueling the speculations of the real
catastrophic level pandemic if isolation, containment, quarantine, and contact-tracing mechanisms
are not urgently implemented. In a country with an already weak health system occasioned by poor
health investment choices, managing such an outbreak will become impossible.

There is, therefore, a need to develop and adopt new strategies, particularly digitally-enabled strategy
to facilitate a more extensive, accurate, seamless and timely response in line with the high frequency
of new infections among contacts of confirmed cases known as secondary infection rate [12]. Digital
solutions adoption in Nigeria has been focused on electronic forms for contact data collection and
visualization for follow-up [13]. Digital technologies can do more than field data-collection and
outbreak investigation platform. Data about households and general population movement patterns
can be extracted through digital technologies [14]. Farrahi et al in their research show that over a
nine months period, 72 participants made 1,973,547 Bluetooth interactions representing physical
proximity movements (b). The participants equally made 10,992 phone calls and 9,432 SMS records
representing communication flow (a) as in Figure 1 [15]. Their findings show that interactions far
surpassed communication, and thus movement management is most critical in epidemic control.

Figure 1: Visualization of practical communication and interaction networks [15]

This paper reviews the global evidence practice in the use of mobile positioning data to achieve a
more targeted and efficient approach at contact tracing and disease surveillance especially for
COVID-19 pandemic. We discuss how this approach is possible within regulatory confines. We also
recommend a novel strategy for coordinating agencies to leverage mobile positioning data, and how

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to ensure patient privacy is preserved.

Methods

COVID-19 disease pandemic is emerging and only three months old with little scholarly work to
justify a systematic search, review and analysis approach. We conducted an exploratory (non-
systematic) internet search for technology approaches and responses to the COVID-19 epidemic.
Results from global and national agencies responsible for infection prevention and control (IPC)
were analyzed to ascertain how they currently use technology. We also reviewed how these use cases
fit within the regulatory framework for contact tracing and isolation. Similar internet search
methodology was adopted for Nigeria’s response and her use of digital tool for contact tracing.

Result
Our search yielded results based on emerging trends and how countries around the world are using
digital technologies to respond. We first present global perspectives and respond strategies around
the world of how countries are using mobile position data during prior and current pandemics. We
then present and Nigeria’s approach.
How it works
The GSM Association (GSMA) puts the total number of mobile subscribers at 5 billion unique
mobile subscribers and 7 billion connected devices [16]. Nigeria has 184 million active mobile
subscriber lines [17]. Mobile telecommunications subscriber communication and movement data was
used for Ebola outbreak contact tracing [14]. Many countries are currently using mobile data for a
more rapid response to the COVID-19 pandemic [18, 19]. There has been a 90% increase in the
number of countries implementing digital tracking measures and a 100% increase in reports of
censorship [20]. These approaches range from the use of anonymized aggregate data to monitor the
general mobility of people, tracking mobile phones of confirmed cases, to tracking suspected patients
and their contacts. In some cases, these approaches were individualized and mandatory while, in
others, they were aggregated and anonymized. In all cases, there were collaborations between
government, Mobile Network Operators (MNO), and other data controllers such as technology
companies and financial services providers. Each mobile subscriber at any time is connected to a
segment of the MNO base station tower. For simplicity, we have presented in Figure 2, a cellular
tower, and a subscriber. We used letters A and B to illustrate the farthest and shortest distance of the
subscriber from the base station tower based on power throughput and internal cell tower position
triangulation. The difference between A and B, representing the diameter of a user’s device which is
a proxy for the user’s location is often between 50 and 300 meters, depending on many other factors
[14].

Figure 2: Location of a subject with respect to MNO cell tower

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Global strategies
Table 1 details some of the strategies governments around the world are adopting to track and isolate
COVID-19 patients and their contacts or for lockdown/lock-in enforcement. In the United States,
500 million USD of the 2 trillion USD economic stimulus bill recently signed into law is for the US
Centre for Disease Control to launch new surveillance and data-collection system to monitor the
spread of COVID-19 [21]. This move is the first for the US as stringent patient data privacy and
security regulations have hampered adoption of contact tracing as a countermeasure for epidemic
control in the past [22]. Similarly, the state of Massachusetts has announced it is launching what it
calls the ‘first contact tracing’ call center with 1000 virtual assistants to call and trace contacts of
COVID-19 positive persons [23].

The EU’s recent General Data Protection Regulation (GDPR) is being tested at a large scale. Within
the regulation, a patient can decide not to disclose who they have been in contact with or legally
resist being traced [24]. At least evidence emerged that Germany, Austria, and Italy are using
aggregated telecommunications call details registry (CDR) information to enforce lockdown and stay
at home [25]. As this is an evolving challenge, and European countries such as Italy and France are
amongst the worst affected, changes to the GDPR regulations are expected and anticipated.

In China, the government worked with telecommunications companies to track and contact people
who had traveled through Hubei province during the early days of the disease outbreak. Location
data was shared with China's National Health Commission and other agencies, enabling them to
retrospectively simulate the location of confirmed cases and their contacts who were then issued
warnings via social media [26]. Information has also emerged that the Chinese government may have
leveraged its large network of sensors and surveillance cameras supported by Artificial Intelligent
facial recognition and recommender system in her response to the COVID-19 outbreak [27]. This
success may not be unconnected with the often criticized and loose patient data privacy and security
regulation in China.
It was, however, observed that the extent of compliance with international and country-level
regulations regarding data privacy considerations in deploying this digital technology varied from
country to country.
Table 1; Country strategies for the use of mobile positioning data in COVID-19 response
Country Strategy planned or adopted
USA [21] The state of Massachusetts announced the launch of first contact tracing
call center to be manned by 1000 virtual assistants [23]. The US federal
government announced $500 million package for COVID-19 surveillance to
CDC [21].
China [22] A mandatory smartphone app ‘Health code’ that leverages mesh
[28] network for infected persons contact tracing and notification.
Italy, Telecommunications providers make available call detail registry allow for
Germany, and sharing location data with health authorities to check whether people are
Austria [25] remaining at home. The data is aggregated and anonymous, mapping
concentrations rather than individuals to respect Europe’s privacy laws.
South Korea The government created a map of cellphone data provided by telecom and
[29] credit card companies. The map was made public, so everyone could track
their level of exposure.
Israel [19] The government is using GMS call detail registry (CDR) in addition to
patient phone position data to locate contacts and trace their movement
patterns.
Iran [30] Iranian authorities developed a mobile application with government
endorsement with self-diagnosis check for COVID-19 disease. It however

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also discretely collects user’s location data.

Singapore Mobile app uses Bluetooth-based mesh network to detect people's
[18, 21] proximity to those who have been exposed to coronavirus and warns them
to get tested if they come in close contact.

Nigerian strategy

Human travel patterns and mobility can be assessed using available mobile phone data, and its
application can be useful in disease epidemiology [31]. Panigutti et al also revealed the adequacy of
mobile phone data for tracking infectious disease spread, particularly in heavily populated and highly
interconnected communities [31].

Border restrictions, internal travel restrictions, and school closures or total lockdown are reasonable
but have minimal impact compared to effective case isolation or quarantine, which have been shown
to have a significant impact if properly conducted [2]. This is particularly important in Nigeria’s
case, where total compliance to these strategies cannot be guaranteed. Therefore, data on case
isolation and quarantine should be a significant priority in our setting. More so, data is useful in
modeling disease transmission. Specifically, collecting and analyzing data on transmission in
different social contexts is highly effective in mapping intervention strategies since the impact of
case isolation and quarantine depends on the reduction of contact rates of the index case and other
cases while they are ill [2].

More so, in order for the NCDC to effectively conduct the current large-scale contact tracing of over
9000 contacts of confirmed cases, use of digital technology is inevitable. The number of contacts
may even be more than this number considering the frequency of new infections. Currently, there are
several digital contact data capture solutions including the Surveillance, Outbreak Response
Management and Analysis System (SORMAS) in use. These solutions require a field epidemiologist
or their representative visiting every contact.

Discussions
Evidence suggest that contact tracing and data protection can go together [32]. Significant progress is
being made with current strategies. As promising as they may seem, data privacy concerns remain a
major impediment with an overriding need to find a balance between deploying the technology,
maintaining data safety and patient privacy. Existing patient privacy regulations are currently being
tested. Some countries have attempted to relax existing stringent regulations that protect patient
privacy to allow for greater access, others have worked around them. According to [21], many of the
new digital technology approaches appear inevitable and legitimate, given the unprecedented high
frequency of COVID-19 infection spread. Many countries have now also invoked speedily legislative
processes to give legitimacy to their workarounds and deployments.

In Israel for instance, the cabinet has passed an emergency law to use mobile data for tracking people
infected with COVID-19, trace their contacts and identify those for quarantine [19]. This law was
speedily passed overnight, bypassing parliamentary approval. In the United States, privacy advocates
are proposing stringent procedures to keep personal information safe, including deletion, once it's no
longer in use to prevent abuse by law enforcement agents [21].

In Nigeria, the National Data Protection Regulation (NDPR) was promulgated in 2019 [33]. Amongst
other stipulations, the regulation states the guiding principles for data processing in Section 5. These
principles consider data processing unlawful if there is no consent by the individual data subjects (in

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this case, the confirmed persons) if it is inaccurate with prejudice to human dignity and not protected
against cybercrime as well as stored beyond the reasonably necessary period. However, regardless of
these guiding principles, Section 6, part 2.0, subsection 2.2 (e) of the document listed the conditions for
lawful data processing and states that;
"processing is necessary for the performance of a task carried out in the public interest or the exercise of
official public mandate vested in the controller."

The Data controller, in the case, of mobile positioning data is the MNO who is the entity that determines
the purposes for and the manner in which network subscriber phone data is processed or is to be
processed. Section 11 of the regulation states that data processing by a third party (in this case a public
authority such as the Federal Ministry of Health, NCDC, or anybody engaged in processing the location
data such as a technology company) shall be governed by a written contract with the Data Controller.
Interestingly, though the NDPR protected the privacy of personal mobile location data, it has
nonetheless provided the window for the use of such data in situations of overriding public interest,
such as the current COVID-19 outbreak.

Recommendations
Mobile phone location data can be effectively utilized in Nigeria for the COVID-19 response. The
government can leverage existing mobile technology resources and infrastructure available in-
country by working with MNOs and technology firms to optimize the ongoing contact tracing
and surveillance of over 9000 known contacts of confirmed cases. This collaboration should
remain guided by the NDPR in order to protect and safeguard individuals' data, prevent a
breach of data privacy rights as well as inappropriate use and abuse by law enforcement
agencies beyond the period of contact tracing and surveillance.

In practice however, the first step should involve anonymized mobile subscriber data in line
with good data governance policy. Where possible, informed consent of confirmed cases should
be appropriately sorted once they are diagnosed in the spirit of goodwill. The use of public
interest exception should be the last resort. A simplified guideline for these process for
adhering to NDPR should be written and made transparently available for data custodians,
requesting bodies, data handlers and the patient or contact.

A third-party agreement should also be formally signed between parties interfacing with
patient data in any way. A typical use case sensitive to data privacy concerns is the use of
information about a visit to public facilities only including public transportation systems, parks,
churches, mosques, or malls used by the confirmed cases as described by [34]. The use of CDR
has proved to be effective in detecting outbreak clusters and then using other frontline data
collection tools for mitigating the impact and containment [14]. A key limitation of using CDR
from MNOs as already illustrated in figure 2 is that for basic phone users (2G- second
generation), the location will rely on mobile network phone mast location triangulation only.
This approach alone has proximity accuracy of between 50 and 300 meters. This accuracy level
is not sufficient to confirm persons who have been in contact with a COVID-19 patient as the
WHO contact definition prescribes two meters [7]. The use of telecommunication CDR should
be complemented with other strategies for effective result.

The immediate action after successful contact trace is communicating the expected course of action
to citizens of an infected community cluster. A simple, user-friendly interface using the Unstructured
Supplementary Service Data (USSD) technology will help improve information requests and
management for low income but literate users. Also, interactive Voice Response (IVR) technology
will be suitable and appropriate for local language awareness response for low literate users.

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Conclusions
Mobile positioning data can significantly improve the capacity and scope of timely outbreak
response and will help governments as well as other responders in Nigeria. When implemented early
[15], there are opportunities to leverage positioning data to break the chains of disease transmission
in community clusters. It can improve the efficiency of currently used field data-collection and
outbreak investigation platforms when used in synergy.

While mobile positioning data can be used within the current regulation, guidelines for data handlers
must include measures to curtail misuse and unauthorized access. Future research will be to design
and implement models for mobile position contact tracing.

Conflicts of Interest
None

Abbreviations
2G – Second generation of mobile telephony
CDC: US Center for Disease Control
CDR: Call Detail Registry
COVID-19: Coronavirus 2019
GDPR: European General Data Protection Regulation
HIPAA: Health Insurance Portability and Accountability Act
IPC: Infection Prevention and Control
MNO: Mobile Network Operators
NCDC: Nigeria Center for Disease Control
NDPR: Nigeria Data Protection Regulation
NITDA: National Information Technology Development Agency
WHO: World Health Organization

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